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Liu NA, Ben-Shlomo A, Carmichael JD, Wang C, Swerdloff RS, Heaney AP, Barkhoudarian G, Kelly D, Noureddin M, Lu L, Desai M, Stolyarov Y, Yuen K, Mamelak AN, Mirocha J, Tighiouart M, Melmed S. Treatment of Cushing Disease With Pituitary-Targeting Seliciclib. J Clin Endocrinol Metab 2023; 108:726-735. [PMID: 36214832 DOI: 10.1210/clinem/dgac588] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/04/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Preclinical studies show seliciclib (R-roscovitine) suppresses neoplastic corticotroph proliferation and pituitary adrenocorticotrophic hormone (ACTH) production. OBJECTIVE To evaluate seliciclib as an effective pituitary-targeting treatment for patients with Cushing disease (CD). METHODS Two prospective, open-label, phase 2 trials, conducted at a tertiary referral pituitary center, included adult patients with de novo, persistent, or recurrent CD who received oral seliciclib 400 mg twice daily for 4 consecutive days each week for 4 weeks. The primary endpoint in the proof-of-concept single-center study was normalization of 24-hour urinary free cortisol (UFC; ≤ 50 µg/24 hours) at study end; in the pilot multicenter study, primary endpoint was UFC normalization or ≥ 50% reduction in UFC from baseline to study end. RESULTS Sixteen patients were consented and 9 were treated. Mean UFC decreased by 42%, from 226.4 ± 140.3 µg/24 hours at baseline to 131.3 ± 114.3 µg/24 hours by study end. Longitudinal model showed significant UFC reductions from baseline to each treatment week. Three patients achieved ≥ 50% UFC reduction (range, 55%-75%), and 2 patients exhibited 48% reduction; none achieved UFC normalization. Plasma ACTH decreased by 19% (P = 0.01) in patients who achieved ≥ 48% UFC reduction. Three patients developed grade ≤ 2 elevated liver enzymes, anemia, and/or elevated creatinine, which resolved with dose interruption/reduction. Two patients developed grade 4 liver-related serious adverse events that resolved within 4 weeks of seliciclib discontinuation. CONCLUSION Seliciclib may directly target pituitary corticotrophs in CD and reverse hypercortisolism. Potential liver toxicity of seliciclib resolves with treatment withdrawal. The lowest effective dose requires further determination.
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Affiliation(s)
- Ning-Ai Liu
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Anat Ben-Shlomo
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - John D Carmichael
- Pituitary Center, Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
| | - Christina Wang
- Department of Medicine, The Lundquist Institute and Harbor-UCLA Medical Center, Torrance, CA 90509, USA
| | - Ronald S Swerdloff
- Department of Medicine, The Lundquist Institute and Harbor-UCLA Medical Center, Torrance, CA 90509, USA
| | - Anthony P Heaney
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA 90024, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, CA 90404, USA
| | - Daniel Kelly
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, CA 90404, USA
| | - Mazen Noureddin
- Karsh Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Lin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Manish Desai
- Southern California Permanente Group-Antelope Valley, Lancaster, CA 93534, USA
| | | | - Kevin Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ 85013, USA
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - James Mirocha
- Biostatistics Core, Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Mourad Tighiouart
- Biostatistics Core, Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Shlomo Melmed
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Jones PS, Swearingen B. Pituitary surgery in Cushing's disease: first line treatment and role of reoperation. Pituitary 2022; 25:713-717. [PMID: 35857269 DOI: 10.1007/s11102-022-01254-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 11/26/2022]
Abstract
Cushing's disease is the most common cause of endogenous hypercortisolemia, and transsphenoidal surgery remains the first line therapy for removal of the ACTH-secreting adenoma. While post-operative remission rates are high in experienced hands, there remains a 2% risk of recurrence per year. Patients with the highest chance for cure are those with small, non-invasive tumors that are visible on pre-operative MRI and identified during surgery and are performed by high-volume pituitary neurosurgeons. Surgery for persistent or recurrent disease is frequently indicated and is most successful in the hands of experienced surgeons and in cases where tumor is visible on MRI.
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Affiliation(s)
- Pamela S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Brooke Swearingen
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Lu L, Wan X, Xu Y, Chen J, Shu K, Lei T. Prognostic Factors for Recurrence in Pituitary Adenomas: Recent Progress and Future Directions. Diagnostics (Basel) 2022; 12:diagnostics12040977. [PMID: 35454025 PMCID: PMC9024548 DOI: 10.3390/diagnostics12040977] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/01/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023] Open
Abstract
Pituitary adenomas (PAs) are benign lesions; nonetheless, some PAs exhibit aggressive behaviors, which lead to recurrence. The impact of pituitary dysfunction, invasion-related risks, and other complications considerably affect the quality of life of patients with recurrent PAs. Reliable prognostic factors are needed for recurrent PAs but require confirmation. This review summarizes research progress on two aspects—namely, the clinical and biological factors (biomarkers) for recurrent PAs. Postoperative residue, age, immunohistological subtypes, invasion, tumor size, hormone levels, and postoperative radiotherapy can predict the risk of recurrence in patients with PAs. Additionally, biomarkers such as Ki-67, p53, cadherin, pituitary tumor transforming gene, matrix metalloproteinase-9, epidermal growth factor receptor, fascin actin-bundling protein 1, cyclooxygenase-2, and some miRNAs and lncRNAs may be utilized as valuable tools for predicting PA recurrence. As no single marker can independently predict PA recurrence, we introduce an array of comprehensive models and grading methods, including multiple prognostic factors, to predict the prognosis of PAs, which have shown good effectiveness and would be beneficial for predicting PA recurrence.
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Affiliation(s)
| | | | | | | | | | - Ting Lei
- Correspondence: ; Tel./Fax: +86-27-8366-5202
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Varlamov EV, Vila G, Fleseriu M. Perioperative Management of a Patient with Cushing’s Disease. J Endocr Soc 2022; 6:bvac010. [PMID: 35178493 PMCID: PMC8845122 DOI: 10.1210/jendso/bvac010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Indexed: 11/19/2022] Open
Abstract
Abstract
Patients with Cushing’s disease (CD) may present with both chronic and acute perioperative complications that necessitate multidisciplinary care. This review highlights several objectives for these patients before and after transsphenoidal surgery. Preoperative management includes treatment of electrolyte disturbances, cardiovascular comorbidities, prediabetes/diabetes, as well as prophylactic consideration(s) for thromboembolism and infection(s). Preoperative medical therapy (PMT) could prove beneficial in patients with severe hypercortisolism or in cases of delayed surgery. Some centers use PMT routinely, although the clinical benefit for all patients is controversial. In this setting, steroidogenesis inhibitors are preferred because of rapid and potent inhibition of cortisol secretion. If glucocorticoids are not used perioperatively, an immediate remission assessment postoperatively is possible. However, perioperative glucocorticoid replacement is sometimes necessary for clinically unstable or medically pretreated patients and for those patients with surgical complications. A nadir serum cortisol < 2-5µg/dl during 24-74 hours postoperatively is generally accepted as remission; higher values suggest non-remission, while a few patients may display delayed remission. If remission is not achieved, additional treatments are pursued. The early postoperative period necessitates multidisciplinary awareness for early diagnosis of adrenal insufficiency (AI) to avoid adrenal crisis, which may be also potentiated by acute postoperative complications. Preferred glucocorticoid replacement is hydrocortisone, if available. Assessment of recovery from postoperative AI should be undertaken periodically. Other postoperative targets include decreasing antihypertensive/diabetic therapy if in remission, thromboprophylaxis, infection prevention/treatment, and management of electrolyte disturbances and/or potential pituitary deficiencies. Evaluation of recovery of thyroid, gonadal and growth hormone deficiencies should be also performed in the following months postoperatively.
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Affiliation(s)
- Elena V Varlamov
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Greisa Vila
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
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