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Gerke MB, Jansen CS, Bilen MA. Circulating Tumor DNA in Genitourinary Cancers: Detection, Prognostics, and Therapeutic Implications. Cancers (Basel) 2024; 16:2280. [PMID: 38927984 DOI: 10.3390/cancers16122280] [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: 05/25/2024] [Revised: 06/18/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
CtDNA is emerging as a non-invasive clinical detection method for several cancers, including genitourinary (GU) cancers such as prostate cancer, bladder cancer, and renal cell carcinoma (RCC). CtDNA assays have shown promise in early detection of GU cancers, providing prognostic information, assessing real-time treatment response, and detecting residual disease and relapse. The ease of obtaining a "liquid biopsy" from blood or urine in GU cancers enhances its potential to be used as a biomarker. Interrogating these "liquid biopsies" for ctDNA can then be used to detect common cancer mutations, novel genomic alterations, or epigenetic modifications. CtDNA has undergone investigation in numerous clinical trials, which could address clinical needs in GU cancers, for instance, earlier detection in RCC, therapeutic response prediction in castration-resistant prostate cancer, and monitoring for recurrence in bladder cancers. The utilization of liquid biopsy for ctDNA analysis provides a promising method of advancing precision medicine within the field of GU cancers.
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Affiliation(s)
- Margo B Gerke
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Caroline S Jansen
- Emory University School of Medicine, Atlanta, GA 30322, USA
- Winship Cancer Institute of Emory University, Atlanta, GA 30322, USA
| | - Mehmet A Bilen
- Winship Cancer Institute of Emory University, Atlanta, GA 30322, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
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Ababneh O, Ghazou A, Alawajneh M, Alhaj Mohammad S, Bani-Hani A, Alrabadi N, Shreenivas A. The Efficacy and Safety of Immune Checkpoint Inhibitors in Adrenocortical Carcinoma: A Systematic Review and Meta-Analysis. Cancers (Basel) 2024; 16:900. [PMID: 38473262 DOI: 10.3390/cancers16050900] [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: 01/08/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of different malignancies. However, their efficacy in advanced adrenocortical carcinoma (ACC) remains uncertain. Thus, we conducted a systematic review and meta-analysis to summarize the efficacy and tolerability of ICIs in patients with advanced ACC. We searched PubMed, Scopus, and CENTRAL for studies that used ICIs in ACC. Studies with more than five patients were included in the meta-analysis of the objective response rate (ORR), disease control rate (DCR), overall survival (OS), progression-free survival (PFS), and grade 3/4 adverse events. Twenty studies with 23 treatment arms and 250 patients were included. Single-agent anti-PD1 or anti-PD-L1 treatment was utilized in 13 treatment arms, whereas an anti-PD1 or anti-PD-L1 and anti-CTLA4 combination was used in 4 treatment arms. Other anti-PD1- or anti-PD-L1-based combinations were used in five treatment arms. The ORR was 14% (95% CI = 10-19%, I2 = 0%), and the DCR was 43% (95% CI = 37-50%, I2 = 13%). The combination anti-PD1- or anti-PD-L1-based treatment strategies did not correlate with higher responses compared with monotherapy. The median OS was 13.9 months (95% CI = 7.85-23.05), and the median PFS was 2.8 months (95% CI = 1.8-5.4). ICIs have a modest efficacy in advanced ACC but a good OS. Further studies are needed to investigate predictive biomarkers for ICI response and to compare ICI-based strategies with the current standard of care.
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Affiliation(s)
- Obada Ababneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Alina Ghazou
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Mohmmad Alawajneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Saleh Alhaj Mohammad
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Abdullah Bani-Hani
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Nasr Alrabadi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Aditya Shreenivas
- Department of Hematology and Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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3
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Weng Y, Wang L, Wang XY, Fan XX, Yan L, Li ZH, Zhang SL. Case report: Remarkable response to a novel combination of mitotane, etoposide, paraplatin, and sintilimab in a patient with metastatic adrenocortical carcinoma. Front Endocrinol (Lausanne) 2023; 14:1115893. [PMID: 37745701 PMCID: PMC10514511 DOI: 10.3389/fendo.2023.1115893] [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: 12/04/2022] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Background Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis and limited treatment options for metastases. However, new effective regimens are emerging for specific conditions in metastatic ACC. Case presentation We report a case of a 36-year-old man diagnosed with metastatic ACC who had a large left adrenal mass (158 mm × 112 mm) and multiple metastases in the liver and lungs. Genetic testing revealed a microsatellite instability-high (MSI-H) tumor, a splice mutation in MLH1, and a high tumor mutational burden (TMB). After the left adrenalectomy, he received sequential treatment with a combination of mitotane, etoposide, paraplatin (EP-M), and sintilimab. His condition has been assessed as a stable disease since the sixth cycle of the combined regimen. Conclusion This case highlights the remarkable response of our patient's ACC with MSI-H tumor, MLH1 spice mutation, and high TMB to treatment with a novel combination of EP-M and sintilimab. Our findings suggest a promising therapeutic option for patients with similar molecular profiles.
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Affiliation(s)
- Yan Weng
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lin Wang
- Department of Pathology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao-Yi Wang
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xin-Xiang Fan
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Yan
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi-Hua Li
- Department of Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shao-Ling Zhang
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Lerario AM, Mohan DR, Hammer GD. Update on Biology and Genomics of Adrenocortical Carcinomas: Rationale for Emerging Therapies. Endocr Rev 2022; 43:1051-1073. [PMID: 35551369 PMCID: PMC9695111 DOI: 10.1210/endrev/bnac012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Indexed: 11/19/2022]
Abstract
The adrenal glands are paired endocrine organs that produce steroid hormones and catecholamines required for life. Adrenocortical carcinoma (ACC) is a rare and often fatal cancer of the peripheral domain of the gland, the adrenal cortex. Recent research in adrenal development, homeostasis, and disease have refined our understanding of the cellular and molecular programs controlling cortical growth and renewal, uncovering crucial clues into how physiologic programs are hijacked in early and late stages of malignant neoplasia. Alongside these studies, genome-wide approaches to examine adrenocortical tumors have transformed our understanding of ACC biology, and revealed that ACC is composed of distinct molecular subtypes associated with favorable, intermediate, and dismal clinical outcomes. The homogeneous transcriptional and epigenetic programs prevailing in each ACC subtype suggest likely susceptibility to any of a plethora of existing and novel targeted agents, with the caveat that therapeutic response may ultimately be limited by cancer cell plasticity. Despite enormous biomedical research advances in the last decade, the only potentially curative therapy for ACC to date is primary surgical resection, and up to 75% of patients will develop metastatic disease refractory to standard-of-care adjuvant mitotane and cytotoxic chemotherapy. A comprehensive, integrated, and current bench-to-bedside understanding of our field's investigations into adrenocortical physiology and neoplasia is crucial to developing novel clinical tools and approaches to equip the one-in-a-million patient fighting this devastating disease.
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Affiliation(s)
- Antonio Marcondes Lerario
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| | - Dipika R Mohan
- Medical Scientist Training Program, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| | - Gary D Hammer
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
- Department of Cell & Developmental Biology, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
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Nazha B, Zhuang TZ, Dada HI, Drusbosky LM, Brown JT, Ravindranathan D, Carthon BC, Kucuk O, Goldman J, Master VA, Bilen MA. Blood-Based Next-Generation Sequencing in Adrenocortical Carcinoma. Oncologist 2022; 27:462-468. [PMID: 35462410 PMCID: PMC9177103 DOI: 10.1093/oncolo/oyac061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/16/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare and heterogeneous malignancy with poor prognosis. We aimed to evaluate the feasibility of next-generation sequencing (NGS) testing of circulating cell-free tumor DNA (ctDNA) in patients with ACC, to characterize the genomic landscape of alterations, and to identify potential clinically actionable mutations. METHODS Retrospective analysis of genomic data from 120 patients with ACC who had ctDNA testing between 12/2016 and 10/2021 using Guardant360 (Guardant Health, CA) was performed. ctDNA NGS analysis interrogated single nucleotide variants, fusions, indels, and copy number amplifications of up to 83 genes. The frequency of genomic alterations, landscape of co-occurring mutations, and pathogenic/likely pathogenic alterations with potential targeted therapies was identified. The prevalence of alterations identified in ctDNA was compared to those detected in tissue using a publicly available database (cBioPortal). RESULTS The median age of this cohort was 53 years (range 21-81), and 56% of patients were female. Ninety-six patients (80%) had ≥1 somatic alteration detected. TP53 (52%), EGFR (23%), CTNNB1 (18%), MET (18%), and ATM (14%) were found to be the most frequently altered genes in ACC samples. Pathogenic and/or likely pathogenic mutations in therapeutically relevant genes were observed in 56 patients (47%) and included EGFR, BRAF, MET, CDKN2A, CDK4/6, and ATM. The most frequent co-occurring mutations were EGFR + MET (9%), MET + CDK4 (7%), EGFR + CDK4 (7%), and BRAF + MET (7%). The frequencies of mutations detected in ctDNA were similar to those detected in tissue. CONCLUSIONS Utilizing blood-based NGS to characterize genomic alterations in advanced ACC is feasible in over 80% of patients. Almost half of the patients had actionable mutations with approved therapies in other cancers. This approach might inform the development of personalized treatment options or identify clinical trials available for this aggressive malignancy.
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Affiliation(s)
- Bassel Nazha
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Tony Z Zhuang
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Jacqueline T Brown
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Deepak Ravindranathan
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Bradley C Carthon
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Omer Kucuk
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jamie Goldman
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Viraj A Master
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Mehmet Asim Bilen
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
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Jimenez C, Armaiz-Pena G, Dahia PLM, Lu Y, Toledo RA, Varghese J, Habra MA. Endocrine and Neuroendocrine Tumors Special Issue—Checkpoint Inhibitors for Adrenocortical Carcinoma and Metastatic Pheochromocytoma and Paraganglioma: Do They Work? Cancers (Basel) 2022; 14:cancers14030467. [PMID: 35158739 PMCID: PMC8833823 DOI: 10.3390/cancers14030467] [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: 12/23/2021] [Revised: 01/15/2022] [Accepted: 01/15/2022] [Indexed: 02/07/2023] Open
Abstract
Adrenocortical cancers and metastatic pheochromocytomas are the most common malignancies originating in the adrenal glands. Metastatic paragangliomas are extra-adrenal tumors that share similar genetic and molecular profiles with metastatic pheochromocytomas and, subsequently, these tumors are studied together. Adrenocortical cancers and metastatic pheochromocytomas and paragangliomas are orphan diseases with limited therapeutic options worldwide. As in any other cancers, adrenocortical cancers and metastatic pheochromocytomas and paragangliomas avoid the immune system. Hypoxia-pseudohypoxia, activation of the PD-1/PD-L1 pathway, and/or microsatellite instability suggest that immunotherapy with checkpoint inhibitors could be a therapeutic option for patients with these tumors. The results of clinical trials with checkpoint inhibitors for adrenocortical carcinoma or metastatic pheochromocytoma or paraganglioma demonstrate limited benefits; nevertheless, these results also suggest interesting mechanisms that might enhance clinical responses to checkpoint inhibitors. These mechanisms include the normalization of tumor vasculature, modification of the hormonal environment, and vaccination with specific tumor antigens. Combinations of checkpoint inhibitors with classical therapies, such as chemotherapy, tyrosine kinase inhibitors, radiopharmaceuticals, and/or novel therapies, such as vaccines, should be evaluated in clinical trials.
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Affiliation(s)
- Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.V.); (M.A.H.)
- Correspondence:
| | - Gustavo Armaiz-Pena
- Division of Endocrinology, Department Medicine, The University of Texas Health Science Center, San Antonio, TX 78229, USA;
| | - Patricia L. M. Dahia
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX 78229, USA;
- Mays Cancer Center, University of Texas Health San Antonio, San Antonio, TX 78229, USA
| | - Yang Lu
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Rodrigo A. Toledo
- CIBERONC, Gastrointestinal and Endocrine Tumors, Vall d’Hebron Institute of Oncology (VHIO), Centro Cellex, 08035 Barcelona, Spain;
| | - Jeena Varghese
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.V.); (M.A.H.)
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.V.); (M.A.H.)
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Zhou Z, Luo HM, Tang J, Xu WJ, Wang BH, Peng XH, Tan H, Liu L, Long XY, Hong YD, Wu XB, Wang JP, Wang BQ, Xie HH, Fang Y, Luo Y, Li R, Wang Y. Multidisciplinary team therapy for left giant adrenocortical carcinoma: A case report. World J Clin Cases 2021; 9:5737-5743. [PMID: 34307633 PMCID: PMC8281393 DOI: 10.12998/wjcc.v9.i20.5737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/06/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare malignant epithelial tumor originating from adrenocortical cells that carries a very poor prognosis. Metastatic or inoperable diseases are often considered incurable, and treatment remains a challenge. Especially for advanced cases such as ACC complicated with renal venous cancer thrombus, there are few cumulative cases in the literature.
CASE SUMMARY The patient in this case was a 39-year-old middle-aged male who was admitted to the hospital for more than half a month due to dizziness and chest tightness. Computed tomography (CT) findings after admission revealed a left retroperitoneal malignant space-occupying lesion, but the origin of the formation of the left renal vein cancer thrombus remained to be determined. It was speculated that it originated from the left adrenal gland, perhaps a retroperitoneal source, and left adrenal mass + left nephrectomy + left renal vein tumor thrombus removal + angioplasty were performed under general anesthesia. Postoperative pathology results indicated a diagnosis of ACC. Postoperative steroid therapy was administered. At 3 mo after surgery, abdominal CT reexamination revealed multiple enlarged retroperitoneal lymph nodes and multiple low-density shadows in the liver, and palliative radiotherapy and mitotane were administered, considering the possibility of metastasis. The patient is currently being followed up.
CONCLUSION ACC is a highly malignant tumor. Even if the tumor is removed surgically, there is still the possibility of recurrence. Postoperative mitotane and adjuvant chemoradiotherapy have certain benefits for patients, but they cannot fully offset the poor prognosis of this disease.
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Affiliation(s)
- Zheng Zhou
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Hong-Mei Luo
- Department of Histology and Embryology, Clinical Anatomy and Reproductive Medicine Application Institute, University of South China, Hengyang 421001, Hunan Province, China
| | - Jian Tang
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Wu-Jun Xu
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Bin-Hui Wang
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Xu-Hui Peng
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Heng Tan
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Li Liu
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Xiang-Yang Long
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Yu-De Hong
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Xiao-Bin Wu
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Jian-Ping Wang
- Department of Endocrinology, The Second Affiliated Hospital of University of South China, Hengyang 421001, Hunan Province, China
| | - Bai-Qi Wang
- Department of Oncology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Hai-Hui Xie
- Department of Radiotherapy , The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Yong Fang
- Department of Pathology, The Second Affiliated Hospital , University of South China, Hengyang 421001, Hunan Province, China
| | - Yong Luo
- Department of ICU, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Rong Li
- Department of Clinical Pharmacy, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Yi Wang
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
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Abstract
Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy. For stage I and II tumors, surgery is a curative option, but even in these cases recurrence is frequent. Practical guidelines advocate a combination of mitotane with etoposide, doxorubicin, and cisplatin as first-line therapy for metastatic adrenocortical carcinoma. However, this scheme presents limited efficacy and high toxicity. The use of Immune Checkpoint Inhibitors (ICI) and multi-Tyrosine Kinase Inhibitors (mTKI) has modified the approach of multiple malignancies. The expectation of their applicability on advanced adrenocortical carcinoma is high but the role of these new therapies persists unclear. This article provides a short summary of last years' findings targeting outcomes, limitations, and adverse effects of these new therapeutic approaches. The results of recent trials and case series pointed pembrolizumab as the most promising drug among these new therapies. It is the most often used ICI and the one presenting the best results with less related adverse effects when in comparison to the standard treatment with mitotane. Hereafter, the identification of specific molecular biomarkers or immune profiles associated with ICI or mTKI good response will facilitate the selection of candidates for these therapies. So far, microsatellite instability and Lynch Syndrome related germline mutations are suggested as predictive biomarkers of good response. Contrarywise, cortisol secretion has been associated with more aggressive ACC tumors and potentially poor responses to immunotherapy.
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Affiliation(s)
- Alexandra Novais Araújo
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Maria João Bugalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Faculty of Medicine, Lisbon University, Lisbon, Portugal
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Georgantzoglou N, Kokkali S, Tsourouflis G, Theocharis S. Tumor Microenvironment in Adrenocortical Carcinoma: Barrier to Immunotherapy Success? Cancers (Basel) 2021; 13:1798. [PMID: 33918733 PMCID: PMC8069982 DOI: 10.3390/cancers13081798] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/26/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022] Open
Abstract
Adrenocortical carcinoma is a rare malignancy with aggressive behavior, with up to 40% of patients presenting with metastases at the time of diagnosis. Both conventional chemotherapeutic regimens and novel immunotherapeutic agents, many of which are currently being tested in ongoing clinical trials, have yielded modest results so far, bringing the need for a deeper understanding of adrenal cancer behavior to the forefront. In the recent years, the tumor microenvironment has emerged as a major determinant of cancer response to immunotherapy and an increasing number of studies on other solid tumors have focused on manipulating the microenvironment in the favor of the host and discovering new potential target molecules. In the present review we aim to explore the characteristics of adrenocortical cancer's microenvironment, highlighting the mechanisms of immune evasion responsible for the modest immunotherapeutic results, and identify novel potential strategies.
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Affiliation(s)
- Natalia Georgantzoglou
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece; (N.G.); (S.K.)
| | - Stefania Kokkali
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece; (N.G.); (S.K.)
- First Medical Oncology Clinic, Saint-Savvas Anti Cancer Hospital, 115 27 Athens, Greece
| | - Gerasimos Tsourouflis
- Second Department of Propedeutic Surgery, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece;
| | - Stamatios Theocharis
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece; (N.G.); (S.K.)
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Alam W, Bouferraa Y, Haibe Y, Shamseddine A. Complete Radiological Response of Recurrent Metastatic Adrenocortical Carcinoma to Pembrolizumab and Mitotane. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2021; 15:11795549211007682. [PMID: 33889043 PMCID: PMC8040600 DOI: 10.1177/11795549211007682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 03/10/2021] [Indexed: 11/29/2022]
Abstract
Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. Treatment options for ACC are limited, with resection the main intervention. Most cases present in late metastatic cases, and data regarding effective therapies is limited. We report a case of ACC in a 40-year-old woman with history of ACC postadrenalectomy, who presented with recurrent metastatic ACC in the left perinephric space. She was started on pembrolizumab which was added to her mitotane maintenance therapy. Complete radiological response was achieved after 4 cycles of pembrolizumab. As far as we know, this is the first case to achieve complete radiological response with mitotane and pembrolizumab in recurrent metastatic ACC, with negative prognostic markers and no prior radiotherapy. As our findings are in the setting of one clinical case, we suggest the need to perform a trial to assess the benefit of combining mitotane and pembrolizumab in treating metastatic ACC.
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Affiliation(s)
- Walid Alam
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Youssef Bouferraa
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yolla Haibe
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Shamseddine
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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11
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Araujo-Castro M, Pascual-Corrales E, Molina-Cerrillo J, Alonso-Gordoa T. Immunotherapy in Adrenocortical Carcinoma: Predictors of Response, Efficacy, Safety, and Mechanisms of Resistance. Biomedicines 2021; 9:biomedicines9030304. [PMID: 33809752 PMCID: PMC8002272 DOI: 10.3390/biomedicines9030304] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/12/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with limited treatment options in the advanced stages. Immunotherapy offers hope for altering the orthodox management of cancer, and its role in advanced ACC has been investigated in different studies. With the aim clarifying the role of immunotherapy in ACC we performed a comprehensive review about this topic focusing on the predictors of response, efficacy, safety, and the mechanisms of resistance. Five clinical trials with four immune checkpoint inhibitors (pembrolizumab, avelumab, nivolumab, and ipilimumab) have investigated the role of immunotherapy in advanced ACC. Despite, the different primary endpoints used in these studies, the reported rates of overall response rate and progression free survival were generally poor. Three main potential markers of response to immunotherapy in ACC have been described: Expression of PD-1 and PD-L1, microsatellite instability and tumor mutational burden. However, none of them has been validated in prospective studies. Several mechanisms of ACC immunoevasion may be responsible of immunotherapy failure, and a greater knowledge of these mechanisms might lead to the development of new strategies to overcome the immunotherapy resistance. In conclusion, although currently the role of immunotherapy is limited, the identification of immunological markers of response and the implementation of strategies to avoid immunotherapy resistance could improve the efficacy of this therapy.
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Affiliation(s)
- Marta Araujo-Castro
- Neuroendocrinology Unit, Endocrinology and Nutrition Department, Ramón y Cajal Health Research Institute (IRYCIS), Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
- Correspondence:
| | - Eider Pascual-Corrales
- Neuroendocrinology Unit, Endocrinology and Nutrition Department, Ramón y Cajal Health Research Institute (IRYCIS), Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | - Javier Molina-Cerrillo
- Medical Oncology Department, Ramón y Cajal Health Research Institute (IRYCIS), Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (J.M.-C.); (T.A.-G.)
| | - Teresa Alonso-Gordoa
- Medical Oncology Department, Ramón y Cajal Health Research Institute (IRYCIS), Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (J.M.-C.); (T.A.-G.)
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12
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Brabo EP, Moraes AB, Neto LV. The role of immune checkpoint inhibitor therapy in advanced adrenocortical carcinoma revisited: review of literature. J Endocrinol Invest 2020; 43:1531-1542. [PMID: 32468513 DOI: 10.1007/s40618-020-01306-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/21/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Adrenocortical carcinoma (ACC) is a rare disease with few therapeutic options. There is an urgency of new effective therapeutic options for these patients. The role of immune checkpoint inhibitors (ICI) in advanced ACC patients is still unclear. METHODS We conducted a MEDLINE search using the following string: adrenocortical carcinoma and immunotherapy or checkpoint inhibitors. RESULTS We found four case series comprising 10 patients, and four prospective studies totaling 115 patients. The response rate (RR) in the group of 10 patients was 1 complete response, 3 partial response (PR), 4 stable disease (SD), and 2 progressive disease (PD). The median progression-free survival (mPFS) ranged from 2 to 31 months and the median overall survival (mOS) ranged from 4.3 to 31 months. The results in the 115 patients from prospective trials was variable, the PR ranged from 6 to 23%, the SD ranged from 18 to 50% and overall disease control rate ranged from 30 to 64%. The mPFS reported varied from 1.8 to 2.6 months while the mOS varied from 10.6 to 24.9 months. There were five patients with sustained response for more than 24 months. The most common treatment-related adverse event (TRAE) was the increase in liver enzymes. No treatment-related deaths were reported. Better results in terms of RR and survival were observed in studies that used pembrolizumab. No predictive biomarker of response was found up to now. CONCLUSION ICI, mainly pembrolizumab, is a potential therapeutic option, which is safe and associated with prolonged OS benefit, in selected patients with advanced ACC.
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Affiliation(s)
- E P Brabo
- Oncology Unit and Neuroendocrine Section, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, 255 Professor Rodolpho Paulo Rocco Street, ground floor, University City, Rio de Janeiro, RJ, 21941-913, Brazil
| | - A B Moraes
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, 255 Professor Rodolpho Paulo Rocco Street, 9th floor, University City, Rio de Janeiro, RJ, 21941-913, Brazil
| | - L V Neto
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, 255 Professor Rodolpho Paulo Rocco Street, 9th floor, University City, Rio de Janeiro, RJ, 21941-913, Brazil.
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13
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Yang Y, Hecht JR, Liu ST, Cohen MJ, Hart SD, Wang HL, Heaney AP. CAUTION ADVISED USING COMBINATION KETOCONAZOLE AND PD-1 INHIBITORS. AACE Clin Case Rep 2020; 6:e239-e242. [PMID: 32984529 DOI: 10.4158/accr-2020-0100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/27/2020] [Indexed: 01/14/2023] Open
Abstract
Objective Immune checkpoint inhibitors are approved to treat multiple cancers. We report life-threatening hepatic failure in 2 consecutive patients with Cushing syndrome that were treated with ketoconazole (KTZ) in combination with 2 different programmed cell death protein 1 (PD-1) inhibitors, Nivolumab and Pembrolizumab. Methods The first patient suffered from corticotroph pituitary carcinoma and the second from metastatic adrenal cortical carcinoma. They were both treated with KTZ for tumor-associated hypercortisolism. Results Hepatic function was normal on KTZ prior to initiation of PD-1 inhibitors, after which they rapidly developed severe hepatic dysfunction. In both cases, liver biopsy was consistent with drug-induced hepatic injury. Liver function fully recovered on discontinuing KTZ and the PD-1 inhibitors along with methylprednisone therapy. Conclusion Antifungal azole therapy is commonly used in oncology patients who may be co-treated with PD-1 inhibitors. Although the specific combination of KTZ and PD-1 inhibitors to treat Cushing syndrome may be relatively uncommon, we recommend careful monitoring of hepatic function using a combination PD-1 inhibitors and azole antifungal agents, especially KTZ, due to the potential of life-threatening hepatic failure.
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Affiliation(s)
- Yingying Yang
- Divisions of Endocrinology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California
| | - Joel R Hecht
- Hematology and Oncology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California
| | - Sandy Ting Liu
- Divisions of Endocrinology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California
| | - Melissa J Cohen
- Divisions of Endocrinology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California
| | - Steven D Hart
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California
| | - Anthony P Heaney
- Divisions of Endocrinology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California
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14
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Miller KC, Chintakuntlawar AV, Hilger C, Bancos I, Morris JC, Ryder M, Smith CY, Jenkins SM, Bible KC. Salvage Therapy With Multikinase Inhibitors and Immunotherapy in Advanced Adrenal Cortical Carcinoma. J Endocr Soc 2020; 4:bvaa069. [PMID: 32666013 PMCID: PMC7326479 DOI: 10.1210/jendso/bvaa069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022] Open
Abstract
Background Median overall survival is 12 to 15 months in patients with metastatic adrenal cortical carcinoma (ACC). Etoposide, doxorubicin, and cisplatin with or without the adrenolytic agent mitotane is considered the best first-line approach in this context, but has limited activity and no curative potential; additional salvage therapeutic options are needed. Methods Fifteen total patients with recurrent/metastatic ACC were treated with single-agent multikinase inhibitors (MKI) (n = 8), single-agent PD-1 inhibition (n = 8), or cytotoxic chemotherapy plus PD-1 inhibition (n = 4) at our institution as later-line systemic therapies in efforts to palliate disease and attempt to achieve a therapeutic response when not otherwise possible using standard approaches. Results Two of 8 patients (25%) treated with single-agent MKI achieved a partial response (PR), including 1 PR lasting 23.5 months. Another 3 patients (38%) had stable disease (SD); median progression-free survival (PFS) with single-agent MKI was 6.4 months (95% confidence interval [CI] 0.8—not reached). On the other hand, 2 of 12 patients (17%) treated with PD-1 inhibitors (either alone or in combination with cytotoxic chemotherapy) attained SD or better, with 1 patient (8%) achieving a PR; median PFS was 1.4 months (95% CI 0.6-2.7). Conclusions Our single-institution experience suggests that select ACC patients respond to late-line MKI or checkpoint inhibition despite resistance to cytotoxic agents. These treatments may be attractive to ACC patients with limited other therapeutic options. The use of MKI and immunotherapy in ACC warrants prospective investigation emphasizing parallel correlative studies to identify biomarkers that predict for response.
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Affiliation(s)
| | | | - Crystal Hilger
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, US
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, MN, US
| | - John C Morris
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, US.,Division of Endocrinology, Mayo Clinic, Rochester, MN, US
| | - Mabel Ryder
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, US.,Division of Endocrinology, Mayo Clinic, Rochester, MN, US
| | - Carin Y Smith
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, US
| | - Sarah M Jenkins
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, US
| | - Keith C Bible
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, US
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15
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Altieri B, Ronchi CL, Kroiss M, Fassnacht M. Next-generation therapies for adrenocortical carcinoma. Best Pract Res Clin Endocrinol Metab 2020; 34:101434. [PMID: 32622829 DOI: 10.1016/j.beem.2020.101434] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Almost one decade ago, etoposide, doxorubicin, cisplatin and mitotane (EDP-M) has been established as first-line systemic therapy of metastatic adrenocortical carcinoma (ACC). Although heterogeneous, the prognosis of advanced stage ACC is still poor and novel treatments are urgently needed. This article provides a short summary of current systemic ACC treatment and provides a comprehensive overview of new therapeutic approaches that have been investigated in the past years, including drugs targeting the IGF pathway, tyrosine kinase inhibitors, radionuclide treatment, and immunotherapy. The results of most of these trials were disappointing and we will discuss possible reasons why these drugs failed (e.g. drug interactions with mitotane, disease heterogeneity with exceptional responses in very few patients, and resistance mechanisms to immunotherapy). We then will present potential new drug targets that have emerged from many molecular studies (e.g. wnt/β-catenin, cyclin-dependent kinases, PARP1) that may be the foundation of next-generation therapies of ACC.
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Affiliation(s)
- Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany.
| | - Cristina L Ronchi
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany; Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
| | - Matthias Kroiss
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany; Comprehensive Cancer Mainfranken, University of Würzburg, Würzburg, Germany; Central Laboratory, University Hospital Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany; Comprehensive Cancer Mainfranken, University of Würzburg, Würzburg, Germany; Central Laboratory, University Hospital Würzburg, Würzburg, Germany
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16
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Advanced Adrenocortical Carcinoma (ACC): a Review with Focus on Second-Line Therapies. Discov Oncol 2020; 11:155-169. [PMID: 32303972 DOI: 10.1007/s12672-020-00385-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/01/2020] [Indexed: 02/07/2023] Open
Abstract
Advanced adrenocortical cancer (ACC) is a rare, highly aggressive malignancy, which typically has a poor prognosis. In advanced ACC, the overall trend is toward a short PFS interval following first-line systemic therapy, highlighting a clear need for improved second-/third-line treatment strategies. We conducted a review of the literature and relevant scientific guidelines related to systemic therapy for advanced ACC. Public indexes including PubMed/MEDLINE were searched. Treatment selection in the second-line setting is based on small phase 2 trials, case reports, and pre-clinical evidence. The best data available for initial second-line therapy selection supports the use of gemcitabine and capecitabine (G + C) or streptozotocin (S), both with or without mitotane. G + C is becoming increasingly recommended based on phase 2 clinical trial data in patients of good PS, due to the inferred superior PFS and OS from non-comparative trials. Alternatively, streptozotocin was better tolerated than EDP + M in the FIRM-ACT study and remains an option when warranted. Beyond this, further treatment approaches should be tailored to individual patient characteristics, utilizing a mixture of systemic therapies, local therapies, and enrolment in clinical trials where available. Additionally, the role of molecular stratification, predictive biomarkers, and immune checkpoint inhibitors in specific individuals, such as Lynch syndrome, is evolving and may become increasingly utilized in clinical practice. Advanced ACC necessitates a multidisciplinary approach and is best managed in a specialist center. Although there is no one definitive second-line treatment strategy, there are some favorable approaches, which require further validation in larger clinical trials.
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17
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Lang J, Capasso A, Jordan KR, French JD, Kar A, Bagby SM, Barbee J, Yacob BW, Head LS, Tompkins KD, Freed BM, Somerset H, Clark TJ, Pitts TM, Messersmith WA, Eckhardt SG, Wierman ME, Leong S, Kiseljak-Vassiliades K. Development of an Adrenocortical Cancer Humanized Mouse Model to Characterize Anti-PD1 Effects on Tumor Microenvironment. J Clin Endocrinol Metab 2020; 105:5568436. [PMID: 31513709 PMCID: PMC7947837 DOI: 10.1210/clinem/dgz014] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/28/2019] [Accepted: 09/05/2019] [Indexed: 01/11/2023]
Abstract
CONTEXT Although the development of immune checkpoint inhibitors has transformed treatment strategies of several human malignancies, research models to study immunotherapy in adrenocortical carcinoma (ACC) are lacking. OBJECTIVE To explore the effect of anti-PD1 immunotherapy on the alteration of the immune milieu in ACC in a newly generated preclinical model and correlate with the response of the matched patient. DESIGN, SETTING, AND INTERVENTION To characterize the CU-ACC2-M2B patient-derived xenograft in a humanized mouse model, evaluate the effect of a PD-1 inhibitor therapy, and compare it with the CU-ACC2 patient with metastatic disease. RESULTS Characterization of the CU-ACC2-humanized cord blood-BALB/c-Rag2nullIl2rγnullSirpaNOD model confirmed ACC origin and match with the original human tumor. Treatment of the mice with pembrolizumab demonstrated significant tumor growth inhibition (60%) compared with controls, which correlated with increased tumor infiltrating lymphocyte activity, with an increase of human CD8+ T cells (P < 0.05), HLA-DR+ T cells (P < 0.05) as well as Granzyme B+ CD8+ T cells (<0.001). In parallel, treatment of the CU-ACC2 patient, who had progressive disease, demonstrated a partial response with 79% to 100% reduction in the size of target lesions, and no new sites of metastasis. Pretreatment analysis of the patient's metastatic liver lesion demonstrated abundant intratumoral CD8+ T cells by immunohistochemistry. CONCLUSIONS Our study reports the first humanized ACC patient-derived xenograft mouse model, which may be useful to define mechanisms and biomarkers of response and resistance to immune-based therapies, to ultimately provide more personalized care for patients with ACC.
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Affiliation(s)
- Julie Lang
- Department of Immunology & Microbiology, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Anna Capasso
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kimberly R Jordan
- Department of Immunology & Microbiology, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jena D French
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Adwitiya Kar
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Stacey M Bagby
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jacob Barbee
- Department of Immunology & Microbiology, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Betelehem W Yacob
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lia S Head
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kenneth D Tompkins
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brian M Freed
- Department of Immunology & Microbiology, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Hilary Somerset
- Department of Pathology, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Toshimasa J Clark
- Department of Radiology, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Todd M Pitts
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Wells A Messersmith
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - S Gail Eckhardt
- Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Margaret E Wierman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
- Research Service Veterans Affairs Medical Center, Denver, Colorado
| | - Stephen Leong
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Katja Kiseljak-Vassiliades
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus, Aurora, Colorado
- Research Service Veterans Affairs Medical Center, Denver, Colorado
- Correspondence and Reprint Requests: Katja Kiseljak-Vassiliades, DO, Endocrinology MS8106, University of Colorado School of Medicine, 12801 East 17th Ave, RC1 South, Aurora, CO 80045. E-mail:
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18
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Head L, Kiseljak-Vassiliades K, Clark TJ, Somerset H, King J, Raeburn C, Albuja-Cruz M, Weyant M, Cleveland J, Wierman ME, Leong S. Response to Immunotherapy in Combination With Mitotane in Patients With Metastatic Adrenocortical Cancer. J Endocr Soc 2019; 3:2295-2304. [PMID: 31745526 PMCID: PMC6853671 DOI: 10.1210/js.2019-00305] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/07/2019] [Indexed: 12/28/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare orphan disease with a dismal prognosis. Surgery remains the first-line treatment, but most patients eventually develop metastatic disease. Mitotane is often used with chemotherapy with modest success. Little information is available concerning the efficacy of immunotherapy in combination with mitotane. We conducted a retrospective review of our initial six patients with metastatic ACC, for whom mitotane alone or with chemotherapy failed, and who were subsequently treated with a combination of pembrolizumab and mitotane, between July 2016 and March 2019. Imaging was analyzed per Response Evaluation Criteria in Solid Tumours 1.1 criteria. Two patients had a partial response and four patients had stable disease (8 to 19 months). One patient had grade 3 hepatitis and pembrolizumab was discontinued after 8 months. She died with disease progression 16 months after initiating pembrolizumab. One patient developed brain metastasis after 19 months of treatment and was transitioned to hospice. One patient had focal pneumonitis after 18 months of treatment, and pembrolizumab was discontinued. Three remaining patients continue pembrolizumab plus mitotane at the time of this writing. The current standard of care for ACC is a combination of etoposide, doxorubicin, cisplatin, and mitotane with an overall survival of 14.8 months. All six patients lived for at least 16 months after starting pembrolizumab added to mitotane therapy. The therapy appeared to be effective in both microsatellite instability-high and microsatellite stable tumors, suggesting some synergistic effect with mitotane. Combined immunotherapy and mitotane should be considered in future clinical trials in patients with ACC.
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Affiliation(s)
- Lia Head
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora Colorado
| | - Katja Kiseljak-Vassiliades
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora Colorado.,Research Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Toshimasa J Clark
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora Colorado
| | - Hilary Somerset
- Department of Pathology; University of Colorado Anschutz Medical Campus, Aurora Colorado
| | - Jonathan King
- Grand Valley Medical Oncology, Grand Junction, Colorado
| | - Christopher Raeburn
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Maria Albuja-Cruz
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Michael Weyant
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Joseph Cleveland
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Margaret E Wierman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora Colorado.,Research Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Stephen Leong
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora Colorado
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Habra MA, Stephen B, Campbell M, Hess K, Tapia C, Xu M, Rodon Ahnert J, Jimenez C, Lee JE, Perrier ND, Boraddus RR, Pant S, Subbiah V, Hong DS, Zarifa A, Fu S, Karp DD, Meric-Bernstam F, Naing A. Phase II clinical trial of pembrolizumab efficacy and safety in advanced adrenocortical carcinoma. J Immunother Cancer 2019; 7:253. [PMID: 31533818 PMCID: PMC6751592 DOI: 10.1186/s40425-019-0722-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/28/2019] [Indexed: 12/13/2022] Open
Abstract
Background Adrenocortical carcinoma (ACC) is a rare malignancy without good treatment options. There are limited data about the use of immunotherapy in ACC. We investigated the efficacy and safety of pembrolizumab in patients with metastatic ACC. Methods This is a pre-specified cohort of a single-center, investigator-initiated, phase II clinical trial using pembrolizumab monotherapy in patients with rare malignancies. Patients must have had prior treatment fail in the past 6 months before study enrollment. Patients were enrolled from August 2016 to October 2018. Follow-up data were updated as of March 26, 2019. Patients received 200 mg pembrolizumab intravenously every 3 weeks without concomitant oncologic therapy. The primary endpoint was non-progression rate (NPR) at 27 weeks. Other endpoints included adverse events, tumor responses measured independently by objective radiologic criteria, and select immunological markers. Results Sixteen patients with ACC (including eight women [50%]) were included in this cohort. Ten patients (63%) had evidence of hormonal overproduction (seven had cortisol-producing ACC). Non-progression rate at 27 weeks was evaluable in 14 patients, one patient was lost to follow-up, and one patient left the study because of an adverse event. Five of 14 patients were alive and progression-free at 27 weeks (non-progression rate at 27 weeks was 36, 95% confidence interval 13–65%). Of the 14 patients evaluable for imaging response by immune-related Response Evaluation Criteria in Solid Tumors, two had a partial response (including one with cortisol-producing ACC), seven had stable disease (including three with cortisol-producing ACC), and five had progressive disease, representing an objective response rate of 14% (95% confidence interval 2–43%). Of those who had stable disease, six had disease stabilization that lasted ≥4 months. Severe treatment-related adverse events (≥grade 3) were seen in 2 of 16 patients (13%) and resulted in one patient discontinuing study participation. All studied tumor specimens (14/14) were negative for programmed cell death ligand-1 expression. Thirteen of 14 tumor specimens (93%) were microsatellite-stable. Eight of 14 patients (57%) had a high tumor-infiltrating lymphocyte score on immunohistochemistry staining. Conclusions Single-agent pembrolizumab has modest efficacy as a salvage therapy in ACC regardless of the tumor’s hormonal function, microsatellite instability status, or programmed cell death ligand-1 status. Treatment was well tolerated in most study participants, with a low rate of severe adverse events. Trial registration ClinicalTrials.gov identifier: NCT02721732, Registered March 29, 2016.
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Affiliation(s)
- Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, Unit 1461, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
| | - Bettzy Stephen
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Matthew Campbell
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Kenneth Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Coya Tapia
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.,Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Mingxuan Xu
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Jordi Rodon Ahnert
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, Unit 1461, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Nancy D Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Russell R Boraddus
- Department of Pathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Shubham Pant
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Vivek Subbiah
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - David S Hong
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Abdulrazzak Zarifa
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Siqing Fu
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Daniel D Karp
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Aung Naing
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
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20
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Abstract
Adrenocortical carcinoma (ACC) is a rare, aggressive, and frequently deadly cancer. Up to 75% of all patients will eventually develop metastatic disease, and our current medical therapies for ACC provide limited - if any - survival benefit. These statistics highlight a crucial need for novel approaches. Recent studies performing comprehensive molecular profiling on ACC have illuminated that ACC is comprised of three clinically distinct molecular subtypes, bearing differential regulation of cell cycle, epigenetics, Wnt/β-catenin signaling, PKA signaling, steroidogenesis and immune cell biology. Furthermore, these studies have spurred the development of molecular subtype-based biomarkers, contextualized outcomes of recent clinical trials, and advanced our understanding of the underlying biology of adrenocortical homeostasis and cancer. In this review, we describe these findings and their implications for new strategies to apply targeted therapies to ACC.
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