1
|
Robertson IJ, Gregory TA, Waguespack SG, Penas-Prado M, Majd NK. Recent Therapeutic Advances in Pituitary Carcinoma. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2023; 6:74-83. [PMID: 37214211 PMCID: PMC10195013 DOI: 10.36401/jipo-22-25] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 05/24/2023]
Abstract
Pituitary carcinoma (PC) is a rare, aggressive malignancy that comprises 0.1-0.2% of all pituitary tumors. PC is defined anatomically as a pituitary tumor that metastasizes outside the primary intrasellar location as noncontiguous lesions in the central nervous system or as metastases to other organs. Similar to pituitary adenoma, PC originates from various cell types of the pituitary gland and can be functioning or nonfunctioning, with the former constituting the majority of the cases. Compression of intricate skull-based structures, excessive hormonal secretion, impaired pituitary function from therapy, and systemic metastases lead to debilitating symptoms and a poor survival outcome in most cases. PC frequently recurs despite multimodality treatments, including surgical resection, radiotherapy, and biochemical and cytotoxic treatments. There is an unmet need to better understand the pathogenesis and molecular characterization of PC to improve therapeutic strategies. As our understanding of the role of signaling pathways in the tumorigenesis of and malignant transformation of PC evolves, efforts have focused on targeted therapy. In addition, recent advances in the use of immune checkpoint inhibitors to treat various solid cancers have led to an interest in exploring the role of immunotherapy for the treatment of aggressive refractory pituitary tumors. Here, we review our current understanding of the pathogenesis, molecular characterization, and treatment of PC. Particular attention is given to emerging treatment options, including targeted therapy, immunotherapy, and peptide receptor radionuclide therapy.
Collapse
Affiliation(s)
- Ian J. Robertson
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Timothy A. Gregory
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven G. Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marta Penas-Prado
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Nazanin K. Majd
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
2
|
Geer EB. Medical therapy for refractory pituitary adenomas. Pituitary 2023:10.1007/s11102-023-01320-9. [PMID: 37115295 DOI: 10.1007/s11102-023-01320-9] [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] [Accepted: 04/11/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Refractory pituitary adenomas are those that have progressed following standard of care treatments. Medical therapy options for these challenging tumors are limited. PURPOSE To review the landscape of tumor directed medical therapies and off-label investigational approaches for refractory pituitary adenomas. METHODS Literature on medical therapies for refractory adenomas was reviewed. RESULTS The established first-line medical therapy for refractory adenomas is temozolomide, which importantly may increase survival, but clinical trial data are still needed to clearly establish its efficacy, identify biomarkers of response, and clarify eligibility and outcome criteria. Other therapies for refractory tumors have only been described in case reports and small case series. CONCLUSION There are currently no approved non-endocrine medical therapies for refractory pituitary tumors. There is an urgent need for identifying effective medical therapies and studying them in multi-center clinical trials.
Collapse
Affiliation(s)
- Eliza B Geer
- Departments of Medicine and Neurosurgery, Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, David H. Koch Center for Cancer Care, 530 East 74th Street, Box 19, New York, NY, 10021, USA.
| |
Collapse
|
3
|
Adrenal Gland Irradiation Causes Fatigue Accompanied by Reactive Changes in Cortisol Levels. J Clin Med 2022; 11:jcm11051214. [PMID: 35268304 PMCID: PMC8911448 DOI: 10.3390/jcm11051214] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Incidental radiotherapy (RT) to the adrenal gland may have systemic effects. This study aimed to investigate the effects of adrenal RT on fatigue. METHODS BALB/c mice were surgically explored to identify the left adrenal gland and delivered intra-operative RT. The swimming endurance test was used for endurance assessment to represent fatigue. Plasma levels of stress hormones and histopathological features were examined. Three patients with inevitable RT to the adrenal gland were enrolled for the preliminary study. Serum levels of cortisol, aldosterone, and adrenocorticotropic hormone (ACTH) were measured before and after RT. Fatigue score by using the fatigue severity scale and RT dosimetric parameters were collected. RESULTS In the experimental mouse model, adrenal RT decreased baseline cortisol from 274.6 ± 37.8 to 193.6 ± 29.4 ng/mL (p = 0.007) and swimming endurance time from 3.7 ± 0.3 to 1.7 ± 0.6 min (p = 0.02). In histopathological assessment, the irradiated adrenal glands showed RT injury features in the adrenal cortex. In the enrolled patients, baseline cortisol significantly declined after RT. There were no significant differences in the levels of morning cortisol, aldosterone, and ACTH before and after RT. CONCLUSIONS The RT dose distributed to the adrenal gland may correlate with unwanted adverse effects, including fatigue and adrenal hormone alterations.
Collapse
|
4
|
Orr M, Findling J, Zwagerman N, Connelly J, Albano K, Bovi J. Adrenocorticotropic Hormone Secreting Pituitary Carcinoma: Rare, Durable Response to Concurrent Chemotherapy and Reirradiation With a Review of the Literature. Adv Radiat Oncol 2021; 7:100813. [PMID: 34849427 PMCID: PMC8608604 DOI: 10.1016/j.adro.2021.100813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/12/2021] [Accepted: 09/08/2021] [Indexed: 11/20/2022] Open
|
5
|
Lin AL, Donoghue MTA, Wardlaw SL, Yang TJ, Bodei L, Tabar V, Geer EB. Approach to the Treatment of a Patient with an Aggressive Pituitary Tumor. J Clin Endocrinol Metab 2020; 105:5905925. [PMID: 32930787 PMCID: PMC7566322 DOI: 10.1210/clinem/dgaa649] [Citation(s) in RCA: 12] [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: 04/22/2020] [Accepted: 09/11/2020] [Indexed: 12/21/2022]
Abstract
A small subset of pituitary adenomas grows despite maximal treatment with standard therapies; namely, surgery and radiotherapy. These aggressive tumors demonstrate 2 patterns of growth: they may be locally aggressive or metastasize distantly, either hematogenously or through the spinal fluid. Further surgery and radiotherapy may be helpful for palliation of symptoms, but they are rarely definitive in the management of these malignant tumors. The only chemotherapy with established activity in the treatment of pituitary tumors is the alkylating agent temozolomide. At most, 50% of patients exhibit an objective response to temozolomide and the median time to progression is short; thus, there remains a significant unmet need for effective treatments within this patient population. Several targeted agents have reported activity in this tumor type-including small molecule inhibitors, checkpoint inhibitors, and other biologics-but remain investigational at this time.
Collapse
Affiliation(s)
- Andrew L Lin
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Multidisciplinary Pituitary and Skull Base Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Correspondence and Reprint Requests: Andrew Lin, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA. E-mail:
| | - Mark T A Donoghue
- Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sharon L Wardlaw
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - T Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa Bodei
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Multidisciplinary Pituitary and Skull Base Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Program in Cell Biology and Genetics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eliza B Geer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Multidisciplinary Pituitary and Skull Base Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
6
|
Yoo F, Kuan EC, Heaney AP, Bergsneider M, Wang MB. Corticotrophic pituitary carcinoma with cervical metastases: case series and literature review. Pituitary 2018; 21:290-301. [PMID: 29404894 DOI: 10.1007/s11102-018-0872-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Pituitary tumors are the second most common intracranial tumors, however, pituitary carcinoma is a rare clinical entity which represents only 0.1-0.2% of all pituitary tumors. Diagnosis of pituitary carcinoma requires the presence of metastasis. Early identification of pituitary carcinoma is difficult, and only recently have guidelines been published for the treatment of aggressive pituitary tumors. We present two cases from our institution, with a review of other cases available in literature in order to better characterize this rare disease. METHODS A retrospective review of two patients with pituitary carcinoma treated at a tertiary medical center was performed. The MEDLINE database was searched for all cases of pituitary carcinoma. Information for age at diagnosis, sex, pituitary tumor type, latency period from pituitary tumor to presentation of carcinoma, sites of metastasis, number of surgical therapies, radiation and chemotherapy, and survival after diagnosis were collected. RESULTS A total of 69 studies were available for review for a total of 72 unique cases. The average age at diagnosis was 46.3 years. The most common tumors were ACTH-secreting (34.7%), Prolactin-secreting (23.6%), and Null Cell (15.3%). The average latency period from pituitary tumor diagnosis to metastasis was 9 years. All patients underwent surgical therapy during their treatment, with an average of 2.76 procedures. The mortality rate was 54.8% with average time to death after diagnosis of approximately 10 months. CONCLUSIONS Pituitary carcinoma is a rare disease with high mortality rate and is a diagnostic and treatment challenge. Further study is required but is difficult due to its low incidence.
Collapse
Affiliation(s)
- Frederick Yoo
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave. 62-132 CHS, Los Angeles, CA, 90095-1624, USA.
| | - Edward C Kuan
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave. 62-132 CHS, Los Angeles, CA, 90095-1624, USA
| | - Anthony P Heaney
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, USA
- Department of Medicine, Division of Endocrinology, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Marvin Bergsneider
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Marilene B Wang
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave. 62-132 CHS, Los Angeles, CA, 90095-1624, USA
| |
Collapse
|
7
|
Lin AL, Sum MW, DeAngelis LM. Is there a role for early chemotherapy in the management of pituitary adenomas? Neuro Oncol 2016; 18:1350-6. [PMID: 27106409 DOI: 10.1093/neuonc/now059] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/16/2016] [Indexed: 12/25/2022] Open
Abstract
Pituitary adenomas are benign intracranial neoplasms that are frequently well-controlled with standard treatments that include surgical resection, radiotherapy, and agents that modulate hormonal excess. Unfortunately, a subset of patients remains uncontrolled or develops complications from these interventions. For these patients, chemotherapy is an additional treatment option that could improve outcomes. Temozolomide is an oral chemotherapy with a favorable side-effect profile that has shown activity against pituitary adenomas. Its non-overlapping toxicity and ability to induce rapid tumor regression renders it a potentially important adjunctive treatment. In patients with tumors that cannot be optimally addressed with standard treatments, there may be a role for early initiation of temozolomide.
Collapse
Affiliation(s)
- Andrew L Lin
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.L.L., L.M.D.A.)
| | - Melissa W Sum
- Division of Endocrinology, Columbia University Medical Center, New York, New York (M.W.S.)
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.L.L., L.M.D.A.)
| |
Collapse
|
8
|
Bruno OD, Juárez-Allen L, Christiansen SB, Manavela M, Danilowicz K, Vigovich C, Gómez RM. Temozolomide Therapy for Aggressive Pituitary Tumors: Results in a Small Series of Patients from Argentina. Int J Endocrinol 2015; 2015:587893. [PMID: 26106414 PMCID: PMC4461777 DOI: 10.1155/2015/587893] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/06/2015] [Accepted: 05/06/2015] [Indexed: 02/01/2023] Open
Abstract
We evaluated results of temozolomide (TMZ) therapy in six patients, aged 34-78 years, presenting aggressive pituitary tumors. In all the patients tested O(6)-methylguanine-DNA methyltransferase (MGMT) immunoexpression in surgical specimens was absent. Patients received temozolomide 140-320 mg/day for 5 days monthly for at least 3 months. In two patients minimum time for evaluation could not be reached because of death in a 76-year-old man with a malignant prolactinoma and of severe neutro-thrombopenia in a 47-year-old woman with nonfunctioning pituitary adenoma. In two patients (a 34-year-old acromegalic woman and a 39-year-old woman with Nelson's syndrome) no response was observed after 4 and 6 months, respectively, and the treatment was stopped. Conversely, two 52- and 42-year-old women with Cushing's disease had long-term total clinical and radiological remissions which persisted after stopping temozolomide. We conclude that TMZ therapy may be of variable efficacy depending on-until now-incompletely understood factors. Cooperative work on a greater number of cases of aggressive pituitary tumors should be crucial to establish the indications, doses, and duration of temozolomide administration.
Collapse
Affiliation(s)
- Oscar D. Bruno
- Foundation of Endocrinology, 1425 Buenos Aires, Argentina
- *Oscar D. Bruno:
| | | | | | - Marcos Manavela
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, 1120 Buenos Aires, Argentina
| | - Karina Danilowicz
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, 1120 Buenos Aires, Argentina
| | - Carlos Vigovich
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, 1120 Buenos Aires, Argentina
| | - Reynaldo M. Gómez
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, 1120 Buenos Aires, Argentina
| |
Collapse
|
9
|
Fleseriu M, Findling JW, Koch CA, Schlaffer SM, Buchfelder M, Gross C. Changes in plasma ACTH levels and corticotroph tumor size in patients with Cushing's disease during long-term treatment with the glucocorticoid receptor antagonist mifepristone. J Clin Endocrinol Metab 2014; 99:3718-27. [PMID: 25013998 PMCID: PMC4399272 DOI: 10.1210/jc.2014-1843] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
CONTEXT Pituitary effects of long-term therapy with mifepristone, a glucocorticoid receptor antagonist, in Cushing's disease (CD) patients are not well understood. OBJECTIVE Our objective was to report changes in ACTH and pituitary magnetic resonance imaging (MRI) findings during long-term use of mifepristone in CD patients. DESIGN AND SETTING The Study of the Efficacy and Safety of Mifepristone in the Treatment of Endogenous Cushing's Syndrome (SEISMIC) was a 24-week, open-label study of mifepristone, and its long-term extension (LTE) is a multicenter U.S. study. PATIENTS Forty-three CD patients (mean age 45.3 years) were enrolled in SEISMIC with 27 continuing into the LTE study. INTERVENTIONS Mifepristone (300-1200 mg) was administered once daily. MAIN OUTCOME MEASURES ACTH and pituitary MRI were assessed at baseline and at regular intervals during treatment. RESULTS A ≥2-fold increase in ACTH was observed in 72% of patients treated for a median duration of 11.3 months. The mean peak increase in ACTH was 2.76 ± 1.65-fold during SEISMIC, and mean ACTH concentrations remained stable during the LTE. ACTH was directly correlated with mifepristone dose and declined to near baseline levels after mifepristone discontinuation. Tumor regressed in 2 patients and progressed in 3 patients with macroadenomas. An additional microadenoma was identified after 25 months of treatment after a baseline tumor-negative MRI. CONCLUSIONS In the largest prospective study to date, long-term mifepristone treatment increased ACTH in approximately two-thirds of patients with CD. ACTH elevations were observed within the first few weeks of treatment, were dose-dependent, and generally remained stable over time. Corticotroph tumor progression and regression may occur over time, but patients may have significant increases in ACTH levels without evidence of tumor growth.
Collapse
Affiliation(s)
- Maria Fleseriu
- Oregon Health & Science University (M.F.), Portland, Oregon 97239; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53051; University of Mississippi Medical Center (C.A.K.), Jackson, Mississippi 39216; University of Erlangen-Nürnberg (S.-M.S., M.B.), 91054 Erlangen, Germany; and Corcept Therapeutics (C.G.), Menlo Park, California 94025
| | | | | | | | | | | |
Collapse
|