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Abstract
OPINION STATEMENT Radioiodine refractory differentiated thyroid cancer (RAI-R DTC) is a challenging malignancy with limited prognosis and treatment options. Recently, clinical trials with targeted therapies have advanced the outlook of these patients, and inhibition of the vascular endothelial growth factor (VEGF) axis has led to the approval of small-molecule tyrosine kinase inhibitors (TKIs) for first-line treatment of radioiodine refractory disease. In addition to approved therapies (sorafenib and lenvatinib), other multi-targeted tyrosine kinase inhibitors that are commercially available have been recognized as viable treatment options for RAI-R DTC. Our preference is to initially use lenvatinib, given the dramatic progression-free survival (PFS) improvement versus placebo, with the caveat that 24 mg daily is not often tolerated and lower doses often used. In patients with BRAF V600E mutation, BRAF inhibitors are now considered for treatment, especially if patients are at high risk from antiangiogenic therapy. Research is continuing to evolve in identifying mechanisms related to radioiodine refractoriness, and trials are evaluating therapeutic molecules to overcome this resistance. Clinical care of patients with RAI-R DTC requires careful consideration of both patient and disease characteristics. Many patients with asymptomatic and indolent disease can be followed for years without treatment while others with high volume or rapidly progressive disease merit early intervention.
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Rajhbeharrysingh U, Taylor M, Milas M. Medical therapy for advanced forms of thyroid cancer. Surg Clin North Am 2014; 94:541-71. [PMID: 24857576 DOI: 10.1016/j.suc.2014.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
More options than ever before are currently available for medical therapy in patients who present with advanced thyroid cancer or develop surgically unresectable recurrences or symptomatic or progressive disease. The newer medical therapies have addressed the need to find effective therapies beyond the conventional treatment with radioactive iodine, thyroid stimulating hormone suppression, and palliative cytotoxic chemotherapy for patients with advanced thyroid cancer. Although tumor responses to these medical therapies vary by type of thyroid cancer and type of therapy selected, they remain encouraging and provide therapeutic options for selected patients while new drugs are in development.
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Affiliation(s)
- Uma Rajhbeharrysingh
- Department of Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Matthew Taylor
- Division of Hematology & Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Mira Milas
- Department of Surgery, Knight Cancer Institute, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, L619, Portland, OR 97239, USA.
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An update on molecular biology of thyroid cancers. Crit Rev Oncol Hematol 2014; 90:233-52. [DOI: 10.1016/j.critrevonc.2013.12.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 10/27/2013] [Accepted: 12/06/2013] [Indexed: 12/31/2022] Open
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Sherman EJ, Su YB, Lyall A, Schöder H, Fury MG, Ghossein RA, Haque S, Lisa D, Shaha AR, Tuttle RM, Pfister DG. Evaluation of romidepsin for clinical activity and radioactive iodine reuptake in radioactive iodine-refractory thyroid carcinoma. Thyroid 2013. [PMID: 23186033 PMCID: PMC3643228 DOI: 10.1089/thy.2012.0393] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Historically, systemic therapy for radioactive iodine (RAI)-refractory thyroid cancer has been understudied. Available drugs have modest efficacy. Romidepsin is a histone deacetylase inhibitor with potent antitumor effects both in vitro and in vivo. In thyroid cancer cell lines, romidepsin increases expression of both thyroglobulin and the sodium iodide symporter messenger RNAs, suggesting the possibility of improved iodine concentrating ability of RAI-resistant tumors. METHODS This was a single-institution Simon 2-stage phase II clinical study. Eligible patients had progressive, RAI-refractory, recurrent/metastatic, nonmedullary, nonanaplastic thyroid cancer. Response Evaluation Criteria in Solid Tumors (RECIST) 1.0 measurable disease and adequate organ/marrow function were required. Romidepsin 13 mg/m² was administered intravenously on days 1, 8, and 15, in cycles of 28 days. The primary endpoint was the response rate by RECIST; change in RAI avidity was a secondary endpoint. The study closed after the first stage due to the lack of response. RESULTS Twenty patients were enrolled: female, 50%; median age, 64 years; histology, 8 papillary/1 follicular/11 Hürthle. Grade 4-5 adverse events (AEs) possibly related to the drug: grade 5, 1 sudden death; grade 4, 1 pulmonary embolus. Twelve of 20 subjects had a reported adverse event. No RECIST major responses have been seen. Response per protocol: stable disease, 13; disease progression, 7. Restoration of RAI avidity was documented in two patients. Median overall survival and time on study was 33.2 (1-71+) and 1.7 (0.46-12) months, respectively. CONCLUSIONS We observed preliminary signs of in vivo reversal of RAI resistance after treatment with romidepsin. However, no major responses were observed and accrual was poor after the grade 5 AE.
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Affiliation(s)
- Eric J Sherman
- Department of Medicine, Memorial Sloan-Kettering Cancer Center , New York, NY 10065, USA.
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Kojic KL, Kojic SL, Wiseman SM. Differentiated thyroid cancers: a comprehensive review of novel targeted therapies. Expert Rev Anticancer Ther 2012; 12:345-57. [PMID: 22369326 DOI: 10.1586/era.12.8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Differentiated thyroid carcinoma (DTC) accounts for more than 90% of new thyroid cancer diagnoses, and includes papillary, follicular and Hürthle cell carcinoma. The prognosis for the vast majority of individuals diagnosed with DTC is excellent, with current treatment that includes surgery, radioactive iodine ablation and postoperative thyroid-stimulating hormone suppression. Unfortunately, the small proportion of individuals who develop radioactive iodine-resistant recurrent disease have few treatment options, and the vast majority will eventually die from their disease. Recently, several novel targets for anticancer agents have been identified and offer new hope for thyroid cancer patients diagnosed with progressive disease. In addition to targeting genes commonly altered in thyroid cancer, which include mutations in BRAF, RAS and RET, proangiogenic growth factor receptors and the sodium-iodide symporter have also been targeted. Several clinical trials evaluating tyrosine kinase and angiogenesis inhibitors for treatment of individuals diagnosed with metastatic or treatment-refractory DTC are currently underway. The objective of this review is to evaluate recent clinical trials that have studied novel targeted drugs for treatment of DTC.
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Affiliation(s)
- Katarina L Kojic
- St Paul's Hospital, Department of Surgery, University of British Columbia, C303-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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Terracciano S, Chini MG, Riccio R, Bruno I, Bifulco G. Design, Synthesis, and Biological Activity of Hydroxamic Tertiary Amines as Histone Deacetylase Inhibitors. ChemMedChem 2012; 7:694-702. [DOI: 10.1002/cmdc.201100531] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 12/22/2011] [Indexed: 12/29/2022]
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Kapiteijn E, Schneider TC, Morreau H, Gelderblom H, Nortier JWR, Smit JWA. New treatment modalities in advanced thyroid cancer. Ann Oncol 2012; 23:10-18. [PMID: 21471561 DOI: 10.1093/annonc/mdr117] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Thyroid cancer is a heterogeneous disease that is classified into differentiated thyroid carcinoma (DTC), undifferentiated/anaplastic thyroid carcinoma (ATC) and medullary thyroid carcinoma. Results of conventional treatment modalities in advanced thyroid cancer have been disappointing and therefore, new therapies are needed. METHODS We searched PubMed, The Cochrane Library, Medline and EMBASE databases and abstracts published in annual proceedings for new treatment modalities in advanced thyroid cancer. We also searched for ongoing trials in www.clinicaltrials.gov. RESULTS Six phase I, 17 phase II and 1 phase III trials with tyrosine kinase inhibitors were carried out. We found 2 pilot studies and 11 phase II trials with redifferentiation therapies, mainly in DTC. For antiproliferative approaches, three phase I and four phase II trials were found. Immunomodulatory gene therapy was tested in a pilot study in ATC patients. Two phase II trials were carried out with immunotherapy. One phase I and nine phase II trials were found with radionucleotide therapy in patients with DTC. CONCLUSION The developments in the treatment of advanced thyroid cancer are intriguing. Future trials should aim at combinations of targeted agents with or without other treatment modalities, and will hopefully contribute to further improvement of outcomes.
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Affiliation(s)
| | | | | | | | | | - J W A Smit
- Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands
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8
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Abstract
PURPOSE OF REVIEW Thyroid cancer incidence has significantly increased and the majority of cases are represented by differentiated thyroid carcinomas that are characterized by a very good prognosis. Nevertheless, after initial treatment up to 15% of patients present disease persistence or relapse and those with locally advanced or metastasized cancers that do not respond to established therapies ultimately risk death. This scenario has started to change following the development of molecular targeted therapies. This review will focus on the principles behind the use of these novel therapies and on the results of the most recent clinical trials with tyrosine kinase inhibitors (TKIs) and other targeted therapies in thyroid cancer. RECENT FINDINGS An understanding of the molecular events involved in cancer formation has prompted the development of numerous drugs that target key molecules implicated in angiogenesis and in the maintenance of the malignant phenotype of cancer cells. The results of several phase I and phase II studies and one phase III trial testing the efficacy of these drugs in advanced thyroid cancer are now available. SUMMARY Among the tested drugs, the TKIs sorafenib for differentiated thyroid carcinoma and vandetanib and XL184 for medullary thyroid carcinoma appear very effective and have reached phase III clinical trials. Second-generation TKIs and selective kinase inhibitors are showing even more promising profiles. Improved knowledge of the targets of the different drugs, combined with molecular profiling of the tumors to treat, will allow a tailored pharmacogenomic approach.
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Biermann K, Biersack HJ, Sabet A, Janzen V. Alternative Therapeutic Approaches in the Treatment of Primary and Secondary Dedifferentiated and Medullary Thyroid Carcinoma. Semin Nucl Med 2011; 41:139-48. [DOI: 10.1053/j.semnuclmed.2010.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wiedenmann B, Pavel M, Kos-Kudla B. From targets to treatments: a review of molecular targets in pancreatic neuroendocrine tumors. Neuroendocrinology 2011; 94:177-90. [PMID: 21893937 DOI: 10.1159/000329386] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 05/15/2011] [Indexed: 12/30/2022]
Abstract
Pancreatic neuroendocrine tumors (pancreatic NET) are relatively rare, slowly growing tumors, although their incidence is increasing, and patients may survive for several years with metastatic disease. Apart from symptomatic relief, there have been few treatment options for these tumors in the past. More recently, investigators have explored the potential of molecularly targeted agents in treating pancreatic NET, with some success. In this review, we consider the data supporting exploitation of different targets in pancreatic NET, including peptide receptors, receptor tyrosine kinases (involved in tumor angiogenesis and more directly supporting tumor growth), and intracellular targets, such as the mammalian target of rapamycin (mTOR), which has a central role in regulating cell growth, metabolism, and apoptosis. Probably due to the paucity of pancreatic NET, many clinical trials to date have included heterogeneous NET populations, and there are few randomized studies of this specific patient population. Very recently, promising results have been achieved in placebo-controlled, phase III trials with the multitargeted tyrosine kinase inhibitor, sunitinib, and the mTOR inhibitor, everolimus. These agents have been approved or are currently being reviewed by authorities for use in patients with pancreatic NET. Here we review potential molecular targets in pancreatic NET and summarize the available data for targeted agents from phase II and III trials open to patients with this tumor.
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Affiliation(s)
- Bertram Wiedenmann
- Department of Hepatology, Gastroenterology and Endocrinology, Charité Medical School, Berlin, Germany.
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11
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Sherman SI. Targeted therapy of thyroid cancer. Biochem Pharmacol 2010; 80:592-601. [PMID: 20471374 DOI: 10.1016/j.bcp.2010.05.003] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 05/05/2010] [Accepted: 05/06/2010] [Indexed: 11/27/2022]
Abstract
Systemic chemotherapies for advanced or metastatic thyroid carcinomas have been of only limited effectiveness. For patients with differentiated or medullary carcinomas unresponsive to conventional treatments, novel therapies are needed to improve disease outcomes. Multiple novel therapies primarily targeting angiogenesis have entered clinical trials for metastatic thyroid carcinoma. Partial response rates up to 30% have been reported in single agent studies, but prolonged disease stabilization is more commonly seen. The most successful agents target the vascular endothelial growth factor receptors, with potential targets including the mutant kinases associated with papillary and medullary oncogenesis. Two drugs approved for other malignancies, sorafenib and sunitinib, have had promising preliminary results reported, and are being used selectively for patients who do not qualify for clinical trials. Additional agents targeting tumor vasculature, nuclear receptors, epigenetic abnormalities, and the immune response to neoplasia have also been investigated. Randomized trials for several agents are underway that may lead to eventual drug approval for thyroid cancer. Treatment for patients with metastatic or advanced thyroid carcinoma now emphasizes clinical trial opportunities for novel agents with considerable promise. Alternative options now exist for use of tyrosine kinase inhibitors that are well tolerated and may prove worthy of regulatory approval for this disease.
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Affiliation(s)
- Steven I Sherman
- The University of Texas M D Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1432, Houston, TX 77030, USA.
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Novel histone deacetylase inhibitors in clinical trials as anti-cancer agents. J Hematol Oncol 2010; 3:5. [PMID: 20132536 PMCID: PMC2827364 DOI: 10.1186/1756-8722-3-5] [Citation(s) in RCA: 334] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 02/04/2010] [Indexed: 12/25/2022] Open
Abstract
Histone deacetylases (HDACs) can regulate expression of tumor suppressor genes and activities of transcriptional factors involved in both cancer initiation and progression through alteration of either DNA or the structural components of chromatin. Recently, the role of gene repression through modulation such as acetylation in cancer patients has been clinically validated with several inhibitors of HDACs. One of the HDAC inhibitors, vorinostat, has been approved by FDA for treating cutaneous T-cell lymphoma (CTCL) for patients with progressive, persistent, or recurrent disease on or following two systemic therapies. Other inhibitors, for example, FK228, PXD101, PCI-24781, ITF2357, MGCD0103, MS-275, valproic acid and LBH589 have also demonstrated therapeutic potential as monotherapy or combination with other anti-tumor drugs in CTCL and other malignancies. At least 80 clinical trials are underway, testing more than eleven different HDAC inhibitory agents including both hematological and solid malignancies. This review focuses on recent development in clinical trials testing HDAC inhibitors as anti-tumor agents.
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Capdevila J, Perez-Garcia J, Obiols G, Tabernero J. Targeted therapies in thyroid cancer. Target Oncol 2009; 4:275-85. [PMID: 19904500 DOI: 10.1007/s11523-009-0124-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Accepted: 10/14/2009] [Indexed: 12/12/2022]
Abstract
Differentiated thyroid carcinoma is the most frequent neoplasm of the endocrine system. Although thyroid cancer usually has an excellent prognosis, no therapeutic options are available for patients that develop metastases and are or became resistant to radioiodine therapy. The deeper knowledge of molecular aberrations that characterize tumor growth has provided novel targets in cancer therapy. Several proteins have been implicated as having a crucial role in the carcinogenesis of differentiated thyroid cancer, such as those involved in RET/PTC-RAS-RAF-MAPK pathway. Moreover, vascular aberrations and angiogenesis equilibrium have also been related to tumor growth. The development of new, targeted therapies and their encouraging initial results have opened a hopeful opportunity of treatment for these orphan therapy tumor patients.
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Affiliation(s)
- Jaume Capdevila
- Medical Oncology Department, Vall d'Hebron University Hospital, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain
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Batty N, Malouf GG, Issa JPJ. Histone deacetylase inhibitors as anti-neoplastic agents. Cancer Lett 2009; 280:192-200. [PMID: 19345475 DOI: 10.1016/j.canlet.2009.03.013] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Accepted: 03/06/2009] [Indexed: 11/25/2022]
Abstract
Histone deacetylase inhibitors (HDACIs) constitute a novel class of targeted drugs that alter the acetylation status of histones and other important cellular proteins. These agents modulate chromatin structure leading to transcriptional changes, induce pleiotropic effects on functional pathways and activate cell death signaling in cancer cells. Anti-neoplastic activity in vitro was shown in several experimental models of cancer, but the exact mechanism of cytotoxicity and responses are not clearly understood. Phase I/II clinical trials of various HDACIs as single agents conducted to date have shown substantial activity in cutaneous T cell lymphoma (CTCL), preliminary activity in Hodgkin's disease and modest activity in myeloid neoplasms. Responses have been rare in solid tumors. Several agents are being tested in combination therapy clinical trials, either as chemosensitizers for cytotoxic chemotherapy or radiation therapy, or in association with DNA methylation inhibitors based on in vitro synergy. In this review, we focus on recent basic and clinical data that highlight the anti-neoplastic role of HDACIs.
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Affiliation(s)
- Nicolas Batty
- Department of Leukemia, MD Anderson Cancer Center, Unit 428, Houston, TX 77030, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of recent advances in the development of histone deacetylase inhibitors (HDACi) for the treatment of cancer. RECENT FINDINGS Recently, there has been a dramatic expansion of HDACi clinical investigation. There are now 11 HDACi in clinical trial, including inhibitors with a broad spectrum of HDAC isoform inhibitory activity as well as drugs with isoform selectivity. Over 70 combination therapy trials are in progress. Major areas of progress covered include the entry of new HDAC inhibitors into clinical development, recent progress in understanding of molecular mechanisms of HDACi anticancer activity, and a preclinical and clinical update on HDACi in combination. SUMMARY In the period under review there have been advances in understanding of HDACi mechanisms of action, identification of rational combinations that address increased efficacy and overcoming resistance, and greatly expanded clinical development of pan-HDAC-inhibitory and isoform-selective inhibitors in monotherapy and combination therapy protocols.
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Affiliation(s)
- Min-Jung Lee
- Medical Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland 20892, USA
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