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Giustina A, Uygur MM, Frara S, Barkan A, Biermasz NR, Chanson P, Freda P, Gadelha M, Haberbosch L, Kaiser UB, Lamberts S, Laws E, Nachtigall LB, Popovic V, Reincke M, van der Lely AJ, Wass JAH, Melmed S, Casanueva FF. Standards of care for medical management of acromegaly in pituitary tumor centers of excellence (PTCOE). Pituitary 2024; 27:381-388. [PMID: 38833044 PMCID: PMC11289172 DOI: 10.1007/s11102-024-01397-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE A series of consensus guidelines on medical treatment of acromegaly have been produced in the last two decades. However, little information is available on their application in clinical practice. Furthermore, international standards of acromegaly care have not been published. The aim of our study was to report current standards of care for medical therapy of acromegaly, using results collected through an audit performed to validate criteria for definition of Pituitary Tumor Centers of Excellence (PTCOE). METHODS Details of medical treatment approaches to acromegaly were voluntarily provided by nine renowned international centers that participated in this audit. For the period 2018-2020, we assessed overall number of acromegaly patients under medical treatment, distribution of patients on different treatment modalities, overall biochemical control rate with medical therapy, and specific control rates for different medical treatment options. RESULTS Median number of total patients and median number of new patients with acromegaly managed annually in the endocrinology units of the centers were 206 and 16.3, respectively. Median percentage of acromegaly patients on medical treatment was 48.9%. Among the patients on medical treatment, first-generation somatostatin receptor ligand (SRL) monotherapy was used with a median rate of 48.7%, followed by combination therapies with a median rate of 29.3%. Cabergoline monotherapy was used in 6.9% of patients. Pegvisomant monotherapy was used in 7 centers and pasireotide monotherapy in 5 centers, with median rates of 7.9% and 6.3%, respectively. CONCLUSIONS Current standards of care in PTCOEs include use of first-generation SRLs as the first medical option in about 50% of patients, as recommended by consensus guidelines. However, some patients are kept on this treatment despite inadequate control suggesting that cost-effectiveness, availability, patient preference, side effects, and therapeutic inertia may play a possible role also in PTCOE. Moreover, at odds with consensus guidelines, other monotherapies for acromegaly appear to have a marginal role as compared to combination therapies as extrapolated from PTCOE practice data. Presence of uncontrolled patients in each treatment category suggest that further optimization of medical therapy, as well as use of other therapeutic tools such as radiosurgery may be needed.
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Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and San Raffaele IRCCS Hospital, Via Olgettina 60, Milan, 20132, Italy.
| | - M M Uygur
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and San Raffaele IRCCS Hospital, Via Olgettina 60, Milan, 20132, Italy
- Department of Endocrinology and Metabolism Disease, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - S Frara
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and San Raffaele IRCCS Hospital, Via Olgettina 60, Milan, 20132, Italy
| | - A Barkan
- Division of Endocrinology, University of Michigan Health System, Ann Arbor, MI, USA
| | - N R Biermasz
- Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - P Chanson
- Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction et Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Université Paris-Saclay, APHP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Inserm, Paris, France
| | - P Freda
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - M Gadelha
- Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
| | - L Haberbosch
- Department of Medicine for Endocrinology, Diabetes and Nutritional Medicine, Charité Universitätsmedizin, Berlin, Germany
| | - U B Kaiser
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - S Lamberts
- Erasmus Medical Center, Rotterdam, The Netherlands
| | - E Laws
- Pituitary/Neuroendocrine Center, Brigham & Women's Hospital, Boston, MA, USA
| | - L B Nachtigall
- Neuroendocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - V Popovic
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - M Reincke
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - A J van der Lely
- Pituitary Center Rotterdam and Endocrinology Section, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J A H Wass
- Department of Endocrinology, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - S Melmed
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - F F Casanueva
- Division of Endocrinology, Santiago de Compostela University and Ciber OBN, Santiago, Spain
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Urbani C, Dassie F, Zampetti B, Mioni R, Maffei P, Cozzi R, Bogazzi F. Real-life data of Pasireotide LAR in acromegaly: a long-term follow-up. J Endocrinol Invest 2024; 47:1733-1741. [PMID: 38244140 PMCID: PMC11196287 DOI: 10.1007/s40618-023-02275-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/07/2023] [Indexed: 01/22/2024]
Abstract
OBJECTIVE Pasireotide LAR (PAS-LAR) was released in Italy in 2017 to treat acromegaly patients resistant to SRLs (Somatostatin Receptors Ligands). The long-term follow-up data of PAS-LAR therapy in Italy are limited. This study aimed to evaluate the efficacy and safety of PAS-LAR in acromegaly. DESIGN Patients with acromegaly in PAS-LAR treatment were enrolled in three tertiary Italian endocrinological centers and evaluated by a retrospective observational real-life multicentre study. METHODS Patients have been studied before (baseline) and 1, 6, 12, 24 and > 36 months after PAS-LAR start. Clinical, biochemical, and pituitary magnetic resonance data were collected, along with information on adverse events. Acromegaly disease activity was classified according to the IGF-1 index (normal value < 1.0). RESULTS Fifty patients (female 23) were enrolled. PAS-LAR treatment (mean follow-up 24 ± 16 months) significantly decreased IGF-1 levels (IGF-1 index baseline vs last visit: 1.9 ± 0.6 vs 1.2 ± 0.6, p < 0.0001). At the last visit, 67% of patients had controlled disease, and 44% showed a decrease in tumor volume. Clinical and biochemical efficacy was observed as early as after 1-month of PAS-LAR treatment (IGF-1 index baseline vs 1-month: 1.9 ± 0.6 vs 1.4 ± 0.7, p < 0.0001). Also, 50% of patients referred headache improvement or disappearance. Fifteen patients discontinued PAS-LAR due to failure of treatment and poor glycaemic control. The prevalence of diabetes increased from 33% at the baseline to 54% at the last visit (p = 0.0072). CONCLUSION In real-life settings, PAS-LAR significantly decreases symptoms, IGF-1 levels, and the size of adenoma in patients with acromegaly resistant to SRLs. Beneficial effects may occur early after the first injection.
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Affiliation(s)
- C Urbani
- Endocrinology Unit, Department of Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - F Dassie
- Department of Medicine, University of Padua, Padua, Italy
| | - B Zampetti
- Endocrine Unit, Grande Ospedale Metropolitano Niguarda-Milano, Milan, Italy
| | - R Mioni
- Department of Medicine, University of Padua, Padua, Italy
| | - P Maffei
- Department of Medicine, University of Padua, Padua, Italy.
| | - R Cozzi
- Endocrine Unit, Grande Ospedale Metropolitano Niguarda-Milano, Milan, Italy
| | - F Bogazzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Pirchio R, Auriemma RS, Vergura A, Pivonello R, Colao A. Investigational drugs for the treatment of acromegaly: new agents to transform therapy. Expert Opin Investig Drugs 2024; 33:509-522. [PMID: 38651260 DOI: 10.1080/13543784.2024.2343056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/10/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Disease control is essential to decrease morbidity burden and mortality in acromegaly patients. In the last decades, the availability of new drugs increased the rate of disease control. However, up to 55% of patients remain uncontrolled despite available treatment strategies in real-world data. The reasons for this finding may include poor adherence, inadequate tolerability, therapeutic inertia, and high costs. Since acromegaly is a chronic disease and medical therapy is usually life-long, patient's adherence to treatment is fundamental in both achieving and maintaining disease control. Less invasive routes of administration could improve adherence and concur to increase disease control rate. AREAS COVERED The aim of current review is to provide a detailed update about investigational drugs for acromegaly treatment currently under investigation as paltusotine, ONO-5788, AP102, GT-02037, ISIS 766720, CAM2024, Lanreotide PRF, DP1038, MTD201, solid dose injection of octreotide. EXPERT OPINION Medical therapy of acromegaly is an evolving field. Current studies are addressing patient's need for both new molecules and less invasive routes of administration for already existing drugs. It cannot be ruled out that drugs currently used for other diseases such as cancer could be considered in the future for the treatment of acromegaly.
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Affiliation(s)
- Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - Renata S Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - Alice Vergura
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
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Brue T, Rahabi H, Barry A, Barlier A, Bertherat J, Borson-Chazot F, Castinetti F, Cazabat L, Chabre O, Chevalier N, Christin-Maitre S, Cortet C, Drui D, Kamenicky P, Lançon C, Lioté F, Pellegrini I, Reynaud R, Salenave S, Tauveron I, Touraine P, Vantyghem MC, Vergès B, Vezzosi D, Villa C, Raverot G, Coutant R, Chanson P, Albarel F. Position statement on the diagnosis and management of acromegaly: The French National Diagnosis and Treatment Protocol (NDTP). ANNALES D'ENDOCRINOLOGIE 2023; 84:697-710. [PMID: 37579837 DOI: 10.1016/j.ando.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
Acromegaly is a rare disease with prevalence of approximately 60 cases per million, slight female predominance and peak onset in adults in the fourth decade. Clinical diagnosis is often delayed by several years due to the slowly progressive onset of symptoms. There are multiple clinical criteria that define acromegaly: dysmorphic syndrome of insidious onset, symptoms related to the pituitary tumor (headaches, visual disorders), general signs (sweating, carpal tunnel syndrome, joint pain, etc.), complications of the disease (musculoskeletal, cardiovascular, pneumological, dental, metabolic comorbidities, thyroid nodules, colonic polyps, etc.) or sometimes clinical signs of associated prolactin hypersecretion (erectile dysfunction in men or cycle disorder in women) or concomitant mass-induced hypopituitarism (fatigue and other symptoms related to pituitary hormone deficiencies). Biological confirmation is based initially on elevated IGF-I and lack of GH suppression on oral glucose tolerance test or an elevated mean GH on repeated measurements. In confirmed cases, imaging by pituitary MRI identifies the causal tumor, to best determine management. In a minority of cases, acromegaly can be linked to a genetic predisposition, especially when it occurs at a young age or in a familial context. The first-line treatment is most often surgical removal of the somatotroph pituitary tumor, either immediately or after transient medical treatment. Medical treatments are most often proposed in patients not controlled by surgical removal. Conformal or stereotactic radiotherapy may be discussed on a case-by-case basis, especially in case of drug inefficacy or poor tolerance. Acromegaly should be managed by a multidisciplinary team, preferably within an expert center such as a reference or skill center for rare pituitary diseases.
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Affiliation(s)
- Thierry Brue
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO, assistance publique-hôpitaux de Marseille (AP-HM), hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France; Aix Marseille université, INSERM, MMG, Marseille Medical Genetics, Marseille, France.
| | - Haïfa Rahabi
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO, assistance publique-hôpitaux de Marseille (AP-HM), hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France
| | - Abdoulaye Barry
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO, assistance publique-hôpitaux de Marseille (AP-HM), hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France
| | - Anne Barlier
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO, assistance publique-hôpitaux de Marseille (AP-HM), hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France; Aix Marseille université, INSERM, MMG, Marseille Medical Genetics, Marseille, France
| | - Jérôme Bertherat
- Service d'endocrinologie, hôpital Cochin, AP-HP centre université Paris Cité, France
| | - Françoise Borson-Chazot
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO « groupement hospitalier Est » hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron, France
| | - Frédéric Castinetti
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO, assistance publique-hôpitaux de Marseille (AP-HM), hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France; Aix Marseille université, INSERM, MMG, Marseille Medical Genetics, Marseille, France
| | - Laure Cazabat
- Hôpital Foch, service de neurochirurgie, UMR 1198 BREED, UFR Simone Veil Santé, UVSQ-Paris Saclay, 40, rue Worth, 92150 Suresnes, France
| | - Olivier Chabre
- University Grenoble Alpes, UMR 1292 Inserm-CEA-UGA, endocrinologie CHU de Grenoble Alpes, 38000 Grenoble, France
| | - Nicolas Chevalier
- Université Côte d'Azur, CHU, Inserm U1065, C3M, équipe 5, Nice, France
| | - Sophie Christin-Maitre
- Service d'endocrinologie, diabétologie et médecine de la reproduction, centre de référence des maladies endocriniennes rares de la croissance et du développement (CMERC) Centre de compétence HYPO, Sorbonne université, hôpital Saint-Antoine, Assistance publique-Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Christine Cortet
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHRU de Lille, rue Polonowski, Lille cedex, France
| | - Delphine Drui
- Service d'endocrinologie, l'institut du thorax, centre hospitalier universitaire de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex, France
| | - Peter Kamenicky
- Service d'endocrinologie et des maladies de la reproduction, centre de référence des maladies rares de l'hypophyse, université Paris-Saclay, Inserm, physiologie et physiopathologie endocriniennes, AP-HP, hôpital BicêtreLe Kremlin-Bicêtre, France
| | - Catherine Lançon
- « Acromégales, pas seulement… », association nationale de l'acromégalie reconnue d'intérêt général, 59234 Villers-Au-Tertre, France
| | - Frédéric Lioté
- Centre Viggo Petersen, faculté de santé, université Paris Cité, Inserm UMR 1132 Bioscar et service de rhumatologie, DMU Locomotion, AP-HP, hôpital Lariboisière, 75475 Paris cedex 10, France
| | - Isabelle Pellegrini
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO, assistance publique-hôpitaux de Marseille (AP-HM), hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France
| | - Rachel Reynaud
- Aix Marseille université, INSERM, MMG, Marseille Medical Genetics, Marseille, France; Service de pédiatrie multidisciplinaire, centre de référence des maladies rares de l'hypophyse HYPO, Assistance publique-Hôpitaux de Marseille (AP-HM), hôpital de la Timone enfants, 13005 Marseille, France
| | - Sylvie Salenave
- Service d'endocrinologie et des maladies de la reproduction, centre de référence des maladies rares de l'hypophyse, université Paris-Saclay, Inserm, physiologie et physiopathologie endocriniennes, AP-HP, hôpital BicêtreLe Kremlin-Bicêtre, France
| | - Igor Tauveron
- Service d'endocrinologie diabétologie, institut génétique, reproduction & développement (iGReD), CHU de Clermont-Ferrand, CNRS, Inserm, université Clermont-Auvergne, Clermont-Ferrand, France
| | - Philippe Touraine
- Service d'endocrinologie et médecine de la reproduction, centre de maladies endocrinennes rares de la croissance et du développement, Sorbonne université médecine, hôpital Pitié Salpêtrière, Paris, France
| | - Marie-Christine Vantyghem
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHRU de Lille, rue Polonowski, Lille cedex, France; Service d'endocrinologie, l'institut du thorax, centre hospitalier universitaire de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex, France
| | - Bruno Vergès
- Service d'endocrinologie, CHU de Dijon, centre Inserm LNC-UMR1231, 14, rue Gaffarel, 21000 Dijon, France
| | - Delphine Vezzosi
- Service d'endocrinologie, hôpital Larrey, CHU Toulouse, 24 chemin de Pouvourville, TSA 30030, université Paul Sabatier, 21059 Toulouse cedex 9, France
| | - Chiara Villa
- Département de neuropathologie de la Pitié Salpêtrière, hôpital de la Pitié-Salpêtrière - AP-HP, Sorbonne université, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - Gérald Raverot
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO « groupement hospitalier Est » hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron, France
| | - Régis Coutant
- Service d'endocrinologie-diabétologie-nutrition, centre de référence des maladies rares de l'hypophyse, université d'Angers, CHU d'Angers, Angers, France
| | - Philippe Chanson
- Service d'endocrinologie et des maladies de la reproduction, centre de référence des maladies rares de l'hypophyse, université Paris-Saclay, Inserm, physiologie et physiopathologie endocriniennes, AP-HP, hôpital BicêtreLe Kremlin-Bicêtre, France
| | - Frédérique Albarel
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO, assistance publique-hôpitaux de Marseille (AP-HM), hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France
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Gadelha MR, Kasuki L. Refractory somatotroph adenomas. Pituitary 2023:10.1007/s11102-023-01324-5. [PMID: 37316636 DOI: 10.1007/s11102-023-01324-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 06/16/2023]
Abstract
Somatotroph adenomas are usually controlled with standard therapy, which can include surgery, medical treatment and radiotherapy. Some tumors have a more aggressive behavior and are refractory to standard therapy. In this review, we summarize the phenotype of these tumors and the current options for their management.
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Affiliation(s)
- Monica R Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital, Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
- , Rua Prof. Rodolpho Paulo Rocco, 255, 9th floor, Ilha do Fundão, Rio de Janeiro, 21941-913, Brazil.
| | - Leandro Kasuki
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital, Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
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Chiloiro S, Giampietro A, Gagliardi I, Bondanelli M, Epifani V, Milardi D, Ambrosio MR, Zatelli MC, Pontecorvi A, De Marinis L, Bianchi A. Systemic comorbidities of acromegaly in real-life experience: which difference among young and elderly patients? Endocrine 2023; 80:142-151. [PMID: 36447087 DOI: 10.1007/s12020-022-03261-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/10/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Acromegaly is a rare but potentially life-threatening disease, if not promptly managed, for the systemic complications due to the GH/IGF-I hypersecretion. According to the increased population life span, the number of older acromegaly patients is growing. We aim to investigate clinical features of elderly acromegaly (elderly-ACRO) and to identify the risk factors for the occurrence of comorbidities in elderly-ACRO. MATERIALS AND METHODS A retrospective and multi-center study was performed on acromegaly patients. Acromegaly comorbidities were compared among elderly-ACRO (>65 years), young acromegaly patients (young-ACRO if ≤65 years) and a control group of age and gender-matched subjects. RESULT Fifty of the 189 enrolled patients were elderly-ACRO (26.5%). Cardiovascular, metabolic, neurological/psychiatric and joint/articular disorders, nodular thyroid disease, sleep apnoea syndrome and skeletal fragility occurred more frequently in elderly-ACRO as compared to controls. Cardiovascular and metabolic disorders, nodular thyroid disease occurred significantly more frequently in elderly-ACRO as compared to young-ACRO and controls. On the other hand, neurological/psychiatric, joint/articular disorders and bone fragility occur with a similar frequency among elderly and young-ACRO. We found that elderly-ACRO had an increased risk for the occurrence of systemic arterial hypertension (p < 0.001, OR: 5.4 95%IC:2.6-10.9), left ventricular hypertrophy (p = 0.01, OR: 3 95%IC: 1.5-5.8) and metabolic disorders (p = 0.006, OR: 4.1 95%IC: 2-8.3). CONCLUSION Our results may suggest that some acromegaly comorbidities may be predominantly due to acromegaly "per-se" rather than to aging. On the contrary, cardiovascular and metabolic disorders seem to be due to aging as well.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Irene Gagliardi
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Marta Bondanelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Valeria Epifani
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico Milardi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Rosaria Ambrosio
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Maria Chiara Zatelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
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Giustina A, di Filippo L, Uygur MM, Frara S. Modern approach to resistant acromegaly. Endocrine 2023; 80:303-307. [PMID: 36790521 DOI: 10.1007/s12020-023-03317-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 01/22/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Targets of acromegaly treatment are normalization of biochemical values, removal/reduction/stabilization of the pituitary mass, control of clinical activity and mortality with a multimodal/multidisciplinary approach. Despite significant technological and pharmacological progress, still several patients with acromegaly bear a resistant somatotroph adenoma and active disease may persist for many years with resultant poor clinical outcomes. AIM To review briefly definition and pathophysiology of resistance to acromegaly treatment and the options of medical treatment in this context, exploring the role of novel clinical and molecular biomarkers in the personalization of therapy and proposing updates to the currently available guidelines for the treatment of resistant GH-secreting adenomas. CONCLUSIONS In the last few years, in parallel with the increased number of medical options available for the therapy of acromegaly, relevant advances occurred in the understanding of the role of novel molecular and clinical biomarkers in predicting the responsiveness to second-line medical treatments, such as Pegvisomant and Pasireotide LAR, and helping clinicians in the personalization of the follow-up and treatment of resistant somatotroph adenomas. The integration of these findings into the existing guidelines may represent a possibly important step forward in the management of "difficult" acromegaly patients.
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Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences (IEMS), Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences (IEMS), Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Melin M Uygur
- Institute of Endocrine and Metabolic Sciences (IEMS), Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Frara
- Institute of Endocrine and Metabolic Sciences (IEMS), Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
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8
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Chiloiro S, Bianchi A, Giampietro A, Pontecorvi A, Raverot G, Marinis LD. Second line treatment of acromegaly: Pasireotide or Pegvisomant? Best Pract Res Clin Endocrinol Metab 2022; 36:101684. [PMID: 35931640 DOI: 10.1016/j.beem.2022.101684] [Citation(s) in RCA: 8] [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] [Indexed: 12/14/2022]
Abstract
Acromegaly is a chronic disease with an increased mortality in case of persistently active disease. The treatment of acromegaly is mainly based on the surgical resection of the GH secreting pituitary tumor and, in cases with persistent disease, on the medical therapy with first generation somatostatin analogues (first gen-SSAs). Data from national registries, meta-analysis and epidemiology studies showed that 24%-65% of acromegaly patients treated with first gen-SSA did not reach the control of disease, requiring second line therapies, as the second gen-SSAs and the GH receptor antagonist. According to the high efficacy of these treatments and their molecular mechanisms of action, the choice of second line therapies should be personalized. In this review, we summarize the evidence on clinical, molecular and morphological aspects that may predict the response to second line therapies, in order to integrate and translate in the clinical practice for a patient-tailored therapeutic approach.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Division of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo A. Gemelli, number 8, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Antonio Bianchi
- Pituitary Unit, Division of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo A. Gemelli, number 8, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Division of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo A. Gemelli, number 8, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Division of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo A. Gemelli, number 8, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gérald Raverot
- Fédération d'endocrinologie, Centre de référence Maladies Rares Hypophysaires (HYPO), Hospices Civils de Lyon, Groupement hospitalier Est, Bron, France; Université Lyon 1, Lyon, France; Inserm U1052, CNRS UMR5286, Cancer Research Center of Lyon, 69372, Lyon, France
| | - Laura De Marinis
- Pituitary Unit, Division of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo A. Gemelli, number 8, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
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9
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Chiloiro S, Costa D, Lauretta R, Mercuri V, Sbardella E, Samperi I, Appetecchia M, Bianchi A, Giampietro A, Gargiulo P, Isidori AM, Poggi M, Pontecorvi A, De Marinis L. Partial response to first generation SSA guides the choice and predict the outcome of second line therapy in acromegaly. Endocrine 2022; 78:343-353. [PMID: 35986839 PMCID: PMC9584996 DOI: 10.1007/s12020-022-03158-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Treatment of acromegaly resistant to first generation somatostatin analogues (first gen-SSA) is often difficult. We aimed to investigate the role of partial response and resistance to first gen-SSA in the choice of second line treatments and their outcomes. PATIENTS AND METHODS A retrospective and multicenter study was conducted on 100 SSA-resistant acromegaly patients and treated with Pasireotide Lar (Pasi-Lar), Peg-V in monotherapy (m-Peg-V) or in combination with first gen-SSA (c-Peg-V). RESULTS Thirty-three patients (33%) were treated with m-Peg-V, 36 (36%) with c-Peg-V and 31 with Pasi-Lar (31%). According to logistic regression, m-Peg-V was chosen in older patients (p = 0.01) and with not-invasive adenomas (p = 0.009), c-Peg-V therapy in younger patients (p = 0.001), with invasive adenomas (p = 0.02), Pasi-Lar was in invasive adenomas (p = 0.01) and in patients partially responsive to first-gen SSA (p = 0.01). At the last follow-up, 68 patients (68%) reached the acromegaly control: 22 with m-Peg-V (32.4%), 23 with c-Peg-V (33.8%) and 23 with Pasi-Lar (33.8%). Patients non-responsive to c-Peg-V had higher IGF-I levels (median 3.2 x ULN, IQR: 1.6, p < 0.001) and required higher Peg-V dosage (median 30 mg/daily IQR: 10, p = 0.002) as compared to responsive patients (median IGF-I x ULN: 2.1 IQR: 1.4; median Peg-V dosage 20 mg/daily IQR: 10). All patients responsive to Pasi-Lar were partially responsive to first gen-SSAs (p = 0.02). CONCLUSION Our data showed that c-Peg-V and Pasi-Lar are chosen for the treatment of invasive tumors. The partial response to first gen-SSA seems to be the main determinant for the choice of Pasi-Lar and positively predicts the treatment outcome.
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Affiliation(s)
- Sabrina Chiloiro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168, Roma, Italy
- UOC Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Roma, Italy
| | - Denise Costa
- Department of Experimental Medicine, Endocrinology-Pituitary Disease, "Sapienza" University of Rome, Roma, Italy
| | - Rosa Lauretta
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Roma, Italy
| | - Valeria Mercuri
- Department of Experimental Medicine, Endocrinology-Pituitary Disease, "Sapienza" University of Rome, Roma, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Endocrinology-Pituitary Disease, "Sapienza" University of Rome, Roma, Italy
| | - Irene Samperi
- Endocrine-Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Marialuisa Appetecchia
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Roma, Italy
| | - Antonio Bianchi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168, Roma, Italy
- UOC Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Roma, Italy
| | - Antonella Giampietro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168, Roma, Italy
- UOC Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Roma, Italy
| | - Patrizia Gargiulo
- Department of Experimental Medicine, Endocrinology-Pituitary Disease, "Sapienza" University of Rome, Roma, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Endocrinology-Pituitary Disease, "Sapienza" University of Rome, Roma, Italy
| | - Maurizio Poggi
- Endocrine-Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Alfredo Pontecorvi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168, Roma, Italy
- UOC Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Roma, Italy
| | - Laura De Marinis
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168, Roma, Italy.
- UOC Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Roma, Italy.
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10
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Brunetti A, Antonini S, Saladino A, Lavezzi E, Zampetti B, Cozzi R. Clinical Management of Acromegaly: Therapeutic Frontiers and New Perspectives for Somatostatin Receptor Ligands (SRLs). MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060794. [PMID: 35744057 PMCID: PMC9228014 DOI: 10.3390/medicina58060794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 05/31/2022] [Accepted: 06/09/2022] [Indexed: 11/28/2022]
Abstract
Somatostatin receptor ligands (SRLs) represent a true milestone in the medical therapy for acromegaly. The first-generation SRLs (FG-SRLs), octreotide and lanreotide, have demonstrated good efficacy in disease control and tumor shrinkage, and are still considered first-line medical therapies. The development of long-acting release (LAR) formulations has certainly improved the therapeutic tolerability of these drugs, although many patients still experience therapy-related burden. As such, new formulations have recently been developed to improve adherence and therapeutic efficacy and more solutions are on the way. In the case of FG-SRL-resistant disease, pasireotide, the only second generation SRL currently available, demonstrated superiority in disease control and tumor shrinkage compared to FG-SRLs. However, its use in clinical practice is still limited due to concern for impairment in glucose homeostasis. In this review, we discuss the news about the present and future role of SRLs in acromegaly, exploring the therapeutical frontiers of this drug class. Moreover, we provide practical guidance on the use of pasireotide, based on the data in the literature and our clinical experience.
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Affiliation(s)
- Alessandro Brunetti
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy; (A.B.); (S.A.); (E.L.)
| | - Simone Antonini
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy; (A.B.); (S.A.); (E.L.)
| | - Andrea Saladino
- Division of Neurosurgery (NCH 1), Fondazione IRCCS Istituto Neurologico “Carlo Besta”, 20133 Milan, Italy;
| | - Elisabetta Lavezzi
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy; (A.B.); (S.A.); (E.L.)
| | - Benedetta Zampetti
- SC Endocrinologia Grande Ospedale Metropolitano Niguarda Milano, Piazza Ospedale Maggiore 3, 20162 Milan, Italy;
| | - Renato Cozzi
- SC Endocrinologia Grande Ospedale Metropolitano Niguarda Milano, Piazza Ospedale Maggiore 3, 20162 Milan, Italy;
- Correspondence:
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11
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Ting Lim DS, Fleseriu M. Personalized Medical Treatment in Patients with Acromegaly: A Review. Endocr Pract 2022; 28:321-332. [PMID: 35032649 DOI: 10.1016/j.eprac.2021.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 12/23/2022]
Abstract
Acromegaly is associated with significant morbidity and mortality if not appropriately treated. In addition to insulin-like growth factor 1 (IGF-1) and growth hormone (GH) normalization, and tumor shrinkage, treatment goals include symptom relief, managing complications and improving quality of life. Surgical resection is a first-line treatment in most patients, with few being pretreated pre-operatively with medications. Somatostatin receptor ligands (SRLs), injectable and more recently oral capsules, have been the cornerstone of first-line medical therapy for persistent disease. However, several factors, including sparsely granulated adenomas, absent/low somatostatin receptor (SSTR2) status, imaging T2-hyperintensity, young age and aryl hydrocarbon receptor interacting protein mutations could predict first-generation SRL resistance. Patients with these characteristics may be better candidates for the GH receptor antagonist, pegvisomant, or in cases of large tumors the second-generation SRL, pasireotide. Combination therapy should be further pursued in patients who remain biochemically uncontrolled or have high remnant tumor after monotherapy. An efficacious and cost-effective pegvisomant dose-sparing effect of SRLs when used in combination has been demonstrated. With such a wide array of medical treatment options, it is increasingly important to tailor treatment to patients' unique characteristics as well as preferences, with a goal of personalizing management to achieve high quality outcomes.
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Affiliation(s)
| | - Maria Fleseriu
- Pituitary Center, and Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.
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12
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Chiloiro S, Giampietro A, Visconti F, Rossi L, Donfrancesco F, Fleseriu CM, Mirra F, Pontecorvi A, Giustina A, Fleseriu M, De Marinis L, Bianchi A. Glucose metabolism outcomes in acromegaly patients on treatment with pasireotide-LAR or pasireotide-LAR plus Pegvisomant. Endocrine 2021; 73:658-666. [PMID: 33907985 PMCID: PMC8325668 DOI: 10.1007/s12020-021-02711-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/23/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Disorders of glucose metabolism are a serious acromegaly comorbidity and may be differently impacted by medical treatments of acromegaly. In this retrospective longitudinal multicenter study, we investigated the outcome of glucose metabolism and its predictors in patients treated with Pasireotide LAR (PAS-LAR) alone or in combination with Pegvisomant (PAS-LAR + Peg-V). SUBJECTS AND METHODS Acromegaly patients treated continously with PAS-LAR or PAS-LAR + Peg-V for at least 6 months. RESULTS Forty patients (25 females, 15 males) were enrolled. At last visit, 27/40 patients (67.5%) reached biochemical control of acromegaly. Overall, glucose metabolism improved in 3 (all in PAS-LAR + Peg-V; 7.5%), worsened in 26 (65%) and remained unchanged in 11 patients (27.5%). Glucose metabolism worsened in 25 patients (73.5%) treated with PAS-LAR and in a single patient (16.7%) treated with PAS-LAR + Peg-V (p < 0.001). Among patients treated with Pas-LAR alone, GH at baseline was higher in those with worsening of glucose metabolism (p = 0.04) as compared to those with stable glucose status. A significantly higher reduction of HbA1c was observed in patients treated with PAS-LAR + Peg-V, as compared with those treated with PAS-LAR alone (p = 0.005). CONCLUSIONS Our data confirmed that glucose metabolism in patients treated with PAS-LAR is often worsened, and may be predicted by entity of baseline GH hypersecretion and by the dose of PAS-LAR. Moreover, our data, although limited by small numbers, may suggest that the combination treatment PAS-LAR + Peg-V can improve glucose homeostasis in selected patients.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Felicia Visconti
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura Rossi
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federico Donfrancesco
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cara M Fleseriu
- Pituitary Center, Oregon Health and Science University, Portland, OR, USA
- University of Pittsburgh, Pittsburgh, PA, USA
| | - Federica Mirra
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Giustina
- Institute of Endocrie and Metabolic Sciences, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, Milano, Italy
| | - Maria Fleseriu
- Pituitary Center, Oregon Health and Science University, Portland, OR, USA
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology and Diabetes, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
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13
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Fleseriu M, Führer-Sakel D, van der Lely AJ, De Marinis L, Brue T, van der Lans-Bussemaker J, Hey-Hadavi J, Camacho-Hubner C, Wajnrajch MP, Valluri SR, Palladino AA, Gomez R, Salvatori R. More than a decade of real-world experience of pegvisomant for acromegaly: ACROSTUDY. Eur J Endocrinol 2021; 185:525-538. [PMID: 34342594 PMCID: PMC8428076 DOI: 10.1530/eje-21-0239] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 08/03/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To report the final long-term safety and efficacy analyses of patients with acromegaly treated with pegvisomant from the ACROSTUDY. DESIGN Global (15 countries), multicentre, non-interventional study (2004-2017). METHODS The complete ACROSTUDY cohort comprised patients with acromegaly, who were being treated with pegvisomant (PEGV) prior to the study or at enrolment. The main endpoints were long-term safety (comorbidities, adverse events (AEs), pituitary tumour volumes, liver tests) and efficacy (IGF1 changes). RESULTS Patients (n = 2221) were treated with PEGV for a median of 9.3 years (range, 0-20.8 years) and followed up for a median of 7.4 years (range, 0-13.9 years). Before PEGV, 96.3% had received other acromegaly treatments (surgery/radiotherapy/medications). Before PEGV treatment, 87.2% of patients reported comorbidities. During ACROSTUDY, 5567 AEs were reported in 56.5% of patients and of these 613 were considered treatment-related (in 16.5% of patients) and led to drug withdrawal in 1.3%. Pituitary imaging showed a tumour size increase in 7.1% of patients; the majority (71.1%) reported no changes. Abnormal AST or ALT liver tests occurred in 3.2% of patients. IGF1 normalization rate improved over time, increasing from 11.4% at PEGV start to 53.7% at year 1, and reaching 75.4% at year 10 with the use of ≥30 mg PEGV/day in an increasing proportion of patients. CONCLUSION This comprehensive review of the complete cohort in ACROSTUDY confirmed the overall favourable benefit-to-risk profile and high efficacy of PEGV as mono- and combination therapy in patients with an aggressive course/uncontrolled/active acromegaly requiring long-term medical therapy for control.
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Affiliation(s)
- Maria Fleseriu
- Pituitary CenterDivision of Endocrinology, Diabetes, & Clinical Nutrition, Department of Medicine
- Pituitary Center, Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
- Correspondence should be addressed to M Fleseriu Email
| | - Dagmar Führer-Sakel
- Department of Endocrinology Diabetology and Metabolism, Endocrine Tumour Center at West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Aart J van der Lely
- Division of Endocrinology, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Thierry Brue
- Assistance Publique-Hôpitaux de Marseille, Hopital de la Conception, and Aix-Marseille Université, Marseille Medical Genetics, Marseille, France
| | | | | | | | - Michael P Wajnrajch
- Pfizer, New York, New York, USA
- Division of Pediatric Endocrinology, Department of Pediatrics, New York University Langone Medical Center, New York, New York, USA
| | | | | | | | - Roberto Salvatori
- Division of Endocrinology and Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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14
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Octreotide and Pasireotide Combination Treatment in Somatotroph Tumor Cells: Predominant Role of SST 2 in Mediating Ligand Effects. Cancers (Basel) 2021; 13:cancers13081816. [PMID: 33920241 PMCID: PMC8069349 DOI: 10.3390/cancers13081816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/08/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary First-generation somatostatin receptor ligands, such as octreotide, are the first-line medical therapy in acromegaly. Octreotide shows preferential binding for somatostatin receptor subtype 2 (SST2), while the second-generation ligand, pasireotide, has high affinity for multiple SSTs. We aimed to elucidate whether pasireotide acts via other receptors than SST2 in somatotroph tumors, and to investigate the potential role of the combination therapy octreotide plus pasireotide. We found that octreotide and pasireotide are superimposable in reducing GH secretion in cultured somatotroph tumor cells, as well as in inhibiting cell proliferation and intracellular pathway activity in rat GH4C1 cells (a model of somatotroph tumors). We did not find any additive/synergistic effect for the combination treatment. Furthermore, we observed that co-incubation with a SST2-selective antagonist reversed the inhibitory effect of both compounds. Therefore, the two drugs act mainly via SST2 in somatotroph tumor cells, and their combination is not superior to single agent treatment. Abstract First-generation somatostatin receptor ligands (fg-SRLs), such as octreotide (OCT), represent the first-line medical therapy in acromegaly. Fg-SRLs show a preferential binding affinity for somatostatin receptor subtype-2 (SST2), while the second-generation ligand, pasireotide (PAS), has high affinity for multiple SSTs (SST5 > SST2 > SST3 > SST1). Whether PAS acts via SST2 in somatotroph tumors, or through other SSTs (e.g., SST5), is a matter of debate. In this light, the combined treatment OCT+PAS could result in additive/synergistic effects. We evaluated the efficacy of OCT and PAS (alone and in combination) on growth hormone (GH) secretion in primary cultures from human somatotroph tumors, as well as on cell proliferation, intracellular signaling and receptor trafficking in the rat GH4C1 cell line. The results confirmed the superimposable efficacy of OCT and PAS in reducing GH secretion (primary cultures), cell proliferation, cAMP accumulation and intracellular [Ca2+] increase (GH4C1 cells), without any additive effect observed for OCT+PAS. In GH4C1 cells, co-incubation with a SST2-selective antagonist reversed the inhibitory effect of OCT and PAS on cell proliferation and cAMP accumulation, while both compounds resulted in a robust internalization of SST2 (but not SST5). In conclusion, OCT and PAS seem to act mainly through SST2 in somatotroph tumor cells in vitro, without inducing any additive/synergistic effect when tested in combination.
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15
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Antunes X, Kasuki L, Gadelha MR. New and emerging pharmacological treatment options for acromegaly. Expert Opin Pharmacother 2021; 22:1615-1623. [PMID: 33783289 DOI: 10.1080/14656566.2021.1908998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Introduction: Transsphenoidal surgery is the first-line treatment for acromegaly, but even in referral centers, approximately 50% of patients are not cured, and adjuvant pharmacological treatment is necessary. Widely used therapies encompass different drug classes, such as injectable somatostatin receptor ligands (SRLs), oral dopamine agonists and injectable growth hormone receptor antagonists, but approximately 40% of patients still have disease activity in real-life practice. Therefore, there is a need for new medical therapies to allow disease control in a larger proportion of patients, increase quality of life, reduce morbidity and mortality and improve treatment adherence in acromegaly.Areas covered: In this review, the authors cover new and emerging drugs under development or drugs recently approved for the treatment of acromegaly.Expert opinion: Disease control is essential to reduce morbidity and mortality in acromegaly but is still not achieved in a significant proportion of patients or takes a long time to be achieved with currently available options and treatment algorithms. Therefore, the development of new drugs as well as the establishment of biomarkers of disease control to allow precision medicine will improve treatment and outcomes in acromegaly.
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Affiliation(s)
- Ximene Antunes
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leandro Kasuki
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.,Endocrinology Division, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.,Neuropatology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
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16
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Giustina A, Barkhoudarian G, Beckers A, Ben-Shlomo A, Biermasz N, Biller B, Boguszewski C, Bolanowski M, Bollerslev J, Bonert V, Bronstein MD, Buchfelder M, Casanueva F, Chanson P, Clemmons D, Fleseriu M, Formenti AM, Freda P, Gadelha M, Geer E, Gurnell M, Heaney AP, Ho KKY, Ioachimescu AG, Lamberts S, Laws E, Losa M, Maffei P, Mamelak A, Mercado M, Molitch M, Mortini P, Pereira AM, Petersenn S, Post K, Puig-Domingo M, Salvatori R, Samson SL, Shimon I, Strasburger C, Swearingen B, Trainer P, Vance ML, Wass J, Wierman ME, Yuen KCJ, Zatelli MC, Melmed S. Multidisciplinary management of acromegaly: A consensus. Rev Endocr Metab Disord 2020; 21:667-678. [PMID: 32914330 PMCID: PMC7942783 DOI: 10.1007/s11154-020-09588-z] [Citation(s) in RCA: 176] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/18/2022]
Abstract
The 13th Acromegaly Consensus Conference was held in November 2019 in Fort Lauderdale, Florida, and comprised acromegaly experts including endocrinologists and neurosurgeons who considered optimal approaches for multidisciplinary acromegaly management. Focused discussions reviewed techniques, results, and side effects of surgery, radiotherapy, and medical therapy, and how advances in technology and novel techniques have changed the way these modalities are used alone or in combination. Effects of treatment on patient outcomes were considered, along with strategies for optimizing and personalizing therapeutic approaches. Expert consensus recommendations emphasize how best to implement available treatment options as part of a multidisciplinary approach at Pituitary Tumor Centers of Excellence.
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Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital, Ospedale San Raffaele, Via Olgettina, 58, 20132, Milan, Italy.
| | - Garni Barkhoudarian
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Albert Beckers
- Department of Endocrinology, University of Liège, Liège, Belgium
| | - Anat Ben-Shlomo
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nienke Biermasz
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Beverly Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cesar Boguszewski
- SEMPR, Endocrine Division, Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Department of Endocrinology, University of Oslo, Oslo, Norway
| | - Vivien Bonert
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - Felipe Casanueva
- Division of Endocrinology, Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - Philippe Chanson
- Centre de Référence des Maladies Rares de l'Hypophyse and Université Paris-Saclay, Univ. Paris-Sud, Inserm, Signalisation Hormonale, Physiopathologie Endocrinienne et Métabolique, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, Paris, France
| | - David Clemmons
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Maria Fleseriu
- Departments of Medicine and Neurological Surgery, Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital, Ospedale San Raffaele, Via Olgettina, 58, 20132, Milan, Italy
| | - Pamela Freda
- Department of Medicine, Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Monica Gadelha
- Neuroendocrinology Research Center/Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliza Geer
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Mark Gurnell
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Anthony P Heaney
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Ken K Y Ho
- The Garvan Institute of Medical Research, St. Vincent's Hospital, University of New South Wales, Sydney, Australia
| | - Adriana G Ioachimescu
- Department of Neurosurgery and Medicine, Division of Endocrinology, Metabolism and Lipids, Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Edward Laws
- Pituitary/Neuroendocrine Center, Brigham & Women's Hospital, Boston, MA, USA
| | - Marco Losa
- Department of Neurosurgery, San Raffaele University Health Institute Milan, Milan, Italy
| | - Pietro Maffei
- Department of Medicine, Padua University Hospital, Padua, Italy
| | - Adam Mamelak
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Moises Mercado
- Medical Research Unit in Endcrine Diseases, Hospital de Especialidades, Centro Médico Nacional, Siglo XXI, IMSS, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Mark Molitch
- Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pietro Mortini
- Department of Neurosurgery, San Raffaele University Health Institute Milan, Milan, Italy
| | - Alberto M Pereira
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Kalmon Post
- Department of Neurosurgery, Medicine, Mount Sinai Health System, New York, NY, USA
| | - Manuel Puig-Domingo
- Germans Trias i Pujol Research Institute, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism and Pituitary Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Susan L Samson
- Departments of Medicine and Neurosurgery, Baylor St. Luke's Pituitary Center, Baylor College of Medicine, Houson, TX, USA
| | - Ilan Shimon
- Endocrine Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Christian Strasburger
- Department of Medicine for Endocrinology, Diabetes and Nutritional Medicine, Charité Universitätsmedizin, Berlin, Germany
| | - Brooke Swearingen
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Peter Trainer
- Department of Endocrinology, The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Mary L Vance
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - John Wass
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Margaret E Wierman
- Pituitary, Adrenal and Neuroendocrine Tumor Program, Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Kevin C J Yuen
- Barrow Pituitary Center and Neuroendocrinology Clinic, Barrow Neurological Institute, University of Arizona College of Medicine, Creighton School of Medicine, Phoenix, AZ, USA
| | - Maria Chiara Zatelli
- Section of Endocrinology & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Shlomo Melmed
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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17
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Abstract
Acromegaly is a systemic disease associated with increased morbidity and mortality. Most of these comorbidities can be prevented or delayed with adequate disease treatment. Although three modalities of treatment (surgery, medical treatment, and radiotherapy) are available and new drugs were approved in the last decades, there are still some patients that maintain disease activity despite treatment. Therefore, there is a need for novel therapies for acromegaly and for that purpose new formulations of currently used drugs and also new drugs are currently under study. In this review, we summarize the novel therapies for acromegaly.
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Affiliation(s)
- Bernardo Maia
- Neuroendocrinology Research Center/Endocrinology Division – Medical School and Hospital Universitário Clementino Fraga Filho – Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leandro Kasuki
- Neuroendocrinology Research Center/Endocrinology Division – Medical School and Hospital Universitário Clementino Fraga Filho – Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division – Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Endocrinology Division – Hospital Federal de Bonsucesso, Rio de Janeiro Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Division – Medical School and Hospital Universitário Clementino Fraga Filho – Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division – Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Neuropatology and Molecular Genetics Laboratory – Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Correspondence should be addressed to M R Gadelha:
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18
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Gatto F, Arvigo M, Ferone D. Somatostatin receptor expression and patients' response to targeted medical treatment in pituitary tumors: evidences and controversies. J Endocrinol Invest 2020; 43:1543-1553. [PMID: 32557353 DOI: 10.1007/s40618-020-01335-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/11/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Somatostatin receptors (SSTs) are widely co-expressed in pituitary tumors. SST2 and SST5 are the most represented SST subtypes. First-generation somatostatin receptor ligands (SRLs) mainly target SST2, while pasireotide, a multi-receptor ligand, shows high binding affinity for both SST5 and SST2. Therefore, SRLs are routinely used as medical treatment for GH-, TSH-, and ACTH-secreting pituitary tumors. METHODS Critical revision of literature data correlating SST expression with patients' response to SRLs. RESULTS SST2 expression in somatroph tumors directly correlates with GH and IGF-1 decrease after first-generation SRL treatment. SST2 immunohistochemistry represents a valuable tool to predict biochemical response to first-generation SRLs in acromegalic patients. Pasireotide seems to exert its biological effects via SST2 in unselected patients. However, in those subjects resistant to first-generation SRLs, harbouring tumors with negligible SST2 expression, pasireotide can act throughout SST5. More than somatotroph tumors, TSH-omas represent the paradigm of tumors showing a satisfactory response to SRLs. This is probably due to the high SST2 expression observed in nearly 100% of cases, as well as to the balanced amount of SST5. In corticotroph tumors, pasireotide mainly act via SST5, although there is a need for translational studies correlating its efficacy with SST expression in this peculiar tumor histotype. CONCLUSIONS The assumption "more target receptor, more drug efficacy" is not straightforward for SRLs. The complex pathophysiology of SSTs, and the technical challenges faced to translate research findings into clinical practice, still need our full commitment to make receptor evaluation a worthwhile procedure for individualizing treatment decisions.
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Affiliation(s)
- F Gatto
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi, 10, 16132, Genoa, Italy.
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DIMI), Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy.
| | - M Arvigo
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DIMI), Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
| | - D Ferone
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi, 10, 16132, Genoa, Italy
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DIMI), Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
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19
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Kasuki L, Antunes X, Lamback EB, Gadelha MR. Acromegaly: Update on Management and Long-Term Morbidities. Endocrinol Metab Clin North Am 2020; 49:475-486. [PMID: 32741483 DOI: 10.1016/j.ecl.2020.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acromegaly is a systemic disease associated with great morbidity and increased mortality if not adequately treated. In the past decades much improvement has been achieved in its treatment and in the knowledge of its comorbidities. We provide an update of acromegaly management with current recommendations. We also address long-term comorbidities emphasizing the changing face of the disease in more recent series, with a decrease of cardiovascular disease severity and an increased awareness of comorbidities like bone disease, manifested mainly as vertebral fractures and the change in the main cause of death (from cardiovascular disease to cancer in more recent series).
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Affiliation(s)
- Leandro Kasuki
- Endocrinology Division, Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, 9° andar - Setor 9, Ilha do Fundão, Rio de Janeiro 21941-913, Brazil; Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, 156th Resende Street, Rio de Janeiro, RJ, Brazil; Endocrinology Division, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Ximene Antunes
- Endocrinology Division, Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, 9° andar - Setor 9, Ilha do Fundão, Rio de Janeiro 21941-913, Brazil
| | - Elisa Baranski Lamback
- Endocrinology Division, Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, 9° andar - Setor 9, Ilha do Fundão, Rio de Janeiro 21941-913, Brazil
| | - Mônica R Gadelha
- Endocrinology Division, Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, 9° andar - Setor 9, Ilha do Fundão, Rio de Janeiro 21941-913, Brazil; Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, 156th Resende Street, Rio de Janeiro, RJ, Brazil; Neuropatology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
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20
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Abstract
Aggressive pituitary tumors (APTs) represent rare pituitary adenomas (PAs) with local invasion of surrounding tissues, increased risk for multiple recurrence, rapid tumor growth, or resistance to standard therapies. The most common APTs in children and adolescents are giant prolactinomas and somatotropinomas. Few cases of Crooke's cell adenomas, silent corticotroph adenomas and pituitary carcinomas have also been reported in the literature. Pediatric patients with APTs have higher risk of harboring germline genetic defects, most commonly in the MEN1 and AIP genes. Since certain genetic defects confer a more aggressive behavior to PAs, genetic testing should be considered in tumors with young onset and positive family history. The management of pediatric APTs involves usually a combination of standard therapies (surgical, medical, radiation). Newer agents, such as temozolomide, have been used in few cases of pediatric pituitary tumors with promising results. In the elderly, PAs are more commonly non-functioning. Their management often poses dilemmas given the coexistence of age-related comorbidities. However, standard surgical treatment and temozolomide seem to be safe and well tolerated in elderly patients.
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Affiliation(s)
- Christina Tatsi
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 10 Center Drive, Building 10, NIH-Clinical Research Center, Room 1-3330, MSC1103, Bethesda, MD, 20892, USA
| | - Constantine A Stratakis
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 10 Center Drive, Building 10, NIH-Clinical Research Center, Room 1-3330, MSC1103, Bethesda, MD, 20892, USA.
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21
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Ambrosio MR, Gagliardi I, Chiloiro S, Ferreira AG, Bondanelli M, Giampietro A, Bianchi A, Marinis LD, Fleseriu M, Zatelli MC. Acromegaly in the elderly patients. Endocrine 2020; 68:16-31. [PMID: 32060689 DOI: 10.1007/s12020-020-02206-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acromegaly is a rare disease characterized by a chronic exposition to growth hormone (GH) and insulin-like growth factor-1 (IGF-1), caused in most cases by a pituitary GH-secreting adenoma. Chronic GH excess induces systemic complications (metabolic, cardiovascular, respiratory, neoplastic, and musculoskeletal) and increased mortality if not appropriately treated. Recent epidemiological data report an improved life span of patients with acromegaly probably due to better acromegaly management; additionally, the number of pituitary incidentaloma in general population also increased over time due to more frequent imaging. Therefore, the number of elderly patients, newly diagnosed with acromegaly or in follow-up, is expected to grow in the coming years and clinicians will need to be aware of particularities in managing these patients. PURPOSE This review aims to explore different aspects of acromegaly of the elderly patients, focusing on epidemiology, diagnosis, clinical presentation, complications, and management options. METHODS Available literature has been assessed through PubMed (data until August 2019) by specific keywords. CONCLUSIONS Available data on acromegaly in the elderly patient are sparse, but point to important differences. Further studies are needed comparing elderly with younger patients with acromegaly to better define a tailored diagnostic and therapeutic management.
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Affiliation(s)
- Maria Rosaria Ambrosio
- Section of Endocrinology & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Irene Gagliardi
- Section of Endocrinology & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Marta Bondanelli
- Section of Endocrinology & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Fleseriu
- Northwest Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Maria Chiara Zatelli
- Section of Endocrinology & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy.
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22
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Cozzi R, Ambrosio MR, Attanasio R, Bozzao A, De Marinis L, De Menis E, Guastamacchia E, Lania A, Lasio G, Logoluso F, Maffei P, Poggi M, Toscano V, Zini M, Chanson P, Katznelson L. Italian Association of Clinical Endocrinologists (AME) and Italian AACE Chapter Position Statement for Clinical Practice: Acromegaly - Part 2: Therapeutic Issues. Endocr Metab Immune Disord Drug Targets 2020; 20:1144-1155. [PMID: 31995025 PMCID: PMC7579256 DOI: 10.2174/1871530320666200129113328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 12/03/2022]
Abstract
Any newly diagnosed patient should be referred to a multidisciplinary team experienced in the treatment of pituitary adenomas. The therapeutic management of acromegaly always requires a personalized strategy. Normal age-matched IGF-I values are the treatment goal. Transsphenoidal surgery by an expert neurosurgeon is the primary treatment modality for most patients, especially if there are neurological complications. In patients with poor clinical conditions or who refuse surgery, primary medical treatment should be offered, firstly with somatostatin analogs (SSAs). In patients who do not reach hormonal targets with first-generation depot SSAs, a second pharmacological option with pasireotide LAR or pegvisomant (alone or combined with SSA) should be offered. Irradiation could be proposed to patients with surgical remnants who would like to be free from long-term medical therapies or those with persistent disease activity or tumor growth despite surgery or medical therapy. Since the therapeutic tools available enable therapeutic targets to be achieved in most cases, the challenge is to focus more on the quality of life.
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Affiliation(s)
- Renato Cozzi
- Address correspondence to this author at the Endocrinologia, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milano, Italy; Tel: +39.347.5225490; E-mail:
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