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Del Rivero J, Else T, Hallanger-Johnson J, Kiseljak-Vassiliades K, Raj N, Reidy-Lagunes D, Srinivas S, Gilbert J, Vaidya A, Aboujaoude E, Bancos I, Tito Fojo A. A review of mitotane in the management of adrenocortical cancer. Oncologist 2024:oyae084. [PMID: 39037424 DOI: 10.1093/oncolo/oyae084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 04/18/2024] [Indexed: 07/23/2024] Open
Abstract
IMPORTANCE Mitotane (Lysodren, o,p'-DDD [1-(o-chlorophenyl)-1-(p-chlorophenyl)-2,2-dichloroethane)] is currently the only United States Food and Drug Administration and European Medicines Agency-approved product for the treatment of adrenocortical carcinoma. OBSERVATIONS Mitotane is challenging to administer; however, its toxicities (specifically adrenal insufficiency) are well known, and the management of adverse consequences has established approaches. While often viewed through the prism of a cytotoxic agent, it can also interfere with hormone production making it a valuable asset in managing functional ACC. A recently completed prospective trial has shed some light on its use in the adjuvant setting, but further clarity is needed. Many think mitotane has a role in the advanced or metastatic setting, although prospective data are lacking and retrospective analyses are often difficult to interpret. CONCLUSIONS AND RELEVANCE When used carefully and thoughtfully, especially in patients with hormonal excess, mitotane is an important component of the treatment armamentarium for ACC.
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Affiliation(s)
- Jaydira Del Rivero
- Developmental Therapeutics Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, United States
| | - Tobias Else
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48104, United States
| | | | - Katja Kiseljak-Vassiliades
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus Aurora, CO 80309, United States
| | - Nitya Raj
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | | | - Sandy Srinivas
- Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Jill Gilbert
- Division of Hematology and Oncology, Vanderbilt University School of Medicine, Nashville, TN 37203, United States
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | | | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, United States
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Altieri B, Kimpel O, Megerle F, Detomas M, Chifu I, Fuss CT, Quinkler M, Kroiss M, Fassnacht M. Recovery of adrenal function after stopping mitotane in patients with adrenocortical carcinoma. Eur J Endocrinol 2024; 190:139-150. [PMID: 38244214 DOI: 10.1093/ejendo/lvae007] [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: 09/06/2023] [Revised: 11/21/2023] [Accepted: 12/28/2023] [Indexed: 01/22/2024]
Abstract
OBJECTIVE Mitotane is the standard therapy of adrenocortical carcinoma (ACC) due to its relative selectivity of its cytotoxic effects toward adrenocortical cells. Therefore, it virtually always leads to adrenal insufficiency. Frequency and characteristics of hypothalamic-pituitary-adrenal axis recovery after discontinuation are ill-defined. METHODS This was a retrospective study of patients with ACC adjuvantly treated with mitotane for ≥12 months who were disease-free at mitotane stop and had a minimum follow-up ≥1 year. Primary endpoint was adrenal recovery. Cox regression analyses were used to identify predictive factors. Moreover, mitotane plasma elimination rate and hormonal changes after mitotane stop were investigated. RESULTS Fifty-six patients (36 women) treated with mitotane for a median time of 25 months and an average daily dose of 2.8 g were included. Median time after discontinuation until mitotane levels dropped below 5 and 2 mg/L, and the detection limit was 152 days (interquartile range: 114-202), 280 days (192-370), and 395 days (227-546), respectively. Full adrenal recovery was documented in 32 (57%) patients after a median time of 26 months (95% confidence interval [CI] = 19.6-32.4). In 4 patients (7.1%), adrenal insufficiency persisted >5 years after discontinuation. Mitotane peak ≥ 27 mg/L significantly correlated with longer time to adrenal recovery (hazard ratio [HR] = 0.2, 95% CI = 0.1-0.8, P = .03). Twenty-seven of 38 patients (71%) followed in reference centers achieved adrenal recovery compared with only 5/18 (28%) followed up in non-reference centers (HR = 4.51, 95% CI = 1.71-11.89, P = .002). Other investigated factors were not associated with adrenal function after discontinuation. CONCLUSIONS Our study demonstrates that adrenal recovery occurs in most patients after stopping mitotane, particularly when followed up in specialized centers, but not in all. Elimination time of mitotane after treatment discontinuation is very long but individually quite variable.
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Affiliation(s)
- Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Otilia Kimpel
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Felix Megerle
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Mario Detomas
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Irina Chifu
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Carmina Teresa Fuss
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Marcus Quinkler
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, 10627 Berlin, Germany
| | - Matthias Kroiss
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
- Department of Internal Medicine IV, University Hospital, Ludwig-Maximilians-University Munich, Ziemssenstrasse 1, 80336 Munich, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Josef-Schneider-Strasse 6, 97080 Würzburg, Germany
- Central Laboratory, University Hospital Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
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Boekstegers A, Schmidt H, Kurzay M, Vallée T, Jung E, Dubinski I, Maxwell R, Schmid I. Cortisol response in children with cancer and fever during chemotherapy: A prospective, observational study using random serum cortisol levels. Cancer Med 2023; 12:9247-9259. [PMID: 36734317 PMCID: PMC10166925 DOI: 10.1002/cam4.5667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/19/2022] [Accepted: 01/20/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Glucocorticoids are crucial components of the treatment of leukemia and lymphoma. High doses can lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis and be causative for an impaired stress response during infection. This study aims to evaluate the cortisol response in pediatric oncologic patients during febrile episodes. METHODS Totally, 75 children and adolescents (5 months-18 years) with fever during chemotherapy were consecutively enrolled in this study. In total, 47 patients received glucocorticoids as part of their treatment. Random serum cortisol and adrenocorticotropic hormone (ACTH) were analyzed in every patient. A low cortisol response (LCR) was defined as a cortisol level < 14.6 μg/dL. RESULTS In total, 52 (69%) patients had a cortisol level < 14.6 μg/dL during fever. There was no significant difference between patients who received glucocorticoids and those who did not. Significantly lower cortisol levels were measured ≤7 days after last glucocorticoid intake compared to later time points. Nearly all patients treated with dexamethasone or prophylactic posaconazole demonstrated a LCR under stress (fever). CONCLUSION The incidence of an impaired HPA axis in pediatric cancer patients might be underestimated since 69% of the children in our study had a LCR during fever. Intake of dexamethasone, posaconazole and a time period of ≤7 days from the last glucocorticoid intake were additional risk factors for an LCR. However, we could not confirm that patients with a LCR fared worse than patients with a high cortisol response (HCR). Therefore, a different cortisol threshold may be necessary for defining an impaired HPA axis in febrile oncologic patients without concomitant symptoms of AI.
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Affiliation(s)
- Ann Boekstegers
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Heinrich Schmidt
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Mathias Kurzay
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Tanja Vallée
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Eva Jung
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Ilja Dubinski
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Rebecca Maxwell
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Irene Schmid
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
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Treatment of adrenocortical carcinoma: oncological and endocrine outcomes. Curr Opin Urol 2023; 33:50-58. [PMID: 36444650 DOI: 10.1097/mou.0000000000001045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Adrenocortical carcinoma (ACC) is a rare, aggressive disease with a paucity of data and great variability between published studies regarding its treatment. This review provides information on current clinical management and oncological and endocrine outcomes. RECENT FINDINGS Complete surgical resection is the only potentially curative treatment for adrenocortical carcinoma (ACC). Adjuvant mitotane treatment is recommended in patients with favourable/intermediate prognosis. As part of the endocrine follow-up, steroid hormones and thyroid hormones may be decreased or increased and may need to be substituted or suppressed. Recurrences are common. If the disease-free interval is more than 12 months, surgery is a treatment if complete resection is feasible. In advanced/metastatic ACC patients, the prognosis is poor. Mitotane monotherapy is only appropriate for patients with low tumour burden and indolent disease. Patients with unfavourable prognosis should be treated with aggressive cytotoxic therapy. Patients requiring third-line treatment should be considered for clinical trials. Immunotherapy and targeted therapy are currently being investigated, but have so far yielded only unsatisfactory results. SUMMARY There is scarce evidence for the treatment of ACC, which often complicates clinical decision-making. Patients who progress on EDP-M should be treated in clinical trials.
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Sex-Based Evaluation of Lipid Profile in Postoperative Adjuvant Mitotane Treatment for Adrenocortical Carcinoma. Biomedicines 2022; 10:biomedicines10081873. [PMID: 36009421 PMCID: PMC9405852 DOI: 10.3390/biomedicines10081873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/28/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background: A wide interindividual variability in mitotane concentrations and treatment-related dyslipidemia have been reported. Here, we aimed to underline the sex-related differences in the lipid profile in patients that underwent radical surgery of adrenocortical carcinoma during treatment with adjuvant mitotane. Methods: A chromatographic method was used to quantify the drug in plasma collected from adult patients with complete tumor resection, also considering active metabolite o,p’-DDE. Results: We observed different lipid profiles between males and females and between pre- and post-menopausal women. Considering the mitotane-related effects on lipid levels, we observed that higher drug concentrations were correlated with higher HDL in all the considered groups (p < 0.001), with total cholesterol both in males (p = 0.005) and females (p = 0.036), with triglycerides in postmenopausal females (p = 0.002) and with LDL in male patients (p < 0.001). Increases in o,p’-DDE were positively correlated with HDL levels in all the groups (p < 0.001) and negatively with LDL in all the groups (males p = 0.008, pre- and post-menopausal females p < 0.001), with total cholesterol in pre- (p = 0.016) and post-menopausal women (p = 0.01) and with triglycerides in premenopausal females (p = 0.005). Conclusions: This is the first study designed to evaluate sex differences in lipoprotein and lipid levels during mitotane adjuvant treatment; the results suggest that a gender and personalized approach could be useful to prevent and manage alterations in the lipid profile.
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Lo Iacono M, Puglisi S, Perotti P, Saba L, Petiti J, Giachino C, Reimondo G, Terzolo M. Molecular Mechanisms of Mitotane Action in Adrenocortical Cancer Based on In Vitro Studies. Cancers (Basel) 2021; 13:cancers13215255. [PMID: 34771418 PMCID: PMC8582505 DOI: 10.3390/cancers13215255] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/16/2021] [Accepted: 10/16/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Mitotane is the only approved drug for the treatment of advanced adrenocortical carcinoma and for postoperative adjuvant therapy. It is known that mitotane destroys the adrenal cortex impairing steroidogenesis, although its exact molecular mechanism is still unclear. However, confounding factors affecting in vitro experiments could reduce the relevance of the studies. In this review, we explore in vitro studies on mitotane effects, highlighting how different experimental conditions might contribute to the controversial findings. On this basis, it may be necessary to re-evaluate the experiments taking into account their potential confounding factors such as cell strains, culture serum, lipoprotein concentration, and culture passages, which could hide important molecular results. As a consequence, the identification of novel pharmacological molecular pathways might be used in the future to implement personalized therapy, maximizing the benefit of mitotane treatment while minimizing its toxicity. Abstract Mitotane is the only approved drug for the treatment of advanced adrenocortical carcinoma and is increasingly used for postoperative adjuvant therapy. Mitotane action involves the deregulation of cytochromes P450 enzymes, depolarization of mitochondrial membranes, and accumulation of free cholesterol, leading to cell death. Although it is known that mitotane destroys the adrenal cortex and impairs steroidogenesis, its exact mechanism of action is still unclear. The most used cell models are H295-derived cell strains and SW13 cell lines. The diverging results obtained in presumably identical cell lines highlight the need for a stable in vitro model and/or a standard methodology to perform experiments on H295 strains. The presence of several enzymatic targets responsive to mitotane in mitochondria and mitochondria-associated membranes causes progressive alteration in mitochondrial structure when cells were exposed to mitotane. Confounding factors of culture affecting in vitro experiments could reduce the significance of any molecular mechanism identified in vitro. To ensure experimental reproducibility, particular care should be taken in the choice of culture conditions: aspects such as cell strains, culture serum, lipoproteins concentration, and culture passages should be carefully considered and explicated in the presentation of results. We aimed to review in vitro studies on mitotane effects, highlighting how different experimental conditions might contribute to the controversial findings. If the concerns pointed out in this review will be overcome, the new insights into mitotane mechanism of action observed in-vitro could allow the identification of novel pharmacological molecular pathways to be used to implement personalized therapy.
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Metabolic and Endocrine Toxicities of Mitotane: A Systematic Review. Cancers (Basel) 2021; 13:cancers13195001. [PMID: 34638485 PMCID: PMC8508479 DOI: 10.3390/cancers13195001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/29/2021] [Accepted: 10/02/2021] [Indexed: 12/05/2022] Open
Abstract
Simple Summary This is, to our knowledge, the first systematic review conducted on the endocrine effects of mitotane, which aims to collect all available evidence in the literature and provide complete and useful information regarding the management of the endocrine and metabolic side effects of mitotane in clinical practice. Abstract Despite the pivotal role of mitotane in adrenocortical carcinoma (ACC) management, data on the endocrine toxicities of this treatment are lacking. The aim of this systematic review is to collect the available evidence on the side effects of mitotane on the endocrine and metabolic systems in both children and adults affected by adrenal carcinoma. Sixteen articles on 493 patients were included. Among the adrenal insufficiency, which is an expected side effect of mitotane, 24.5% of patients increased glucocorticoid replacement therapy. Mineralocorticoid insufficiency usually occurred late in treatment in 36.8% of patients. Thyroid dysfunction is characterized by a decrease in FT4, which occurs within 3–6 months of treatment in 45.4% of patients, while TSH seems to not be a reliable marker. Dyslipidemia is characterized by an increase in both LDL-c and HDL-c (54.2%). Few studies have found evidence of hypertriglyceridemia. In males, gynecomastia and hypogonadism can occur after 3–6 months of treatment (38.4% and 35.6%, respectively), while in pre-menopausal women, mitotane can cause ovarian cysts and, less frequently, menstrual disorders. Most of these side effects appear to be reversible after mitotane discontinuation. We finally suggest an algorithm that could guide metabolic and endocrine safety assessments in patients treated with mitotane for ACC.
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Uchihara M, Tanioka M, Kojima Y, Nishikawa T, Sudo K, Shimoi T, Noguchi E, Maeshima AM, Yonemori K. Clinical management and outcomes associated with etoposide, doxorubicin, and cisplatin plus mitotane treatment in metastatic adrenocortical carcinoma: a single institute experience. Int J Clin Oncol 2021; 26:2275-2281. [PMID: 34468885 DOI: 10.1007/s10147-021-02021-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare and aggressive disease that is often diagnosed at an advanced stage. There is no standard treatment for metastatic ACC; EDP-M (etoposide, doxorubicin, and cisplatin plus mitotane) is one treatment option. A randomized controlled trial (FIRM-ACT) evaluating the efficacy of EDP-M showed progression-free survival (PFS) was 5.0 months, overall survival (OS) was 14.8 months, the response rate was 19%, and adrenal insufficiency occurred in 3.4% of patients. However, the efficacy and safety of this regimen in Asia are not fully reported. METHODS We retrospectively analyzed 43 patients diagnosed with metastatic ACC at the National Cancer Center Hospital between 1997 and 2020. We evaluated PFS, OS, and response in 17 patients who received EDP-M as first-line therapy. RESULTS The median age at treatment initiation was 45 years (range 18-74). Eight patients (47%) had autonomous hormone production, including six patients with hypercortisolism. The best response of partial response and stable disease was seen in two (12%) and ten (59%) patients, respectively. The median PFS was 6.2 months [95% confidence interval (CI): 4.3-10.0]. The median OS was 15.4 months (95% CI 11.6-not reached). Three patients received only one cycle due to adverse effects associated with hypercortisolism. Grade 3/4 adverse events associated with adrenal insufficiency occurred in three (17%) cases, resulting in EDP-M discontinuation. CONCLUSIONS The EDP-M regimen had similar PFS to that observed in FIRM-ACT. Adrenal insufficiency was more frequent in the current study, but this could be managed with supportive endocrinological care such as cortisol replacement.
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Affiliation(s)
- Masaki Uchihara
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan.,Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku City, Tokyo, 162-8655, Japan
| | - Maki Tanioka
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Yuki Kojima
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tadaaki Nishikawa
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Kazuki Sudo
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tatsunori Shimoi
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Emi Noguchi
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Akiko Miyagi Maeshima
- Department of Diagnostic Pathology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Kan Yonemori
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
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Zhou Z, Luo HM, Tang J, Xu WJ, Wang BH, Peng XH, Tan H, Liu L, Long XY, Hong YD, Wu XB, Wang JP, Wang BQ, Xie HH, Fang Y, Luo Y, Li R, Wang Y. Multidisciplinary team therapy for left giant adrenocortical carcinoma: A case report. World J Clin Cases 2021; 9:5737-5743. [PMID: 34307633 PMCID: PMC8281393 DOI: 10.12998/wjcc.v9.i20.5737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/06/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare malignant epithelial tumor originating from adrenocortical cells that carries a very poor prognosis. Metastatic or inoperable diseases are often considered incurable, and treatment remains a challenge. Especially for advanced cases such as ACC complicated with renal venous cancer thrombus, there are few cumulative cases in the literature.
CASE SUMMARY The patient in this case was a 39-year-old middle-aged male who was admitted to the hospital for more than half a month due to dizziness and chest tightness. Computed tomography (CT) findings after admission revealed a left retroperitoneal malignant space-occupying lesion, but the origin of the formation of the left renal vein cancer thrombus remained to be determined. It was speculated that it originated from the left adrenal gland, perhaps a retroperitoneal source, and left adrenal mass + left nephrectomy + left renal vein tumor thrombus removal + angioplasty were performed under general anesthesia. Postoperative pathology results indicated a diagnosis of ACC. Postoperative steroid therapy was administered. At 3 mo after surgery, abdominal CT reexamination revealed multiple enlarged retroperitoneal lymph nodes and multiple low-density shadows in the liver, and palliative radiotherapy and mitotane were administered, considering the possibility of metastasis. The patient is currently being followed up.
CONCLUSION ACC is a highly malignant tumor. Even if the tumor is removed surgically, there is still the possibility of recurrence. Postoperative mitotane and adjuvant chemoradiotherapy have certain benefits for patients, but they cannot fully offset the poor prognosis of this disease.
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Affiliation(s)
- Zheng Zhou
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Hong-Mei Luo
- Department of Histology and Embryology, Clinical Anatomy and Reproductive Medicine Application Institute, University of South China, Hengyang 421001, Hunan Province, China
| | - Jian Tang
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Wu-Jun Xu
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Bin-Hui Wang
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Xu-Hui Peng
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Heng Tan
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Li Liu
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Xiang-Yang Long
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Yu-De Hong
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Xiao-Bin Wu
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Jian-Ping Wang
- Department of Endocrinology, The Second Affiliated Hospital of University of South China, Hengyang 421001, Hunan Province, China
| | - Bai-Qi Wang
- Department of Oncology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Hai-Hui Xie
- Department of Radiotherapy , The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Yong Fang
- Department of Pathology, The Second Affiliated Hospital , University of South China, Hengyang 421001, Hunan Province, China
| | - Yong Luo
- Department of ICU, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Rong Li
- Department of Clinical Pharmacy, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
| | - Yi Wang
- Department of Urology, The Second Affiliated Hospital, University of South China, Hengyang 421001, Hunan Province, China
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Corso CR, Acco A, Bach C, Bonatto SJR, de Figueiredo BC, de Souza LM. Pharmacological profile and effects of mitotane in adrenocortical carcinoma. Br J Clin Pharmacol 2021; 87:2698-2710. [PMID: 33382119 DOI: 10.1111/bcp.14721] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 12/20/2022] Open
Abstract
Mitotane is the only adrenolytic drug approved by the Food and Drug Administration for treating adrenocortical carcinoma (ACC). This drug has cytotoxic effects on tumour tissues; it induces cell death and antisecretory effects on adrenal cells by inhibiting the synthesis of adrenocortical steroids, which are involved in the pathogenesis of ACC. However, high doses of mitotane are usually necessary to reach the therapeutic plasma concentration, which may result in several adverse effects. This suggests that important pharmacological processes, such as first pass metabolism, tissue accumulation and extensive time for drug elimination, are associated with mitotane administration. Few studies have reported the pharmacological aspects and therapeutic effects of mitotane. Therefore, the aim of this review was to summarize the chemistry, pharmacokinetics and pharmacodynamics, and therapeutic and toxic effects of mitotane. This review also discusses new perspectives of mitotane formulation that are currently under investigation. Understanding the pharmacological profile of mitotane can improve the monitoring and efficacy of this drug in ACC treatment and can provide useful information for the development of new drugs with specific action against ACC with fewer adverse effects.
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Affiliation(s)
- Claudia Rita Corso
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, Brazil.,Faculdades Pequeno Príncipe, Curitiba, Brazil
| | - Alexandra Acco
- Pharmacology Department, Federal University of Paraná, Curitiba, Brazil
| | - Camila Bach
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, Brazil.,Faculdades Pequeno Príncipe, Curitiba, Brazil
| | - Sandro José Ribeiro Bonatto
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, Brazil.,Faculdades Pequeno Príncipe, Curitiba, Brazil
| | | | - Lauro Mera de Souza
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, Brazil.,Faculdades Pequeno Príncipe, Curitiba, Brazil
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Vikner ME, Krogh J, Daugaard G, Andreassen M. Metabolic and hormonal side effects of mitotane treatment for adrenocortical carcinoma: A retrospective study in 50 Danish patients. Clin Endocrinol (Oxf) 2021; 94:141-149. [PMID: 32996176 DOI: 10.1111/cen.14345] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Mitotane is used in the treatment of adrenocortical carcinoma (ACC). Metabolic and hormonal side effects of mitotane, the effect of subsequent treatment with statins and hormones and the effects of discontinuation of mitotane were assessed. PATIENTS AND METHODS Fifty patients were included. Lipid profiles, thyroid hormones, sex hormones and adrenal function from first year of mitotane treatment and after cessation were evaluated. RESULTS After 6 months of mitotane treatment total cholesterol increased from (median) 5.1 (IQR 4.3 to 5.8) to 7.4 (6.2-9.0) mmol/L, p < .001. LDL, HDL and triglyceride also increased, all p ≤ .03. Three months of treatment with statins decreased total and LDL-cholesterol, and cessation of mitotane led to further reduction in lipids. Plasma thyroxine decreased from 90 (78-111) to 57 (47-63) nmol/L and free thyroxine from 16.0 (13.0-18.3) to 11.7 (10.5-12.6) pmol/L on mitotane, both p < .001, while TSH remained unchanged. Treatment with thyroxin significantly increased plasma thyroxine and free thyroxine and decreased TSH. Cessation of mitotane increased total T4 (p < .001). Mitotane increased plasma SHBG from 36 (22-51) to 189 (85-259) nmol/L and LH from 4.6 (1.6-8.1) to 20.0 (10.0-34.9) IU/L, both p < .001. In males the changes were accompanied by an increase in testosterone from 9.8 (7.2-14.5) to 27.0 (15.3-34.8) nmol/L, p < .03. Fifteen of 24 tested patients regained normal adrenal function 6 (3-16) months after cessation of mitotane. CONCLUSIONS Mitotane treatment exerts multiple severe side effects involving both the metabolic and endocrine systems that may require treatment, but the effect appears to be partially reversible.
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Affiliation(s)
- Malene Elbaek Vikner
- Department of Endocrinology, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark
| | - Jesper Krogh
- Department of Endocrinology, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark
| | - Gedske Daugaard
- Department of Oncology, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark
| | - Mikkel Andreassen
- Department of Endocrinology, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark
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Muratori L, Pia A, Reimondo G, Pisano C, La Salvia A, Puglisi S, Scagliotti GV, Sperone P. Prolonged Adrenal Insufficiency After the Discontinuation of Mitotane Therapy. Endocr Metab Immune Disord Drug Targets 2021; 20:485-487. [PMID: 31544707 DOI: 10.2174/1871530319666190809144620] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/02/2019] [Accepted: 07/04/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Adrenocortical carcinoma (ACC) is a rare neoplasm characterized by a high risk of recurrence after radical resection. The role of adjuvant systemic therapy in radically resected patients is unclear. Mitotane, a steroidogenesis inhibitor, is the only drug approved for the systemic treatment of advanced ACC. In 2007, a retrospective case-control study provided the evidence that mitotane, administered for two years after successful surgery, could prolong recurrence-free survival. Adrenal insufficiency (AI), which occurs in almost all patients during the first 12 months of treatment, is an expected side effect of mitotane and requires steroid replacement therapy. Due to its long halflife, mitotane-induced AI persists several months after treatment discontinuation and is managed by cautious tapering of glucocorticoid replacement therapy. RESULTS We report a case of symptomatic AI diagnosed after a severe allergic reaction occurring three years after the discontinuation of adjuvant mitotane therapy. CONCLUSION The case suggests that mitotane-induced AI should be monitored for a long time to asses full recovery of adrenal function, in order to prevent adrenal crises.
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Affiliation(s)
- Leonardo Muratori
- Medical Oncology, Department of Oncology, University of Turin, Azienda Ospedaliera Universitaria San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Anna Pia
- Internal Medicine and Endocrinology Unit, Department of Clinical and Biological Sciences, University of Turin, Azienda Ospedaliera Universitaria San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Giuseppe Reimondo
- Internal Medicine and Endocrinology Unit, Department of Clinical and Biological Sciences, University of Turin, Azienda Ospedaliera Universitaria San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Chiara Pisano
- Medical Oncology, Department of Oncology, University of Turin, Azienda Ospedaliera Universitaria San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Anna La Salvia
- Medical Oncology, Department of Oncology, Hospital Universitario 12 de Octubre, Avenida Cordoba, s/n, 28041 Madrid, Spagna, Madrid, Spain
| | - Soraya Puglisi
- Internal Medicine and Endocrinology Unit, Department of Clinical and Biological Sciences, University of Turin, Azienda Ospedaliera Universitaria San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Giorgio Vittorio Scagliotti
- Medical Oncology, Department of Oncology, University of Turin, Azienda Ospedaliera Universitaria San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Paola Sperone
- Medical Oncology, Department of Oncology, University of Turin, Azienda Ospedaliera Universitaria San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
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13
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Steroid-Induced Iatrogenic Adrenal Insufficiency in Children: A Literature Review. ENDOCRINES 2020. [DOI: 10.3390/endocrines1020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The present review focuses on steroid-induced adrenal insufficiency (SIAI) in children and discusses the latest findings by surveying recent studies. SIAI is a condition involving adrenocorticotropic hormone (ACTH) and cortisol suppression due to high doses or prolonged administration of glucocorticoids. While its chronic symptoms, such as fatigue and loss of appetite, are nonspecific, exposure to physical stressors, such as infection and surgery, increases the risk of adrenal crisis development accompanied by hypoglycemia, hypotension, or shock. The low-dose ACTH stimulation test is generally used for diagnosis, and the early morning serum cortisol level has also been shown to be useful in screening for the condition. Medical management includes gradually reducing the amount of steroid treatment, continuing administration of hydrocortisone corresponding to the physiological range, and increasing the dosage when physical stressors are present.
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14
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Paragliola RM, Corsello A, Locantore P, Papi G, Pontecorvi A, Corsello SM. Medical Approaches in Adrenocortical Carcinoma. Biomedicines 2020; 8:biomedicines8120551. [PMID: 33260476 PMCID: PMC7760807 DOI: 10.3390/biomedicines8120551] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/15/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
Adrenocortical carcinoma (ACC) represents one of the most aggressive endocrine tumors. In spite of a correct therapeutic strategy based on a multidisciplinary approach between endocrinologist, surgeon and oncologist, the prognosis is often poor. Surgery is the mainstay treatment in ACC. Mitotane, a dichloro-diphenyl-trichloro-ethane derivate, represents the main medical treatment of ACC in consideration of its adrenocytolitic activity and it is mainly employed as adjuvant treatment after complete surgical resection and for the treatment of advanced ACC. However, the use of mitotane as adjuvant therapy is still controversial, also in consideration of the retrospective nature of several studies. The recurrence of disease is frequent, especially in advanced disease at the diagnosis. Therefore, in these contexts, conventional chemotherapy must be considered in association with mitotane, being the combination etoposide, doxorubicin and cisplatin (EDP) the standard of care in this setting. A more modern therapeutic approach, based on the need of a salvage therapy for advanced ACC that progresses through first-line EDP, is focused on molecular-targeted therapies. However, robust clinical trials are necessary to assess the real efficacy of these treatments.
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15
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Unwanted Hormonal and Metabolic Effects of Postoperative Adjuvant Mitotane Treatment for Adrenocortical Cancer. Cancers (Basel) 2020; 12:cancers12092615. [PMID: 32937772 PMCID: PMC7565701 DOI: 10.3390/cancers12092615] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Mitotane is the only drug approved for treatment of adrenocortical cancer. Although mitotane is a derivative of the pesticide dichlorodiphenyltrichloroethane (DDT), limited data are available on its toxicity. Herein, we reported on the type and frequency of mitotane adverse events and on supportive therapies used to deal with toxicity in 74 mitotane-treated patients. Beyond the expected glucocorticoid insufficiency, a significant number of patients had a deficit of mineralocorticoid hormones, hypothyroid state and impaired testicular function, while fertile women frequently developed ovarian cysts during mitotane treatment. Multiple hormone replacement therapies were needed in >30% of patients. Statins were used in 50% of patients for significant hypercholesterolemia. Supportive therapies were able to revert the biochemical alterations, although higher doses were frequently used due to pharmacokinetic interactions with mitotane. Our study underlines the need of a careful and global approach to manage mitotane toxicity, to make adjuvant therapy safer and easier for patients. Abstract Mitotane is widely used for the treatment of adrenocortical cancer (ACC), although the drug-related toxicity complicates its use. The aim of this study is to assess comprehensively the different endocrine and metabolic unwanted effects of the drug, and to provide data on the supportive therapies. We retrospectively analyzed 74 ACC patients adjuvantly treated with mitotane for ≥12 months. During the treatment period (40 months, 12–195), 32.4% of patients needed replacement therapy for mineralocorticoid deficit, 36.2% for hypothyroidism and 34.3% for male hypogonadism. In fertile women, hypogonadism was uncommon, while 65.4% of women developed ovarian cysts. Although no significant change in low-density lipoprotein (LDL) was observed, statins were started in 50% of patients for a significant increase in total cholesterol and triglycerides. Dyslipidemia occurred early, after a median time of 6 months from mitotane start. Conversely, testosterone replacement was usually started after >2 years. In many cases, ranging from 29.4% to 50% according to the side effect, toxicity occurred well before the achievement of the target mitotane concentrations. Supportive therapies were able to revert the biochemical alterations induced by mitotane, although higher doses were needed for a likely pharmacokinetic interaction of exogenous steroids and statins with mitotane. In conclusion, adjuvant mitotane therapy is associated with a spectrum of unwanted effects encompassing the function of different endocrine glands and requires a careful clinical and biochemical assessment associated with the therapeutic drug monitoring.
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16
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Puglisi S, Calabrese A, Basile V, Pia A, Reimondo G, Perotti P, Terzolo M. New perspectives for mitotane treatment of adrenocortical carcinoma. Best Pract Res Clin Endocrinol Metab 2020; 34:101415. [PMID: 32179008 DOI: 10.1016/j.beem.2020.101415] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Adrenocortical carcinoma (ACC) is an aggressive cancer characterized by poor survival. Apart from radical surgery, there is a limited range of therapeutic options and mitotane remains the cornerstone of medical treatment of ACC in either adjuvant or palliative settings. The aim of adjuvant mitotane therapy is to reduce the risk of ACC recurrence following surgical removal of the tumor. Use of mitotane in an adjuvant setting is off-label, but the recent guidelines endorsed by the European Society of Endocrinology (ESE) and the European Network for the Study of Adrenal Tumors (ENSAT) recommend it in ACC patients at high risk of recurrence. The palliative use of mitotane for treatment of advanced ACC aims at controlling tumor progression and, when present, hormone secretion. In this clinical setting, mitotane is used in association with chemotherapy to treat the more aggressive forms, while mitotane monotherapy is reserved for less progressive ACC. Many years after its introduction in clinical practice, there are still uncertainties surrounding the use of this old drug and the derived benefits. Moreover, physicians who use mitotane should recognize and manage the systemic effects of the drug that need a complex supporting therapy.
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Affiliation(s)
- S Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - A Calabrese
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - V Basile
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - A Pia
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - G Reimondo
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - P Perotti
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - M Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy.
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17
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Involvement of 27-Hydroxycholesterol in Mitotane Action on Adrenocortical Carcinoma. Cells 2020; 9:cells9040885. [PMID: 32260362 PMCID: PMC7226725 DOI: 10.3390/cells9040885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 12/25/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare cancer with poor prognosis. Mitotane, the standard treatment for ACC, impairs adrenocortical steroid biosynthesis and cholesterol metabolism. In the H295R cell line, a standard ACC in vitro model, mitotane was previously reported to enhance the production of some oxysterols. To verify the possible mechanistic involvement of oxysterols in the anti-ACC effect of mitotane, a gas chromatography mass spectrometry (GC-MS) profiling of oxysterols and the main cholesterol precursors was carried out in H295R cells. Among the oxysterols detected in mitotane-treated cells, 27OHC was markedly produced, as well as lanosterol and lathosterol cholesterol precursors. In this cell model, mitotane was confirmed to affect mitochondrial transmembrane potential and induce apoptosis. Such cytotoxic effects were perfectly matched by H295R cell treatment with a single identical micromolar amount of 27OHC. The mitotane-dependent strong increase in 27OHC was confirmed in vivo, in the plasma of ACC patients under treatment with the drug. Moreover, lanosterol, lathosterol, desmosterol and, to a minor extent, 24-hydroxycholesterol and 25-hydroxycholesterol plasma levels were significantly increased in those patients. The cytotoxic effect of mitotane on ACC cells may be partly related to the increased intracellular level of 27OHC induced by the drug itself.
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18
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Recovery of Adrenal Insufficiency Is Frequent After Adjuvant Mitotane Therapy in Patients with Adrenocortical Carcinoma. Cancers (Basel) 2020; 12:cancers12030639. [PMID: 32164326 PMCID: PMC7139486 DOI: 10.3390/cancers12030639] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Mitotane is a steroidogenesis inhibitor and adrenolytic drug used for treatment of adrenocortical cancer (ACC). Mitotane therapy causes adrenal insufficiency requiring glucocorticoid replacement in all patients. However, it is unclear whether chronic therapy with mitotane induces complete destruction of zona fasciculata and whether hypothalamic-pituitary-adrenal (HPA) axis can recover after treatment cessation. Our objective was to assess the HPA axis recovery in a cohort of patients after cessation of adjuvant mitotane therapy for ACC. We retrospectively reviewed patient files with stage I-II-III ACC in two referral centers in Canada and Italy. Data on demographics, tumor characteristics, hormonal profile, and HPA axis were collected. Data from 23 patients with pathologically proven ACC treated with adjuvant mitotane for a minimum of two years were analyzed. Eight patients were males and 15 were females and the median age was 41 years old (range 18 to 73). After mitotane cessation, 18/23 (78.3%) patients achieved a complete HPA axis recovery while 3/23 (13.0%) were unable to tolerate glucocorticoid withdrawal despite having normal hormonal test values and 2/23 (8.7%) never achieved recovery. The mean time interval between mitotane cessation and HPA axis recovery was 2.7 years. A high proportion of patients achieved HPA axis recovery following cessation of mitotane adjuvant therapy. However, complete recovery was often delayed up to 2.5 years and regular assessment of the hormonal profile is required.
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19
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Fassnacht M, Dekkers O, Else T, Baudin E, Berruti A, de Krijger R, Haak H, Mihai R, Assie G, Terzolo M. European Society of Endocrinology Clinical Practice Guidelines on the management of adrenocortical carcinoma in adults, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2018; 179:G1-G46. [PMID: 30299884 DOI: 10.1530/eje-18-0608] [Citation(s) in RCA: 486] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Adrenocortical carcinoma (ACC) is a rare and in most cases steroid hormone-producing tumor with variable prognosis. The purpose of these guidelines is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with ACC based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions, which we judged as particularly important for the management of ACC patients and performed systematic literature searches: (A) What is needed to diagnose an ACC by histopathology? (B) Which are the best prognostic markers in ACC? (C) Is adjuvant therapy able to prevent recurrent disease or reduce mortality after radical resection? (D) What is the best treatment option for macroscopically incompletely resected, recurrent or metastatic disease? Other relevant questions were discussed within the group. Selected Recommendations: (i) We recommend that all patients with suspected and proven ACC are discussed in a multidisciplinary expert team meeting. (ii) We recommend that every patient with (suspected) ACC should undergo careful clinical assessment, detailed endocrine work-up to identify autonomous hormone excess and adrenal-focused imaging. (iii) We recommend that adrenal surgery for (suspected) ACC should be performed only by surgeons experienced in adrenal and oncological surgery aiming at a complete en bloc resection (including resection of oligo-metastatic disease). (iv) We suggest that all suspected ACC should be reviewed by an expert adrenal pathologist using the Weiss score and providing Ki67 index. (v) We suggest adjuvant mitotane treatment in patients after radical surgery that have a perceived high risk of recurrence (ENSAT stage III, or R1 resection, or Ki67 >10%). (vi) For advanced ACC not amenable to complete surgical resection, local therapeutic measures (e.g. radiation therapy, radiofrequency ablation, chemoembolization) are of particular value. However, we suggest against the routine use of adrenal surgery in case of widespread metastatic disease. In these patients, we recommend either mitotane monotherapy or mitotane, etoposide, doxorubicin and cisplatin depending on prognostic parameters. In selected patients with a good response, surgery may be subsequently considered. (vii) In patients with recurrent disease and a disease-free interval of at least 12 months, in whom a complete resection/ablation seems feasible, we recommend surgery or alternatively other local therapies. Furthermore, we offer detailed recommendations about the management of mitotane treatment and other supportive therapies. Finally, we suggest directions for future research.
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Affiliation(s)
- Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Olaf Dekkers
- Department of Clinical Epidemiology
- Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Tobias Else
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric Baudin
- Endocrine Oncology and Nuclear Medicine, Institut Gustave Roussy, Villejuif, France
- INSERM UMR 1185, Faculté de Médecine, Le Kremlin-Bicêtre, Université Paris Sud, Paris, France
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia at ASST Spedali Civili, Brescia, Italy
| | - Ronald de Krijger
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Pathology, Reinier de Graaf Hospital, Delft, the Netherlands
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Harm Haak
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
- Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, the Netherlands
- Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Guillaume Assie
- Department of Endocrinology, Reference Center for Rare Adrenal Diseases, Reference Center dor Rare Adrenal Cancers, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Institut Cochin, Institut National de la Santé et de la Recherche Médicale U1016, Centre National de la Recherche Scientifique UMR8104, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Hospital, University of Turin, Orbassano, Italy
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20
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Paragliola RM, Torino F, Papi G, Locantore P, Pontecorvi A, Corsello SM. Role of Mitotane in Adrenocortical Carcinoma - Review and State of the art. EUROPEAN ENDOCRINOLOGY 2018; 14:62-66. [PMID: 30349596 PMCID: PMC6182924 DOI: 10.17925/ee.2018.14.2.62] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/29/2018] [Indexed: 12/29/2022]
Abstract
Adrenocortical carcinoma (ACC) is a rare and aggressive endocrine tumour deriving from the adrenal cortex. A correct therapeutic strategy requires a multidisciplinary approach between endocrinologist, surgeon and oncologist. Surgery is the mainstay treatment in ACC while mitotane, deriving from the insecticide dichloro-diphenyl-trichloro-ethane, is the main base of the medical treatment of ACC in consideration of its adrenocytolitic activity. However, the use of mitotane as adjuvant therapy is still controversial, also in consideration of the retrospective nature of several studies. A prospective randomised trial (ADIUVO), recruiting patients with low-intermediate risk of recurrence, is evaluating the utility of adjuvant treatment with mitotane in this setting. The therapeutic response is observed with plasma levels of mitotane >14 mg/L. However, the major difficulty in the management of mitotane treatment is related to side effects and to the risk of toxicity, which is related to plasmatic levels >20 mg/L, that is considered the upper limit of the therapeutic window. Mitotane therapy results in adrenal insufficiency, and glucocorticoid replacement therapy has to be administered at higher doses than those used in other aetiologies of primary adrenal insufficiency. Furthermore, other endocrine side effects related to mitotane should be considered, in particular on thyroid hormone and testosterone metabolism. Waiting for new medical strategies on molecular targets, it will be mandatory to optimise the current knowledge by prospective trials and, in consideration of the rarity of the disease, collaborative studies between endocrinologists and oncologists are necessary.
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Affiliation(s)
- Rosa Maria Paragliola
- Unit of Endocrinology, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Francesco Torino
- Department of Systems Medicine, Medical Oncology, University of Rome Teor Vergata, Rome, Italy
| | - Giampaolo Papi
- Unit of Endocrinology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pietro Locantore
- Unit of Endocrinology, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Alfredo Pontecorvi
- Unit of Endocrinology, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Salvatore Maria Corsello
- Unit of Endocrinology, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
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Puglisi S, Perotti P, Cosentini D, Roca E, Basile V, Berruti A, Terzolo M. Decision-making for adrenocortical carcinoma: surgical, systemic, and endocrine management options. Expert Rev Anticancer Ther 2018; 18:1125-1133. [PMID: 30117750 DOI: 10.1080/14737140.2018.1510325] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Adrenocortical carcinoma (ACC) is a rare tumor characterized by poor prognosis in most cases. Moreover, in most cases ACC produces an excess of adrenal steroid hormones with relevant clinical consequences. Areas covered: After an extensive literature search, this narrative review addresses diagnostic management, including hormonal, radiological and pathological assessment, and treatment, which should be directed toward both cancer and hormone related problems. While surgery is the first option in ACC without evidence of metastatic disease, and the only possibility of cure, the therapeutic management of metastatic patients is centered on systemic therapy including mitotane alone or in combination with chemotherapy. Mitotane is also used in the adjuvant setting, because up to 80% of patients with nonmetastatic ACC show locoregional or distant metastases after an apparent complete surgical excision. Expert commentary: Management of ACC patients is fraught with many difficulties and should be limited to experienced physicians. Each step of clinical management, such as diagnosis, prognostication, treatment (both surgical and medical) is challenging and carries the possibility of severe mistakes. For this reason, each step of the management strategy should be decided in the setting of a multidisciplinary team including different expertise (endocrinology, radiology, pathology, oncology), in expert centers.
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Affiliation(s)
- Soraya Puglisi
- a Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Hospital , University of Turin , Orbassano (TO) , Italy
| | - Paola Perotti
- a Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Hospital , University of Turin , Orbassano (TO) , Italy
| | - Deborah Cosentini
- b Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili Hospital , University of Brescia , Brescia , Italy
| | - Elisa Roca
- b Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili Hospital , University of Brescia , Brescia , Italy
| | - Vittoria Basile
- a Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Hospital , University of Turin , Orbassano (TO) , Italy
| | - Alfredo Berruti
- b Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili Hospital , University of Brescia , Brescia , Italy
| | - Massimo Terzolo
- a Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Hospital , University of Turin , Orbassano (TO) , Italy
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