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Baudin E, Capdevila J, Hörsch D, Singh S, Caplin ME, Wolin EM, Buikhuisen W, Raderer M, Dansin E, Grohe C, Ferone D, Houchard A, Truong-Thanh XM, Reidy-Lagunes D. Treatment of advanced BP-NETS with lanreotide autogel/depot vs placebo: the phase III SPINET study. Endocr Relat Cancer 2024; 31:e230337. [PMID: 38913539 PMCID: PMC11301421 DOI: 10.1530/erc-23-0337] [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: 12/11/2023] [Accepted: 06/24/2024] [Indexed: 06/26/2024]
Abstract
Prospective data are lacking on early somatostatin analog (SSA) therapy in bronchopulmonary neuroendocrine tumors (BP-NETs; typical carcinoids and atypical carcinoids (TCs and ACs)). SPINET (EudraCT: 2015-004992-62; NCT02683941) was a phase III, double-blind study of lanreotide autogel/depot (LAN; 120 mg every 28 days) plus best supportive care (BSC) vs placebo plus BSC, with an optional open-label treatment phase (LAN plus BSC). Patients had metastatic/unresectable, somatostatin receptor (SSTR)-positive TCs or ACs. Recruitment was stopped early owing to slow accrual; eligible patients from the double-blind phase transitioned to open-label LAN. The adapted primary endpoint was progression-free survival (PFS) during either phase for patients receiving LAN. Seventy-seven patients were randomized (LAN, n = 51 (TCs, n = 29; ACs, n = 22); placebo, n = 26 (TCs, n = 16; ACs, n = 10)). Median (95% CI) PFS during double-blind and open-label phases in patients receiving LAN was 16.6 (11.3; 21.9) months overall (primary endpoint), 21.9 (12.8, not calculable (NC)) months in TCs, and 13.8 (5.4; 16.6) months in ACs. During double-blind treatment, median (95% CI) PFS was 16.6 (11.3; 21.9) months for LAN vs 13.6 (8.3; NC) months for placebo (not significant); corresponding values were 21.9 (13.8; NC) and 13.9 (13.4; NC) months, respectively, in TCs and 13.8 (5.4; 16.6) and 11.0 (2.8; 16.9) months, respectively, in ACs. Patients' quality of life did not deteriorate and LAN was well tolerated. Although recruitment stopped early and the predefined sample size was not met, SPINET is the largest prospective study to date of SSA therapy in SSTR-positive TCs and ACs and suggests clinical benefit in TCs.
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Affiliation(s)
- E Baudin
- Endocrine Oncology Unit, Imaging Department, Gustave Roussy, Villejuif, France
| | - J Capdevila
- Medical Oncology Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Oncology (VHIO), IOB Quirón-Teknon, Barcelona, Spain
| | - D Hörsch
- ENETS Center of Excellence, Zentralklinik Bad Berka GmbH, Bad Berka, Germany
| | - S Singh
- Division of Medical Oncology, University of Toronto, Sunnybrook Odette Cancer Center, Sunnybrook HSC, Toronto, Ontario, Canada
| | - M E Caplin
- Neuroendocrine Tumour Unit, Royal Free Hospital School of Medicine, London, UK
| | - E M Wolin
- Division of Hematology and Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - W Buikhuisen
- Department of Thorax Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M Raderer
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - E Dansin
- Thoracic Oncology Unit, Centre Oscar Lambret, Lille, France
| | - C Grohe
- Department of Respiratory Diseases, Evangelische Lungenklinik, Berlin, Germany
| | - D Ferone
- Neuroendocrine Tumour Unit, Department of Internal Medicine and Medical Specialties, University of Genova, Genova, Italy
| | - A Houchard
- Data and Insights Generation and Strategy, Ipsen, Boulogne-Billancourt, France
| | | | - D Reidy-Lagunes
- Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York, USA
| | - the SPINET Study Group
- Endocrine Oncology Unit, Imaging Department, Gustave Roussy, Villejuif, France
- Medical Oncology Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Oncology (VHIO), IOB Quirón-Teknon, Barcelona, Spain
- ENETS Center of Excellence, Zentralklinik Bad Berka GmbH, Bad Berka, Germany
- Division of Medical Oncology, University of Toronto, Sunnybrook Odette Cancer Center, Sunnybrook HSC, Toronto, Ontario, Canada
- Neuroendocrine Tumour Unit, Royal Free Hospital School of Medicine, London, UK
- Division of Hematology and Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Thorax Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Thoracic Oncology Unit, Centre Oscar Lambret, Lille, France
- Department of Respiratory Diseases, Evangelische Lungenklinik, Berlin, Germany
- Neuroendocrine Tumour Unit, Department of Internal Medicine and Medical Specialties, University of Genova, Genova, Italy
- Data and Insights Generation and Strategy, Ipsen, Boulogne-Billancourt, France
- Medical Affairs, Ipsen, Boulogne-Billancourt, France
- Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York, USA
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Das BK, Chowdhury A, Chatterjee S, Tripathi NM, Pati B, Dutta S, Bandyopadhyay A. Harnessing a bis-electrophilic boronic acid lynchpin for azaborolo thiazolidine (ABT) grafting in cyclic peptides. Chem Sci 2024:d4sc04348k. [PMID: 39144456 PMCID: PMC11320178 DOI: 10.1039/d4sc04348k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 07/24/2024] [Indexed: 08/16/2024] Open
Abstract
Chemical modifications of native peptides have significantly advanced modern drug discovery in recent decades. On this front, the installation of multitasking molecular grafts onto macrocyclic peptides offers numerous opportunities in biomedical applications. Here, we showcase a new class of borono-cyclic peptides featuring an azaborolo thiazolidine (ABT) graft, which can be readily assembled utilizing a bis-electrophilic boronic acid lynchpin while harnessing the inherent reactivity difference (>103 M-1 s-1) between the N-terminal cysteine and backbone cysteine for rapid and highly regioselective macrocyclization (∼1 h) under physiological conditions. The ABT-crosslinked peptides are fairly stable in endogenous environments, but can provide the linear diazaborine peptides via treatment with α-nucleophiles. This efficient peptide crosslinking protocol was further extended for regioselective bicyclizations and engineering of α-helical structures. Finally, ABT-grafted peptides were exploited in biorthogonal conjugation, leading to highly effective intracellular delivery of an apoptotic peptide (KLA) in cancer cells. The mechanism of action by which ABT-grafted KLA peptide induces apoptosis was also explored.
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Affiliation(s)
- Basab Kanti Das
- Biomimetic Peptide Engineering Laboratory, Department of Chemistry, Indian Institute of Technology Ropar Rupnagar Punjab 140001 India
| | - Arnab Chowdhury
- Biomimetic Peptide Engineering Laboratory, Department of Chemistry, Indian Institute of Technology Ropar Rupnagar Punjab 140001 India
| | - Saurav Chatterjee
- Biomimetic Peptide Engineering Laboratory, Department of Chemistry, Indian Institute of Technology Ropar Rupnagar Punjab 140001 India
| | - Nitesh Mani Tripathi
- Biomimetic Peptide Engineering Laboratory, Department of Chemistry, Indian Institute of Technology Ropar Rupnagar Punjab 140001 India
| | - Bibekananda Pati
- Biomimetic Peptide Engineering Laboratory, Department of Chemistry, Indian Institute of Technology Ropar Rupnagar Punjab 140001 India
| | - Soumit Dutta
- Biomimetic Peptide Engineering Laboratory, Department of Chemistry, Indian Institute of Technology Ropar Rupnagar Punjab 140001 India
| | - Anupam Bandyopadhyay
- Biomimetic Peptide Engineering Laboratory, Department of Chemistry, Indian Institute of Technology Ropar Rupnagar Punjab 140001 India
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Asmundo L, Ambrosini V, Mojtahed A, Fanti S, Ferrone C, Hesami M, Sertic M, Najmi Z, Furtado FS, Dhami RS, Anderson MA, Samir A, Sharma A, Campana D, Ursprung S, Nikolau K, Domachevsky L, Blake MA, Norris EC, Clark JW, Catalano OA. Imaging of Neuroendocrine Neoplasms; Principles of Treatment Strategies. What Referring Clinicians Want to Know. J Comput Assist Tomogr 2024; 48:628-639. [PMID: 38626751 DOI: 10.1097/rct.0000000000001619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
ABSTRACT Neuroendocrine neoplasms (NENs) are a diverse group of tumors that express neuroendocrine markers and primarily affect the lungs and digestive system. The incidence of NENs has increased over time due to advancements in imaging and diagnostic techniques. Effective management of NENs requires a multidisciplinary approach, considering factors such as tumor location, grade, stage, symptoms, and imaging findings. Treatment strategies vary depending on the specific subtype of NEN. In this review, we will focus on treatment strategies and therapies including the information relevant to clinicians in order to undertake optimal management and treatment decisions, the implications of different therapies on imaging, and how to ascertain their possible complications and treatment effects.
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Affiliation(s)
| | | | - Amirkasra Mojtahed
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Cristina Ferrone
- Department of Surgery, Cedar-Sinai Health System, Los Angeles, CA
| | - Mina Hesami
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Madeleine Sertic
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Zahra Najmi
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Felipe S Furtado
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ranjodh S Dhami
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mark A Anderson
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anthony Samir
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Amita Sharma
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Davide Campana
- Department of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Stephan Ursprung
- Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Konstantin Nikolau
- Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Liran Domachevsky
- Department of Nuclear Medicine, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Michael A Blake
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Evan C Norris
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey W Clark
- Department of Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Onofrio A Catalano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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4
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Lanreotide Depot to Treat Gastroenteropancreatic Neuroendocrine Tumors in a US Community Oncology Setting: A Prospective, Observational Study. Oncol Ther 2022; 10:463-479. [PMID: 36136274 DOI: 10.1007/s40487-022-00208-1] [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: 07/05/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022] Open
Abstract
INTRODUCTION Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) can result in symptoms such as diarrhea, flushing, abdominal pain, and fatigue and are often associated with a significant disease burden and poor prognosis. This non-interventional, prospective, observational study evaluated the real-world safety and effectiveness of lanreotide depot, a somatostatin analog (SSA) used to treat GEP-NETs, in a community setting. METHODS In this prospective, non-interventional study (NCT02730104), adult patients with locally advanced (inoperable), metastatic GEP-NETs treated with lanreotide depot were evaluated by their physician every 6 months from enrollment for 24 months. Clinically defined time to disease progression (TTDP) and overall survival (OS) were estimated for the total population and by primary tumor type (gastrointestinal [GI], pancreatic, unknown origin), and an exploratory analysis determined the rate of progression-free survival (PFS) at 12 and 24 months. Patient satisfaction was evaluated via the Treatment Satisfaction Questionnaire for Medication (TSQM-9), and safety information was recorded. RESULTS Of 99 patients, the 24-month PFS rate was 73.7% (95% confidence interval [CI] 63.1-81.7) and 24-month OS rate was 84.2% (95% CI 74.0-90.7). Median TTDP was not reached because few patients experienced disease progression during the study period. The majority of responding patients expressed satisfaction with treatment on each domain of the TSQM-9. Treatment-related adverse events (AEs) occurred in 19.2% of patients, while no serious AEs (SAEs) were related to the study drug. CONCLUSIONS Lanreotide depot is an effective and well-tolerated treatment for GEP-NETs in the real-world community setting. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02730104.
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Somatostatin analogue pasireotide (SOM230) inhibits catecholamine secretion in human pheochromocytoma cells. Cancer Lett 2022; 524:232-244. [PMID: 34637845 DOI: 10.1016/j.canlet.2021.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/22/2021] [Accepted: 10/06/2021] [Indexed: 12/11/2022]
Abstract
Increasingly common, neuroendocrine tumors (NETs) are regarded nowadays as neoplasms potentially causing debilitating symptoms and life-threatening medical conditions. Pheochromocytoma is a NET that develops from chromaffin cells of the adrenal medulla, and is responsible for an excessive secretion of catecholamines. Consequently, patients have an increased risk for clinical symptoms such as hypertension, elevated stroke risk and various cardiovascular complications. Somatostatin analogues are among the main anti-secretory medical drugs used in current clinical practice in patients with NETs. However, their impact on pheochromocytoma-associated catecholamine hypersecretion remains incompletely explored. This study investigated the potential efficacy of octreotide and pasireotide (SOM230) on human tumor cells directly cultured from freshly resected pheochromocytomas using an implemented catecholamine secretion measurement by carbon fiber amperometry. SOM230 treatment efficiently inhibited nicotine-induced catecholamine secretion both in bovine chromaffin cells and in human tumor cells whereas octreotide had no effect. Moreover, SOM230 specifically decreased the number of exocytic events by impairing the stimulation-evoked calcium influx as well as the nicotinic receptor-activated inward current in human pheochromocytoma cells. Altogether, our findings indicate that SOM230 acts as an inhibitor of catecholamine secretion through a mechanism involving the nicotinic receptor and might be considered as a potential anti-secretory treatment for patients with pheochromocytoma.
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Pusceddu S, Vernieri C, Di Maio M, Prinzi N, Torchio M, Corti F, Coppa J, Buzzoni R, Di Bartolomeo M, Milione M, Regnault B, Truong Thanh XM, Mazzaferro V, de Braud F. Impact of Diabetes and Metformin Use on Enteropancreatic Neuroendocrine Tumors: Post Hoc Analysis of the CLARINET Study. Cancers (Basel) 2021; 14:cancers14010069. [PMID: 35008233 PMCID: PMC8750688 DOI: 10.3390/cancers14010069] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 12/20/2022] Open
Abstract
The prognostic role of diabetes mellitus (DM) in advanced enteropancreatic neuroendocrine tumors (NETs) is unclear. Progression free survival (PFS) was assessed in post-hoc analyses of the 96-week, phase III, double-blind, placebo-controlled CLARINET study of lanreotide 120 mg in patients with advanced non-functional enteropancreatic NETs with DM (with/without metformin) and without DM. Of 204 patients, there were 79 with DM (lanreotide, n = 42 {metformin, n = 14}; placebo, n = 37 {metformin, n = 10}) and 125 without DM (lanreotide, n = 59; placebo, n = 66). Median PFS was 96.0 and 98.0 weeks with and without DM, respectively (hazard ratio 1.20 {95% confidence interval 0.79 to 1.82}; p = 0.380). No difference in PFS was observed in lanreotide-treated patients with/without DM (p = 0.8476). In the placebo group, median PFS was numerically shorter with versus without DM (p = 0.052) and was significantly longer in patients with DM and metformin (85.7 weeks) versus without metformin (38.7 weeks; p = 0.009). Multivariable Cox analyses showed that DM at baseline was not associated with PFS (p = 0.079); lanreotide was significantly associated with lower disease progression risk (p = 0.017). Lanreotide efficacy was confirmed in patients with advanced enteropancreatic NETs, regardless of diabetic status; DM was not a negative prognostic factor. A potential antitumor effect of metformin was observed in patients receiving placebo.
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Affiliation(s)
- Sara Pusceddu
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori (ENETS Center of Excellence), 20133 Milan, Italy; (C.V.); (N.P.); (M.T.); (F.C.); (M.D.B.); (M.M.); (F.d.B.)
- Correspondence:
| | - Claudio Vernieri
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori (ENETS Center of Excellence), 20133 Milan, Italy; (C.V.); (N.P.); (M.T.); (F.C.); (M.D.B.); (M.M.); (F.d.B.)
- IFOM, The FIRC Institute of Molecular Oncology, 20139 Milan, Italy
| | - Massimo Di Maio
- Department of Oncology, University of Turin, A.O. Ordine Mauriziano, 10124 Turin, Italy;
| | - Natalie Prinzi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori (ENETS Center of Excellence), 20133 Milan, Italy; (C.V.); (N.P.); (M.T.); (F.C.); (M.D.B.); (M.M.); (F.d.B.)
| | - Martina Torchio
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori (ENETS Center of Excellence), 20133 Milan, Italy; (C.V.); (N.P.); (M.T.); (F.C.); (M.D.B.); (M.M.); (F.d.B.)
| | - Francesca Corti
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori (ENETS Center of Excellence), 20133 Milan, Italy; (C.V.); (N.P.); (M.T.); (F.C.); (M.D.B.); (M.M.); (F.d.B.)
| | - Jorgelina Coppa
- Department of Gastro-Entero-Pancreatic Surgical and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori (ENETS Center of Excellence), 20133 Milan, Italy;
| | - Roberto Buzzoni
- Oncology, Clinica San Carlo Paderno Dugnan, 20037 Milan, Italy;
| | - Maria Di Bartolomeo
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori (ENETS Center of Excellence), 20133 Milan, Italy; (C.V.); (N.P.); (M.T.); (F.C.); (M.D.B.); (M.M.); (F.d.B.)
| | - Massimo Milione
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori (ENETS Center of Excellence), 20133 Milan, Italy; (C.V.); (N.P.); (M.T.); (F.C.); (M.D.B.); (M.M.); (F.d.B.)
- First Division of Pathology, Department of Pathology and Laboratory Medicine, IRCCS Foundation National Cancer Institute, 20133 Milan, Italy
| | | | | | - Vincenzo Mazzaferro
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori (ENETS Center of Excellence), 20133 Milan, Italy;
- Oncology, Università Degli Studi di Milano, 20122 Milan, Italy
| | - Filippo de Braud
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori (ENETS Center of Excellence), 20133 Milan, Italy; (C.V.); (N.P.); (M.T.); (F.C.); (M.D.B.); (M.M.); (F.d.B.)
- Oncology, Università Degli Studi di Milano, 20122 Milan, Italy
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Manaka T, Hirai H, Kusano Y. Lanreotide and diazoxide have comparable effects on glucose levels in an elderly Japanese insulinoma patient: a case report. J Rural Med 2021; 16:280-285. [PMID: 34707739 PMCID: PMC8527614 DOI: 10.2185/jrm.2020-065] [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: 01/12/2021] [Accepted: 05/27/2021] [Indexed: 12/01/2022] Open
Abstract
An insulinoma is a pancreatic neuroendocrine tumor that causes hypoglycemia. In the
elderly, as surgery is not always possible, drugs are an important alternative. However,
the effects of lanreotide on insulinomas have not yet been elucidated. We report the case
of an 85-year-old Japanese woman who was admitted for loss of consciousness and
hypoglycemia, which was resolved after intravenous glucose infusion. Insulin secretion was
not inhibited during hypoglycemia. Enhanced computed tomography and OctreoScan
scintigraphy revealed a pancreatic tumor (diameter, 13 mm) with radiotracer accumulation.
Thus, clinical insulinoma was confirmed. However, the patient refused further examination
and surgery. Diazoxide (150 mg/day) therapy resolved hypoglycemia but caused fluid
retention. Consequently, we switched to lanreotide (120 mg/6 weeks). Continuous glucose
monitoring revealed that both drugs had comparable effects on interstitial glucose
normalization. Furthermore, 447 days after the initiation of lanreotide treatment, the
patient had no hypoglycemic symptoms. Therefore, lanreotide may be a useful alternative
treatment option for inoperable insulinomas in elderly individuals.
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Affiliation(s)
- Tomoo Manaka
- Department of Internal Medicine, Shirakawa Kosei General Hospital, Japan
| | - Hiroyuki Hirai
- Department of Internal Medicine, Shirakawa Kosei General Hospital, Japan
| | - Yoshiro Kusano
- Department of Internal Medicine, Shirakawa Kosei General Hospital, Japan
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Ronde EM, Heidsma CM, Eskes AM, Schopman JE, Nieveen van Dijkum EJM. Health-related quality of life and treatment effects in patients with well-differentiated gastroenteropancreatic neuroendocrine neoplasms: A systematic review and meta-analysis. Eur J Cancer Care (Engl) 2021; 30:e13504. [PMID: 34462979 PMCID: PMC9286581 DOI: 10.1111/ecc.13504] [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: 11/19/2020] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/30/2022]
Abstract
Introduction Gastroenteropancreatic neuroendocrine neoplasms (GEPNENs) are often diagnosed in an advanced stage. As the optimal sequence of therapy remains largely unclear, all treatment‐related outcomes, including health‐related quality of life (HRQoL) prospects, should be assessed according to patients' preferences. Methods A targeted search was performed in PubMed and EMBASE to identify studies on treatment effect and HRQoL, measured using the EORTC QLQ‐C30 tool, in patients with advanced, well‐differentiated GEPNENs. Study quality was assessed, and meta‐analyses were performed for global health status/QOL and tumour response. Results The search yielded 1,322 records, and 20 studies were included, examining somatostatin analogues (SSA), peptide receptor radionuclide therapies (PRRT), chemotherapy, SSA‐based combination therapies, and targeted therapies. Global HRQoL was stable, and rates for disease stabilisation were moderate to high across all treatments. Meta‐analyses for global health status/QOL after SSA treatment were not significant (mean difference: –0.3 [95% CI: −1.3 to 0.7]). The highest pooled overall tumour response rate was 33% (95% CI: 24–45%) for PRRT. The highest pooled clinical benefit rate was 94% (95% CI: 65–99%) for chemotherapy. Conclusion All treatments appeared beneficial for disease stabilisation while maintaining stable global health status/QOL. High‐quality HRQoL reporting was lacking. HRQoL should be a central outcome next to well‐established outcomes.
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Affiliation(s)
- Elsa M Ronde
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Charlotte M Heidsma
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne M Eskes
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Josefine E Schopman
- Department of Medical Oncology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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9
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Koffas A, Toumpanakis C. Comparative safety review of the current therapies for gastroenteropancreatic neuroendocrine tumors. Expert Opin Drug Saf 2020; 20:321-334. [PMID: 33338383 DOI: 10.1080/14740338.2021.1867097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Neuroendocrine neoplasms (NENs) comprise a heterogeneous group of neoplasms, whose management requires complex and individualized clinical decisions. Over the last decades the advent of novel medications and advanced diagnostic and therapeutic modalities, alongside our deeper understanding of the disease, revolutionized the landscape of their management, significantly improving both prognosis and quality of life of patients.Area covered: Treatment-related adverse events and safety concerns as demonstrated in clinical trials, as well as in real-world clinical practice.Expert opinion: The only true curative option for NENs remains surgery, whereas high-grade advanced neuroendocrine carcinomas should be primarily managed with platinum-based chemotherapy. For the remaining cases, that comprise the vast majority, the current armamentarium includes somatostatin analogs, interferon, telotristat ethyl, molecular targeted therapies, chemotherapy, peptide receptor radionuclide therapy, and locoregional treatment. The use of the aforementioned therapeutic options is associated with several and not uncommonly severe treatment-related adverse events. However, the benefits offered inclusive of improved prognosis, amelioration of symptoms, and better quality of life amidst others, by far outweighs any adverse event.
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Affiliation(s)
- Apostolos Koffas
- Department of Gastroenterology, General University Hospital of Larisa, Mezourlo Larisa, Greece
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
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10
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[Gastroenteropancreatic neuroendocrine neoplasms-Heterogeneity, management and perspectives of treatment and research]. Internist (Berl) 2020; 61:875-890. [PMID: 32676723 DOI: 10.1007/s00108-020-00832-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The term neuroendocrine neoplasms (NEN) encompasses a molecularly and biologically very heterogeneous group of tumors, which have in common their origin in neuroendocrine cells. The also very heterogeneous subgroup of gastroenteropancreatic neuroendocrine neoplasms (GEP-NEN) is the best classified and investigated group. This article provides a systematic review of the current classification, diagnostics and treatment options of GEP-NEN. In order to achieve a better overview, it was consciously decided not to use an approach based on the primary localization. Instead, a thematic organization according to classification, clinical phenotype, diagnostics and treatment was chosen.
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11
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Trikalinos NA, Tan BR, Amin M, Liu J, Govindan R, Morgensztern D. Effect of metastatic site on survival in patients with neuroendocrine neoplasms (NENs). An analysis of SEER data from 2010 to 2014. BMC Endocr Disord 2020; 20:44. [PMID: 32245472 PMCID: PMC7126407 DOI: 10.1186/s12902-020-0525-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 03/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Neuroendocrine neoplasms (NENs) display variable behaviors based on origin and grade. We assumed that both tumor origin and the location of metastasis may play a role in survival. METHODS We queried the SEER database (2010-2014) for patients with an established diagnosis of NENs and documented site of metastasis and identified 2005 patients. Overall survival (OS) at the time points were estimated by the Kaplan-Meier method Cox proportional-hazards models were used to evaluate the relationship of the interested variables and OS. RESULTS Lung, liver, bone and brain metastases were observed in 9, 77, 7 and 6% of metastatic patients respectively. In the multivariate model, metastasis locations were significantly associated with worse survival (liver HR: 1.677 (1.226-2.294); (bone metastasis HR: 1.412 (0.965-2.065); brain HR: 1.666 (1.177-2.357)). We produced a scoring system based on site of origin, metastasis location, age, gender, histology and tumor size that can stratify metastatic NEN patients in low, intermediate and high-risk categories to help physicians with decision making. CONCLUSION Site of metastasis plays an important role in survival of metastatic NEN patients independent of commonly described prognostic factors and should be considered in survival estimates.
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Affiliation(s)
- Nikolaos A Trikalinos
- Department of Medicine, Washington University in St. Louis, St. Louis, USA.
- Division of Oncology, Washington University in St Louis, 660 S. Euclid Avenue, Campus Box 8056-29, St Louis, MO, 63110, USA.
| | - Benjamin R Tan
- Department of Medicine, Washington University in St. Louis, St. Louis, USA
| | - Manik Amin
- Department of Medicine, Washington University in St. Louis, St. Louis, USA
| | - Jingxia Liu
- Department of Surgery, Washington University in St. Louis, St. Louis, USA
| | - Ramaswamy Govindan
- Department of Medicine, Washington University in St. Louis, St. Louis, USA
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Laskaratos FM, Armeni E, Shah H, Megapanou M, Papantoniou D, Hayes AR, Navalkissoor S, Gnanasegaran G, von Stempel C, Phillips E, Furnace M, Kamieniarz L, Kousteni M, Luong TV, Watkins J, Mandair D, Caplin M, Toumpanakis C. Predictors of antiproliferative effect of lanreotide autogel in advanced gastroenteropancreatic neuroendocrine neoplasms. Endocrine 2020; 67:233-242. [PMID: 31556004 PMCID: PMC6968981 DOI: 10.1007/s12020-019-02086-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/27/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE The antiproliferative properties of lanreotide autogel (LAN) in gastroenteropancreatic neuroendocrine neoplasms (GEP NENs) were demonstrated in the CLARINET study. However, there is limited literature regarding factors that affect progression-free survival (PFS) in patients with GEP NENs treated with LAN. METHODS We identified a total of 191 treatment-naive patients with advanced GEP NENs and positive SSTR uptake on imaging (Octreoscan or 68Gallium DOTATATE Positron Emission Tomography [68GaPET]) who received first-line LAN monotherapy, albeit at various starting doses (60, 90 or 120 mg/month). A group of 102 patients who initiated treatment at the standard dose of 120 mg/month were included in the study and further evaluated by univariate and multivariate analyses to identify predictors of PFS. RESULTS The location of tumour primary was in the small bowel in 63 (62%), pancreas in 31 (30%) and colon/rectum in 8 patients (8%). The tumours were well-differentiated, and the majority were grade 1 (52%), or 2 (38%). About 60% of cases had progressive disease at the time of treatment initiation. Most patients with available pretreatment nuclear medicine imaging (Octreoscan or 68Ga PET) had a Krenning score of 3 (44%) or 4 (50%). The median PFS for the entire cohort was 19 months (95% CI 12, 26 months). The univariate analysis demonstrated that grade 2 tumours, progressive disease at baseline and metastatic liver disease were associated with a significantly shorter PFS, while other evaluated variables did not affect PFS at a statistically significant level. However, at multivariate analysis only the tumour grade remained statistically significant. CONCLUSIONS The current study showed that, of many evaluated variables, only the tumour grade was predictive of PFS duration and this should be considered during patient selection for treatment.
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Affiliation(s)
- Faidon-Marios Laskaratos
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK.
| | - Eleni Armeni
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | | | - Maria Megapanou
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Dimitrios Papantoniou
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Aimee R Hayes
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Shaunak Navalkissoor
- Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, London, UK
| | | | - Conrad von Stempel
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Edward Phillips
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Myles Furnace
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Tu Vinh Luong
- Academic Centre for Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
| | - Jennifer Watkins
- Academic Centre for Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
| | - Dalvinder Mandair
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Martyn Caplin
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Christos Toumpanakis
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
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13
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Prinzi N, Raimondi A, Maccauro M, Milione M, Garanzini E, Torchio M, Corti F, Nichetti F, Lo Russo G, Giacomelli L, Mazzaferro V, Di Bartolomeo M, Seregni E, de Braud F, Pusceddu S. Somatostatin analogs in association with peptide receptor radionucleotide therapy in advanced well-differentiated NETs. Future Oncol 2019; 15:3015-3024. [PMID: 31424273 DOI: 10.2217/fon-2019-0138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Data from 69 well-differentiated gastroenteropancreatic neuroendocrine tumors treated with peptide receptor radionucleotide therapy + somatostatin analogs (SSAs) after SSA treatment failure were evaluated. Methods: We identified two groups: S1 - patients who kept the same SSA treatment beyond progression; S2 - patients who switched the SSA with another SSA after progression. Results: Median progression-free survival was 53 and 127 months in S1 and S2, respectively (p = 0.001; hazard ratio: 0.31; 95% CI: 0.15-0.63). Median overall survival was 69 versus 150 months in S1 and S2, respectively (p = 0.004; hazard ratio: 0.32; 95% CI: 0.14-0.71). Conclusion: In patients with advanced well-differentiated gastroenteropancreatic neuroendocrine tumors treated with peptide receptor radionucleotide therapy plus SSA after SSA failure, the 'switch' strategy of SSA after progression improve progression-free survival and overall survival.
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Affiliation(s)
- Natalie Prinzi
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Alessandra Raimondi
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Marco Maccauro
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Massimo Milione
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Enrico Garanzini
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - Martina Torchio
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Francesca Corti
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Federico Nichetti
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Giuseppe Lo Russo
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Luca Giacomelli
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Vincenzo Mazzaferro
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Maria Di Bartolomeo
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Ettore Seregni
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Filippo de Braud
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
| | - Sara Pusceddu
- Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Department of Medical Oncology, Milan, Italy
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14
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Biological and Biochemical Basis of the Differential Efficacy of First and Second Generation Somatostatin Receptor Ligands in Neuroendocrine Neoplasms. Int J Mol Sci 2019; 20:ijms20163940. [PMID: 31412614 PMCID: PMC6720449 DOI: 10.3390/ijms20163940] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/1970] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 02/07/2023] Open
Abstract
Endogenous somatostatin shows anti-secretory effects in both physiological and pathological settings, as well as inhibitory activity on cell growth. Since somatostatin is not suitable for clinical practice, researchers developed synthetic somatostatin receptor ligands (SRLs) to overcome this limitation. Currently, SRLs represent pivotal tools in the treatment algorithm of neuroendocrine tumors (NETs). Octreotide and lanreotide are the first-generation SRLs developed and show a preferential binding affinity to somatostatin receptor (SST) subtype 2, while pasireotide, which is a second-generation SRL, has high affinity for multiple SSTs (SST5 > SST2 > SST3 > SST1). A number of studies demonstrated that first-generation and second-generation SRLs show distinct functional properties, besides the mere receptor affinity. Therefore, the aim of the present review is to critically review the current evidence on the biological effects of SRLs in pituitary adenomas and neuroendocrine tumors, by mainly focusing on the differences between first-generation and second-generation ligands.
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16
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Moody TW, Ramos-Alvarez I, Jensen RT. Neuropeptide G Protein-Coupled Receptors as Oncotargets. Front Endocrinol (Lausanne) 2018; 9:345. [PMID: 30008698 PMCID: PMC6033971 DOI: 10.3389/fendo.2018.00345] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/11/2018] [Indexed: 12/15/2022] Open
Abstract
Neuropeptide G protein-coupled receptors (GPCRs) are overexpressed on numerous cancer cells. In a number of tumors, such as small cell lung cancer (SCLC), bombesin (BB) like peptides and neurotensin (NTS) function as autocrine growth factors whereby they are secreted from tumor cells, bind to cell surface receptors and stimulate growth. BB-drug conjugates and BB receptor antagonists inhibit the growth of a number of cancers. Vasoactive intestinal peptide (VIP) increases the secretion rate of BB-like peptide and NTS from SCLC leading to increased proliferation. In contrast, somatostatin (SST) inhibits the secretion of autocrine growth factors from neuroendocrine tumors (NETs) and decreases proliferation. SST analogs such as radiolabeled octreotide can be used to localize tumors, is therapeutic for certain cancer patients and has been approved for four different indications in the diagnosis/treatment of NETs. The review will focus on how BB, NTS, VIP, and SST receptors can facilitate the early detection and treatment of cancer.
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Affiliation(s)
- Terry W. Moody
- Department of Health and Human Services, National Cancer Institute, Center for Cancer Research, National Institute of Diabetes, Digestive, and Kidney Disease (NIDDK), Bethesda, MD, United States
| | - Irene Ramos-Alvarez
- Digestive Diseases Branch, National Institute of Diabetes, Digestive, and Kidney Disease (NIDDK), Bethesda, MD, United States
| | - Robert T. Jensen
- Digestive Diseases Branch, National Institute of Diabetes, Digestive, and Kidney Disease (NIDDK), Bethesda, MD, United States
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Zatelli MC, Guadagno E, Messina E, Lo Calzo F, Faggiano A, Colao A. Open issues on G3 neuroendocrine neoplasms: back to the future. Endocr Relat Cancer 2018; 25:R375-R384. [PMID: 29669844 DOI: 10.1530/erc-17-0507] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 04/18/2018] [Indexed: 12/12/2022]
Abstract
The recent recognition that grade 3 (G3) neuroendocrine neoplasms (NENs) can be divided into two different categories according to the histopathological differentiation, that is G3 neuroendocrine tumors (NETs) and G3 neuroendocrine carcinomas (NECs) has generated a lot of interest concerning not only the diagnosis, but also the differential management of such new group of NENs. However, several issues need to be fully clarified in order to put G3 NETs and G3 NECs in the right place. The aim of this review is to focus on those issues that are still undetermined starting from the current knowledge, evaluating the available evidence and the possible clinical implications.
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Affiliation(s)
- Maria Chiara Zatelli
- Department of Medical SciencesSection of Endocrinology and Internal Medicine, University of Ferrara, Ferrara, Italy
| | - Elia Guadagno
- Department of Advanced Biomedical SciencesPathology Section, University of Naples Federico II, Naples, Italy
| | - Erika Messina
- Department of Clinical and Experimental MedicineUniversity of Messina, Messina, Italy
| | - Fabio Lo Calzo
- Department of Clinical Medicine and SurgeryFederico II University, Naples, Italy
| | - Antongiulio Faggiano
- Department of Clinical Medicine and SurgeryFederico II University, Naples, Italy
| | - Annamaria Colao
- Department of Clinical Medicine and SurgeryFederico II University, Naples, Italy
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Tapia Rico G, Li M, Pavlakis N, Cehic G, Price TJ. Prevention and management of carcinoid crises in patients with high-risk neuroendocrine tumours undergoing peptide receptor radionuclide therapy (PRRT): Literature review and case series from two Australian tertiary medical institutions. Cancer Treat Rev 2018; 66:1-6. [PMID: 29602040 DOI: 10.1016/j.ctrv.2018.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/12/2018] [Indexed: 01/19/2023]
Abstract
Peptide receptor radionuclide therapy (PRRT) is an important therapeutic option for somatostatin receptor (SSTR) positive metastatic and/or inoperable neuroendocrine tumours (NETs). However, in patients with poorly controlled carcinoid syndrome, it may lead to an acute flare of carcinoid symptoms or even carcinoid crisis. We report seven patients who received PRRT with (177Lu-DOTA0, Tyr3) octreotate (177Lu-octreotate-LuTate) across two Australian tertiary medical institutions who developed acute flare of carcinoid symptoms/carcinoid crisis during/after PRRT. Cases were identified as high-risk due to previous history of carcinoid crises, high tumour burden and markedly elevated tumour markers. We propose a protocol to prevent and manage severe carcinoid symptoms in high-risk patients treated with PRRT.
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Affiliation(s)
- Gonzalo Tapia Rico
- Department of Medical Oncology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Minmin Li
- Department of Medical Oncology, Royal North Shore Hospital, University of New South Wales, Australia
| | - Nick Pavlakis
- Department of Medical Oncology, Royal North Shore Hospital, University of New South Wales, Australia
| | - Gabrielle Cehic
- Department of Nuclear Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Timothy J Price
- Department of Medical Oncology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia.
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