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Zhang X, Chen Y, Yu Y, Li J. Diagnosis and Management of Aggressive/Refractory Growth Hormone-Secreting Pituitary Neuroendocrine Tumors. Int J Endocrinol 2024; 2024:5085905. [PMID: 39224564 PMCID: PMC11368557 DOI: 10.1155/2024/5085905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 07/16/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024] Open
Abstract
The majority of acromegaly and gigantism are caused by growth hormone-secreting pituitary neuroendocrine tumors (PitNETs). Most cases can be cured or controlled by surgery, medical therapy, and/or radiotherapy. However, a few of these tumors are resistant to traditional therapy and always have a poor prognosis. The title aggressive/refractory is used to differentiate them from pituitary carcinomas. To date, there is no definitive conclusion on how to diagnose aggressive/refractory growth hormone-secreting PitNETs, which may have slowed the process of exploring new therapeutical strategies. We summarized the literature described diagnosis and treatment of the disease. Potential disease markers and prospective therapies were also included.
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Affiliation(s)
- Xiaojuan Zhang
- Department of Endocrinology and MetabolismWest China Hospital of Sichuan University, Chengdu, China
| | - Yu Chen
- Department of Endocrinology and MetabolismWest China Hospital of Sichuan University, Chengdu, China
| | - Yerong Yu
- Department of Endocrinology and MetabolismWest China Hospital of Sichuan University, Chengdu, China
| | - Jianwei Li
- Department of Endocrinology and MetabolismWest China Hospital of Sichuan University, Chengdu, China
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2
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Burman P, Casar-Borota O, Perez-Rivas LG, Dekkers OM. Aggressive Pituitary Tumors and Pituitary Carcinomas: From Pathology to Treatment. J Clin Endocrinol Metab 2023; 108:1585-1601. [PMID: 36856733 PMCID: PMC10271233 DOI: 10.1210/clinem/dgad098] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/13/2023] [Accepted: 02/15/2023] [Indexed: 03/02/2023]
Abstract
Aggressive pituitary tumors (APTs) and pituitary carcinomas (PCs) are heterogeneous with regard to clinical presentation, proliferative markers, clinical course, and response to therapy. Half of them show an aggressive course only many years after the first apparently benign presentation. APTs and PCs share several properties, but a Ki67 index greater than or equal to 10% and extensive p53 expression are more prevalent in PCs. Mutations in TP53 and ATRX are the most common genetic alterations; their detection might be of value for early identification of aggressiveness. Treatment requires a multimodal approach including surgery, radiotherapy, and drugs. Temozolomide is the recommended first-line chemotherapy, with response rates of about 40%. Immune checkpoint inhibitors have emerged as second-line treatment in PCs, with currently no evidence for a superior effect of dual therapy compared to monotherapy with PD-1 blockers. Bevacizumab has resulted in partial response (PR) in few patients; tyrosine kinase inhibitors and everolimus have generally not been useful. The effect of peptide receptor radionuclide therapy is limited as well. Management of APT/PC is challenging and should be discussed within an expert team with consideration of clinical and pathological findings, age, and general condition of the patient. Considering that APT/PCs are rare, new therapies should preferably be evaluated in shared standardized protocols. Prognostic and predictive markers to guide treatment decisions are needed and are the scope of ongoing research.
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Affiliation(s)
- Pia Burman
- Department of Endocrinology, Skåne University Hospital, Lund
University, 205 02 Malmö, Sweden
| | - Olivera Casar-Borota
- Department of Immunology, Genetics, and Pathology; Uppsala
University, 751 85 Uppsala, Sweden
- Department of Clinical Pathology, Uppsala University
Hospital, 751 85 Uppsala, Sweden
| | - Luis Gustavo Perez-Rivas
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München,
Ludwig-Maximilians-Universität München, 80804
Munich, Germany
| | - Olaf M Dekkers
- Department of Internal Medicine (Section of Endocrinology & Clinical
Epidemiology), Leiden University Medical Centre, 2333 ZA
Leiden, The Netherlands
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3
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Padovan M, Cerretti G, Caccese M, Barbot M, Bergo E, Occhi G, Scaroni C, Lombardi G, Ceccato F. Knowing when to discontinue Temozolomide therapy in responding aggressive pituitary tumors and carcinomas: a systematic review and Padua (Italy) case series. Expert Rev Endocrinol Metab 2023; 18:181-198. [PMID: 36876325 DOI: 10.1080/17446651.2023.2185221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023]
Abstract
INTRODUCTION Pituitary adenomas can show a tendency to grow, despite multimodal treatment. Temozolomide (TMZ) has been used in the last 15 years in patients with aggressive pituitary tumors. TMZ requires a careful balance of different expertise, especially for selection criteria. AREAS COVERED We conducted: (1) a systematic review of the published literature from 2006 to 2022, collecting only cases with a complete description of patient follow-up after TMZ discontinuation; (2) a description of all patients with aggressive pituitary adenoma or carcinoma treated in Padua (Italy). EXPERT OPINION There is considerable heterogeneity in the literature: TMZ cycles duration ranged from 3 to 47 months; the follow-up time after TMZ discontinuation ranged from 4 to 91 months (mean 24 months, median 18 months), at least a stable disease has been reported in 75% of patients after a mean 13 months (range 3-47 months, median 10 months). The Padua (Italy) cohort reflects the literature. Future directions to explore are to understand the pathophysiological mechanism of TMZ resistance escape, to develop predicting factors to TMZ treatment (especially through the delineation of the underlying transformation processes), and to further expand the therapeutic applications of TMZ (as neoadjuvant, combined with radiotherapy).
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Affiliation(s)
- Marta Padovan
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Giulia Cerretti
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Mario Caccese
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padua, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padua, Padua, Italy
| | - Eleonora Bergo
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Gianluca Occhi
- Department of Biology DIBIO, University of Padua, Padua, Italy
| | - Carla Scaroni
- Department of Medicine DIMED, University of Padua, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padua, Padua, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Filippo Ceccato
- Department of Medicine DIMED, University of Padua, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padua, Padua, Italy
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Gamboa NT, Wilkerson C, Kundu B, Sherrod BA, Dailey AT, Couldwell WT. Natural history of pituitary carcinoma with metastasis to the cervical spine: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE22363. [PMID: 36647250 PMCID: PMC9844525 DOI: 10.3171/case22363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/19/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Pituitary carcinoma is a rare tumor of the adenohypophysis with noncontiguous craniospinal dissemination and/or systemic metastases. Given the rarity of this malignancy, there is limited knowledge and consensus regarding its natural history, prognosis, and optimal treatment. OBSERVATIONS The authors present the case of a 46-year-old woman initially treated with invasive prolactin-secreting pituitary macroadenoma who developed metastatic disease of the cervical spine 6 years later. The patient presented with acutely worsening compressive cervical myelopathy and required posterior cervical decompression, tumor resection, and instrumented arthrodesis for posterolateral fusion. LESSONS This case underscores the importance of long-term monitoring of hormone levels and having a high clinical suspicion for metastatic disease to the spine in patients presenting with acute myelopathy or radiculopathy in the setting of previously treated invasive secreting pituitary adenoma.
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Affiliation(s)
- Nicholas T. Gamboa
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Christopher Wilkerson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Bornali Kundu
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Brandon A. Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Andrew T. Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Gilis-Januszewska A, Bogusławska A, Rzepka E, Ziaja W, Hubalewska-Dydejczyk A. Individualized medical treatment options in Cushing disease. Front Endocrinol (Lausanne) 2022; 13:1060884. [PMID: 36531477 PMCID: PMC9755355 DOI: 10.3389/fendo.2022.1060884] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/17/2022] [Indexed: 12/05/2022] Open
Abstract
Cushing disease (CD) is caused by a pituitary tumor which oversecretes adrenocorticotropic hormone (ACTH). It is a serious endocrine disease associated with increased mortality and impaired quality of life. The management of CD remains challenging. Although transsphenoidal surgery is the treatment of choice in most cases, in approximately half of CD patients, second or third-line treatment options are needed. Currently, new medical therapies are available which target adrenal steroidogenesis, pituitary somatostatin and dopamine receptors, and glucocorticoid receptors. Selection of which medication to use should be individualized and is determined by many factors including severity of the disease, possible side effects, patients preferences and local availability. The aim of this article is to describe currently available medical therapy to help clinicians individualize the treatment options in the context of recently updated Pituitary Society recommendations.
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Miao YB, Chen KH, Chen CT, Mi FL, Lin YJ, Chang Y, Chiang CS, Wang JT, Lin KJ, Sung HW. A Noninvasive Gut-to-Brain Oral Drug Delivery System for Treating Brain Tumors. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2021; 33:e2100701. [PMID: 34270814 DOI: 10.1002/adma.202100701] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/06/2021] [Indexed: 06/13/2023]
Abstract
Most orally administered drugs fail to reach the intracerebral regions because of the intestinal epithelial barrier (IEB) and the blood-brain barrier (BBB), which are located between the gut and the brain. Herein, an oral prodrug delivery system that can overcome both the IEB and the BBB noninvasively is developed for treating gliomas. The prodrug is prepared by conjugating an anticancer drug on β-glucans using a disulfide-containing linker. Following oral administration in glioma-bearing mice, the as-prepared prodrug can specifically target intestinal M cells, transpass the IEB, and be phagocytosed/hitchhiked by local macrophages (Mϕ). The Mϕ-hitchhiked prodrug is transported to the circulatory system via the lymphatic system, crossing the BBB. The tumor-overexpressed glutathione then cleaves the disulfide bond within the prodrug, releasing the active drug, improving its therapeutic efficacy. These findings reveal that the developed prodrug may serve as a gut-to-brain oral drug delivery platform for the well-targeted treatment of gliomas.
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Affiliation(s)
- Yang-Bao Miao
- Department of Chemical Engineering and Frontier Research Center on Fundamental and Applied Sciences of Matters, National Tsing Hua University, Hsinchu, 30013, Taiwan
| | - Kuan-Hung Chen
- Department of Chemical Engineering and Frontier Research Center on Fundamental and Applied Sciences of Matters, National Tsing Hua University, Hsinchu, 30013, Taiwan
| | - Chiung-Tong Chen
- Institute of Biotechnology and Pharmaceutical Research, National Health Research Institutes, Zhunan, Miaoli, 35053, Taiwan
| | - Fwu-Long Mi
- Department of Biochemistry and Molecular Cell Biology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 23142, Taiwan
| | - Yu-Jung Lin
- Research Center for Applied Sciences, Academia Sinica, Taipei, 11529, Taiwan
| | - Yen Chang
- Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan
| | - Chi-Shiun Chiang
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, 30013, Taiwan
| | - Jui-To Wang
- Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei, 11221, Taiwan
| | - Kun-Ju Lin
- Department of Nuclear Medicine and Molecular Imaging Center, Linkou Chang Gung Memorial Hospital, and Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Hsing-Wen Sung
- Department of Chemical Engineering and Frontier Research Center on Fundamental and Applied Sciences of Matters, National Tsing Hua University, Hsinchu, 30013, Taiwan
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7
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Luo M, Tan Y, Chen W, Hu B, Wang Z, Zhu D, Jiao H, Duan C, Zhu Y, Wang H. Clinical Efficacy of Temozolomide and Its Predictors in Aggressive Pituitary Tumors and Pituitary Carcinomas: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:700007. [PMID: 34220696 PMCID: PMC8250148 DOI: 10.3389/fneur.2021.700007] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/18/2021] [Indexed: 12/14/2022] Open
Abstract
Background: A growing number of evidences suggest that TMZ applications can generate impressive benefits for APT and PC patients. However, the definite role of TMZ for individuals remains unclarified due to the variation between studies. And the predictive factors to alter its efficacy remain debatable. Objective: To evaluate the long-term effectiveness and safety profile of TMZ in the treatment of pituitary malignancies, and delineate the predictors during its clinical employment. Results: A literature retrieval was conducted from online databases for studies published up to December 31, 2020. Twenty one studies involving 429 patients were identified. TMZ exhibited 41% radiological overall response rate (rORR). The biochemical response rate was determinate in 53% of the functioning subset. Two-year and 4-year survival rate were 79 and 61%, respectively. TMZ prolonged the median PFS and OS as 20.18 and 40.24 months. TMZ-related adverse events occurred in 19% of patients. Regarding predictors of TMZ response, rORR was dramatically improved in patients with low/intermediate MGMT expression than those with high-MGMT (>50%) (p < 0.001). The benefit of TMZ varied according to functioning subtype of patients, with greater antitumor activities in functioning subgroups and fewer activities in non-functioning sets (p < 0.001). Notably, the concomitant therapy of radiotherapy and TMZ significantly increased the rORR (p = 0.007). Conclusion: TMZ elicits clinical benefits with moderate adverse events in APT and PC patients. MGMT expression and clinical subtype of secreting function might be vital predictors of TMZ efficacy. In the future, the combination of radiotherapy with TMZ may further improve the clinical outcomes than TMZ monotherapy.
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Affiliation(s)
- Mei Luo
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yiheng Tan
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wenli Chen
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Bin Hu
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zongming Wang
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Diming Zhu
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Haosen Jiao
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Chengbin Duan
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yonghong Zhu
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Haijun Wang
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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Liu X, Dai C, Feng M, Li M, Chen G, Wang R. Diagnosis and treatment of refractory pituitary adenomas: a narrative review. Gland Surg 2021; 10:1499-1507. [PMID: 33968701 DOI: 10.21037/gs-20-873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although aggressive pituitary adenomas (PAs) have been proposed and widely discussed for more than a decade, there is no general agreement regarding their definition, diagnosis or management. As one of the largest pituitary centers in China, we have diagnosed and treated more than fifty cases of aggressive PA and 3 pituitary carcinomas in the past 5 years and proposed a new term, i.e., refractory PAs, to define these adenomas. The definitions of aggressive and refractory PAs overlap with each other, though there are some differences between them. We interpret the definition for refractory PA in this review, emphasizing that more attention and early identification of these adenomas are needed. Although temozolomide (TMZ) has been used to treat pituitary carcinomas and refractory PA since 2006, which has significantly improved the prognosis of these patients, treatment of refractory PA is a tremendous challenge for endocrinologists and neurosurgeons. Overall, refractory PA is defined as PA with a Ki-67 labeling index ≥3%, a faster growth rate than that of normal PA, infiltration of surrounding tissues, recurrence or regrowth in the early postoperative period, and continued growth and/or secretion of excessive hormones despite attempts to control it. These criteria for refractory PA are stricter than for aggressive PA. The diagnosis and treatment of refractory PA requires the collaboration of a multidisciplinary team to achieve the best results.
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Affiliation(s)
- Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Congxin Dai
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Tongren Hospital Capital Medical University, Beijing, China
| | - Ming Feng
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingchu Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Ge Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Renzhi Wang
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Li Y, Wu L, Quan T, Fu J, Cao L, Li X, Liang S, Huang M, Deng Y, Yu J. Characteristic of Tumor Regrowth After Gamma Knife Radiosurgery and Outcomes of Repeat Gamma Knife Radiosurgery in Nonfunctioning Pituitary Adenomas. Front Oncol 2021; 11:627428. [PMID: 33763363 PMCID: PMC7982800 DOI: 10.3389/fonc.2021.627428] [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: 11/09/2020] [Accepted: 01/21/2021] [Indexed: 11/16/2022] Open
Abstract
Objective This study aimed to report the characteristic of tumor regrowth after gamma knife radiosurgery (GKRS) and outcomes of repeat GKRS in nonfunctioning pituitary adenomas (NFPAs). Design and Methods This retrospective study consisted of 369 NFPA patients treated with GKRS. The median age was 45.2 (range, 7.2–84.0) years. The median tumor volume was 3.5 (range, 0.1–44.3) cm3. Results Twenty-four patients (6.5%) were confirmed as regrowth after GKRS. The regrowth-free survivals were 100%, 98%, 97%, 86% and 77% at 1, 3, 5, 10 and 15 year, respectively. In multivariate analysis, parasellar invasion and margin dose (<12 Gy) were associated with tumor regrowth (hazard ratio [HR] = 3.125, 95% confidence interval [CI] = 1.318–7.410, p = 0.010 and HR = 3.359, 95% CI = 1.347–8.379, p = 0.009, respectively). The median time of regrowth was 86.1 (range, 23.2–236.0) months. Previous surgery was associated with tumor regrowth out of field (p = 0.033). Twelve patients underwent repeat GKRS, including regrowth in (n = 8) and out of field (n = 4). Tumor shrunk in seven patients (58.3%), remained stable in one (8.3%) and regrowth in four (33.3%) with a median repeat GKRS margin dose of 12 (range, 10.0–14.0) Gy. The actuarial tumor control rates were 100%, 90%, 90%, 68%, and 68% at 1, 3, 5, 10, and 15 years after repeat GKRS, respectively. Conclusions Parasellar invasion and tumor margin dose (<12 Gy) were independent risk factors for tumor regrowth after GKRS. Repeat GKRS might be effective on tumor control for selected patients. For regrowth in field due to relatively insufficient radiation dose, repeat GKRS might offer satisfactory tumor control. For regrowth out of field, preventing regrowth out of field was the key management. Sufficient target coverage and close follow-up might be helpful.
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Affiliation(s)
- Yanli Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Lisha Wu
- Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tingting Quan
- Department of Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Junyi Fu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Linhui Cao
- Department of Traditional Chinese Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xi Li
- Department of Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shunyao Liang
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Minyi Huang
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yinhui Deng
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jinxiu Yu
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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10
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Yamamoto M, Nakao T, Ogawa W, Fukuoka H. Aggressive Cushing's Disease: Molecular Pathology and Its Therapeutic Approach. Front Endocrinol (Lausanne) 2021; 12:650791. [PMID: 34220707 PMCID: PMC8242934 DOI: 10.3389/fendo.2021.650791] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/26/2021] [Indexed: 12/13/2022] Open
Abstract
Cushing's disease is a syndromic pathological condition caused by adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas (ACTHomas) mediated by hypercortisolemia. It may have a severe clinical course, including infection, psychiatric disorders, hypercoagulability, and metabolic abnormalities, despite the generally small, nonaggressive nature of the tumors. Up to 20% of ACTHomas show aggressive behavior, which is related to poor surgical outcomes, postsurgical recurrence, serious clinical course, and high mortality. Although several gene variants have been identified in both germline and somatic changes in Cushing's disease, the pathophysiology of aggressive ACTHomas is poorly understood. In this review, we focused on the aggressiveness of ACTHomas, its pathology, the current status of medical therapy, and future prospects. Crooke's cell adenoma (CCA), Nelson syndrome, and corticotroph pituitary carcinoma are representative refractory pituitary tumors that secrete superphysiological ACTH. Although clinically asymptomatic, silent corticotroph adenoma is an aggressive ACTH-producing pituitary adenoma. In this review, we summarize the current understanding of the pathophysiology of aggressive ACTHomas, including these tumors, from a molecular point of view based on genetic, pathological, and experimental evidence. The treatment of aggressive ACTHomas is clinically challenging and usually resistant to standard treatment, including surgery, radiotherapy, and established medical therapy (e.g., pasireotide and cabergoline). Temozolomide is the most prescribed pharmaceutical treatment for these tumors. Reports have shown that several treatments for patients with refractory ACTHomas include chemotherapy, such as cyclohexyl-chloroethyl-nitrosourea combined with 5-fluorouracil, or targeted therapies against several molecules including vascular endothelial growth factor receptor, cytotoxic T lymphocyte antigen 4, programmed cell death protein 1 (PD-1), and ligand for PD-1. Genetic and experimental evidence indicates that some possible therapeutic candidates are expected, such as epidermal growth factor receptor tyrosine kinase inhibitor, cyclin-dependent kinase inhibitor, and BRAF inhibitor. The development of novel treatment options for aggressive ACTHomas is an emerging task.
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Affiliation(s)
- Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | | | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
- *Correspondence: Hidenori Fukuoka,
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11
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Nakano-Tateno T, Lau KJ, Wang J, McMahon C, Kawakami Y, Tateno T, Araki T. Multimodal Non-Surgical Treatments of Aggressive Pituitary Tumors. Front Endocrinol (Lausanne) 2021; 12:624686. [PMID: 33841328 PMCID: PMC8033019 DOI: 10.3389/fendo.2021.624686] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/12/2021] [Indexed: 12/20/2022] Open
Abstract
Up to 35% of aggressive pituitary tumors recur and significantly affect mortality and quality of life. Management can be challenging and often requires multimodal treatment. Current treatment options, including surgery, conventional medical therapies such as dopamine agonists, somatostatin receptor agonists and radiotherapy, often fail to inhibit pituitary tumor growth. Recently, anti-tumor effects of chemotherapeutic drugs such as Temozolomide, Capecitabine, and Everolimus, as well as peptide receptor radionuclide therapy on aggressive pituitary tumors have been increasingly investigated and yield mixed, although sometimes promising, outcomes. The purpose of this review is to provide thorough information on non-surgical medical therapies and their efficacies and used protocols for aggressive pituitary adenomas from pre-clinical level to clinical use.
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Affiliation(s)
- Tae Nakano-Tateno
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kheng Joe Lau
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Justin Wang
- Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis, MN, United States
| | - Cailin McMahon
- Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis, MN, United States
| | - Yasuhiko Kawakami
- Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis, MN, United States
- Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States
| | - Toru Tateno
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Toru Tateno, ; Takako Araki,
| | - Takako Araki
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- *Correspondence: Toru Tateno, ; Takako Araki,
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12
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Osterhage K, Rotermund R, Droste M, Dierlamm J, Saeger W, Petersenn S, Aberle J, Flitsch J. Bevacizumab in Aggressive Pituitary Adenomas - Experience with 3 Patients. Exp Clin Endocrinol Diabetes 2020; 129:178-185. [PMID: 33285600 DOI: 10.1055/a-1260-3975] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate bevacizumab as alternative treatment of aggressive pituitary adenomas after exhaustion of standard therapies. DESIGN AND METHODS Retrospectively, 3 patients undergoing microscopic transsphenoidal surgery of aggressive pituitary adenomas from 2008 till 2018 that were treated with bevacizumab were identified. Development of disease and treatment were evaluated. RESULTS Two patients suffered from ACTH-secreting adenomas, one from a non-functioning adenoma. All patients underwent multiple surgical, chemo- and radiotherapeutical approaches including temozolomide, showing favorable results in one patient. Deterioration of clinical condition in all patients led to an individual, palliative attempt of bevacizumab. Patients 1 and 2 showed a decrease of ACTH after first administrations, but therapy had to be ended shortly after due to a further deterioration of their condition. Patient 3 showed a stabilization of the disease for 18 months. Patients died 8, 15 and 7 years after initial diagnosis, respectively, and 2, 4, and 24 months after initiation of bevacizumab therapy, respectively. CONCLUSION The demonstrated results suggest a considerable effect of bevacizumab in aggressive pituitary adenomas. The advanced stage of disease in all three patients, the overall short period of administration and just one patient showing a clinical benefit do not allow a general statement on the effectiveness. At the current stage of clinical experience, an approach with bevacizumab can be considered as an individual palliative attempt of treatment, when standard treatments are exhausted. Our results underline the need for further studies to evaluate this drug as potential player in therapy resistant aggressive pituitary tumors.
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Affiliation(s)
- Katharina Osterhage
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Judith Dierlamm
- Department of Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jens Aberle
- Department of Endocrinology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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13
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Lizzul L, Lombardi G, Barbot M, Ceccato F, Gardiman MP, Regazzo D, Bellu L, Mazza E, Losa M, Scaroni C. Long-course temozolomide in aggressive pituitary adenoma: real-life experience in two tertiary care centers and review of the literature. Pituitary 2020; 23:359-366. [PMID: 32232709 DOI: 10.1007/s11102-020-01040-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE Aggressive pituitary adenomas (APAs) and pituitary carcinomas (PCs) are challenging for their invasive nature, resistance to treatment and recurrences. Temozolomide (TMZ) is used with benefit and well-tolerated toxicity profile in APAs and PCs. In most studies patients received ≤ 12 cycles but the best length of treatment is debated since other options after discontinuation are scarce and a second course is mainly unsuccessful. METHODS We report outcomes of 8 patients with APAs and PCs treated with TMZ for more than 12 continuous cycles with a literature review. Data were retrospectively collected from Padua and Milan University Hospitals. TMZ was used as a single agent (150-200 p.o. mg/m2 daily, 5/28 days) for 14 to 45 cycles. RESULTS Eight patients (7 M), 7 APAs and 1 PC. Previous treatments included neurosurgery and radiotherapy in all cases except two giant masses (ACTH-silent APA and prolactinoma). No patient had progression disease (PD) during long-term treatment nor toxicities. No one had complete response (CR) but four had partial response (PR). Four ACTH+ tumors maintained stable disease (SD) but the secretion pattern improved in all. After drug withdrawal, three had delayed PD (2 after 18 and one after 29 months, all ACTH+); two are still in SD. CONCLUSIONS TMZ may be useful and well-tolerated in APAs and PCs as a long-term therapy. PR appears within the first cycles with no escape throughout the treatment; most patients achieve SD. We suggest extended protocols particularly in responsive ACTH+ PAs and PCs, when further therapies may be unsuccessful.
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Affiliation(s)
- Laura Lizzul
- Endocrinology Unit, Department of Medicine (DIMED), Padua University Hospital, 35121, Padua, Italy
| | - Giuseppe Lombardi
- Neurooncology Unit, Venetian Oncologic Institute (IOV), 35121, Padua, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine (DIMED), Padua University Hospital, 35121, Padua, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine (DIMED), Padua University Hospital, 35121, Padua, Italy
| | - Marina Paola Gardiman
- Pathology Unit, Department of Medicine (DIMED), Padua University Hospital, 35121, Padua, Italy
| | - Daniela Regazzo
- Endocrinology Unit, Department of Medicine (DIMED), Padua University Hospital, 35121, Padua, Italy
| | - Luisa Bellu
- Neurooncology Unit, Venetian Oncologic Institute (IOV), 35121, Padua, Italy
| | - Elena Mazza
- Department of Oncology and Pathology Unit, San Raffaele University Hospital, 20132, Milan, Italy
| | - Marco Losa
- Pituitary Unit, Department of Neurosurgery, San Raffaele University Hospital, 20132, Milan, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine (DIMED), Padua University Hospital, 35121, Padua, Italy.
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14
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Elbelt U, Schlaffer SM, Buchfelder M, Knappe UJ, Vila G, Micko A, Deutschbein T, Unger N, Lammert A, Topuzoglu-Müller T, Bojunga J, Droste M, Johanssen S, Kolenda H, Ritzel K, Buslei R, Strasburger CJ, Petersenn S, Honegger J. Efficacy of Temozolomide Therapy in Patients With Aggressive Pituitary Adenomas and Carcinomas-A German Survey. J Clin Endocrinol Metab 2020; 105:5634134. [PMID: 31746334 DOI: 10.1210/clinem/dgz211] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 11/18/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Despite growing evidence that temozolomide (TMZ) therapy is effective for the treatment of aggressive pituitary tumors (APTs) or carcinomas (PCs), individual therapy decisions remain challenging. OBJECTIVE We therefore aimed to report on clinical characteristics leading to initiation of TMZ therapy and to add evidence on TMZ long-term effectiveness. DESIGN AND SUBJECTS Retrospective survey on TMZ treatment in patients with APTs or PCs. TMZ therapy was initiated in 47 patients (22 females) with APTs (n = 34) or PCs (n = 13). Mean age at diagnosis was 45 ± 15 years. The immunohistochemical subtypes were corticotroph (n = 20), lactotroph (n = 18), and nonfunctioning (n = 9) tumors. TMZ therapy started 8 years after initial diagnosis using a standard regimen (median 6 cycles) for the majority of patients. RESULTS Long-term radiological response to TMZ after a median follow-up of 32 months with 4 patients still on TMZ therapy was tumor regression for 9 (20%), stable disease for 8 (17%), and tumor progression for 29 patients (63%) (outcome data available for 46 patients). Progression occurred 16 months after initiation of TMZ. Median estimated progression-free survival was 23 months. Disease stabilization and median progression-free survival did not differ between patients with APTs or PCs. Predictors of tumor response were not identified. Overall, TMZ was well tolerated. CONCLUSION We performed a nationwide survey on TMZ therapy in patients with APTs and PCs. While early response rates to TMZ are promising, long-term outcome is less favorable. Prolonged TMZ administration should be considered. We were not able to confirm previously reported predictors of tumor response to TMZ.
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Affiliation(s)
- Ulf Elbelt
- Department of Endocrinology, Diabetes and Nutrition, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sven M Schlaffer
- Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Klinikum, Universitätsklinikum der Ruhruniversität Bochum, Minden, Germany
| | - Greisa Vila
- Department of Internal Medicine III, Division of Endocrinology and Metabolism, Medical University Vienna, Vienna, Austria
| | - Alexander Micko
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Nicole Unger
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, Essen, Germany
| | - Alexander Lammert
- Vth Department of Medicine, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Tengü Topuzoglu-Müller
- Department of Endocrinology, Diabetes and Preventive Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jörg Bojunga
- Department of Internal Medicine 1, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany
| | | | | | - Herbert Kolenda
- Department of Neurosurgery, Agaplesion Diakonieklinikum Rotenburg, Rotenburg, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Rolf Buslei
- Institute of Pathology, SozialStiftung Bamberg, Bamberg, Germany
| | - Christian J Strasburger
- Department of Endocrinology, Diabetes and Nutrition, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Jürgen Honegger
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
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15
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Xu L, Khaddour K, Chen J, Rich KM, Perrin RJ, Campian JL. Pituitary carcinoma: Two case reports and review of literature. World J Clin Oncol 2020; 11:91-102. [PMID: 32133278 PMCID: PMC7046923 DOI: 10.5306/wjco.v11.i2.91] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/11/2019] [Accepted: 12/15/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pituitary carcinoma is a rare type of malignancy that can be very difficult to diagnose and treat. Many cases were diagnosed at autopsy. Delays in diagnosis often adversely impact patients' outcomes. Even with prompt diagnosis, treatment decisions remain challenging in the absence of randomized controlled trials.
CASE SUMMARY We report two cases of pituitary carcinoma in men with a history of pituitary adenoma. In the first case, a 55-year-old man was initially diagnosed with pituitary macroadenoma. He underwent subtotal debulking of the tumor followed by adjuvant radiotherapy. Subsequently, he developed relapsed disease and multifocal intracranial metastases and a diagnosis of pituitary carcinoma was rendered. He passed away despite several lines of systemic therapies including temozolomide, lomustine and bevacizumab. Another 52-year-old man was diagnosed with atypical pituitary adenoma with presentation of sudden onset of vision loss in the right eye. He had recurrent pituitary carcinoma with spinal metastases, treated with surgery, radiation and temozolomide.
CONCLUSION Pituitary carcinoma is a rare neoplasm with poor prognosis that is difficult to diagnose and treat. The small number of cases restricts our ability to design randomized clinical trials. Management is largely driven by retrospective studies and case series. Establishing molecular biomarkers and comprehensive genomic profiling could help in decisions about diagnosis and management of pituitary carcinoma.
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Affiliation(s)
- Lai Xu
- Divisions of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Karam Khaddour
- Divisions of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Jie Chen
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Richard J Perrin
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Jian Li Campian
- Divisions of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, United States
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16
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Kontogeorgos G, Thodou E, Koutourousiou M, Kaltsas G, Seretis A. MGMT immunohistochemistry in pituitary tumors: controversies with clinical implications. Pituitary 2019; 22:614-619. [PMID: 31571099 DOI: 10.1007/s11102-019-00993-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Temozolomide (TMZ) is currently considered as a rational therapeutic option for patients with progressively aggressive pituitary adenomas and carcinomas not responding to conventional therapies. Administration of TMZ results in clinical response and improvement in survival of many of these patients depending upon the expression of the DNA repair enzyme O-6 methylguanine DNA transferase (MGMT). Low or negative MGMT immunoreactivity predicts responsiveness to TMZ therapy. Therefore, MGMT serves as a criterion to select candidate patients anticipating response to treatment. MATERIALS AND METHODS The MGMT expression was investigated in 25 pituitary adenomas with Ki-67 labeling index more that 3% and p53 expression, using various antigen retrieval protocols. After direct application of the antibody, only one adenoma yielded positive for MGMT. However, after pretreatment of tissue sections with antigen retrieval protocols, another 3 adenomas, initially negative turned to positive. CONCLUSIONS These findings could explain lack of response to TMZ treatment in patients with false negative MGMT immunohistochemistry. Evaluation of tumor samples for MGMT expression should carefully be carried-out using the optimum immunohistochemical protocol to obtain consistent and reliable results that help to identify patients that could respond to TMZ therapy.
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Affiliation(s)
- George Kontogeorgos
- First Propaepeudic Department of Internal Medicine, Laikon Hospital, National and Kapodistrian University of Athens, 75 Mikras Asias Str., 11527, Athens, Attica, Greece.
- Department of Pathology, "G. Gennimatas" Athens General Hospital, 154 Messogion Ave., 11527, Athens, Attica, Greece.
| | - Eleni Thodou
- Department of Pathology, School of Medicine, University of Thessaly, Viopolis, 41110, Larissa, Thessaly, Greece
| | - Mary Koutourousiou
- Department of Neurological Surgery, University of Louisville, 220 Abraham Flexner Way, Louisville, KY, 40202, USA
| | - Gregory Kaltsas
- First Propaepeudic Department of Internal Medicine, Laikon Hospital, National and Kapodistrian University of Athens, 75 Mikras Asias Str., 11527, Athens, Attica, Greece
| | - Andreas Seretis
- Neurosurgery Department, Henry Dunant Hospital, 107 Messogion Ave., 11527, Athens, Attica, Greece
- Department of Neurosurgery, "G. Gennimatas" Athens General Hospital, 154 Messogion Ave., 11527, Athens, Attica, Greece
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17
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Kontogeorgos G, Thodou E. Is MGMT the best marker to predict response of temozolomide in aggressive pituitary tumors? Alternative markers and prospective treatment modalities. Hormones (Athens) 2019; 18:333-337. [PMID: 31721137 DOI: 10.1007/s42000-019-00145-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/15/2019] [Indexed: 01/02/2023]
Affiliation(s)
- George Kontogeorgos
- First Propaedeutic Department of Internal Medicine, Laikon Hospital, National and Kapodistrian University of Athens, 75 Mikras Asias Str., Athens, 11527, Attica, Greece.
- Department of Pathology, "G. Gennimatas" Athens General Hospital, Athens, Greece.
| | - Eleni Thodou
- Department of Pathology, University of Thessaly, School of Medicine, Larissa, Greece
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18
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Aharon-Hananel G, Percik R, Badarna M, Uri I, Tirosh A. Lower all-cause mortality rates in patients harboring pituitary carcinoma following the introduction of temozolomide. Endocrine 2019; 65:393-398. [PMID: 31267325 DOI: 10.1007/s12020-019-01996-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 06/24/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the impact of temozolomide (TMZ) introduction on the survival of patients with pituitary carcinoma (PC) compared to aggressive pituitary adenoma (APA). METHODS Retrospective analysis of the Surveillance Epidemiology and End-Results database (SEER), including patients diagnosed with PC or APA between 1973 and 2015. Age-adjusted Kaplan-Meier analyses were performed, comparing all-cause mortality (ACM) rates before the year 2006, the time of TMZ introduction ("period 1"), and afterwards ("period 2"), in patients harboring PC and APA. RESULTS Among 107 patients, 18 (16.8%) harbored PC. The prevalence of PC and APA was comparable between genders, ethnicities and age strata. Patients harboring any pituitary tumor (PC or APA) had comparable risk for ACM and disease-specific mortality between the two time periods. However, among patients harboring PC, the risk for ACM was significantly lower in period 2 vs. period 1 (p = 0.021), becoming comparable to the risk of ACM in patients diagnosed with APA (p = 0.48). CONCLUSIONS In this large cancer-database-based analysis we observed improved overall survival in patients harboring PC in the years following the introduction of TMZ.
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Affiliation(s)
- Genya Aharon-Hananel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Endocrinology, Diabetes and Metabolism, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Ruth Percik
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Endocrinology, Diabetes and Metabolism, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Neuroendocrine Tumors Service, Division of Endocrinology, Diabetes and Metabolism, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Endocrine Oncology Clinic, Cancer Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Muhamad Badarna
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Endocrinology, Diabetes and Metabolism, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Inbal Uri
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuroendocrine Tumors Service, Division of Endocrinology, Diabetes and Metabolism, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Endocrine Oncology Clinic, Cancer Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Amit Tirosh
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Division of Endocrinology, Diabetes and Metabolism, The Chaim Sheba Medical Center, Tel Hashomer, Israel.
- Neuroendocrine Tumors Service, Division of Endocrinology, Diabetes and Metabolism, The Chaim Sheba Medical Center, Tel Hashomer, Israel.
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19
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Manojlovic-Gacic E, Bollerslev J, Casar-Borota O. Invited Review: Pathology of pituitary neuroendocrine tumours: present status, modern diagnostic approach, controversies and future perspectives from a neuropathological and clinical standpoint. Neuropathol Appl Neurobiol 2019; 46:89-110. [PMID: 31112312 DOI: 10.1111/nan.12568] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/08/2019] [Indexed: 12/21/2022]
Abstract
Neuroendocrine tumours of the adenohypophysis have traditionally been designated as pituitary adenomas to underline their usually indolent growth and lack of metastatic potential. However, they may demonstrate a huge spectrum of growth patterns and endocrine disturbances, some of them significantly affecting health and quality of life. To predict tumour growth, risk of postoperative recurrence and response to medical therapy in patients with pituitary neuroendocrine tumours is challenging. A thorough histopathological and immunohistochemical diagnostic work-up is an obligatory part of a multidisciplinary effort to precisely define the tumour type and assess prognostic and predictive factors on an individual basis. In this review, we have summarized the current status in the pathology in pituitary neuroendocrine tumours based on the selection of references from the PubMed database. We have presented possible diagnostic approaches according to the current pituitary cell lineage-based classification. The importance of recognizing histological subtypes with potentially aggressive behaviour and identification of prognostic and predictive tissue biomarkers have been highlighted. Controversies related to particular subtypes of pituitary tumours and a still limited prognostic impact of the current classification indicate the need for further refinement. Multidisciplinary approach including clinical, pathological and molecular genetic characterization will be essential for improved personalized therapy and the search for novel therapeutic targets in patients with pituitary neuroendocrine tumours.
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Affiliation(s)
- E Manojlovic-Gacic
- Institute of Pathology, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - J Bollerslev
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - O Casar-Borota
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.,Department of Clinical Pathology, Uppsala University Hospital, Uppsala, Sweden
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20
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Alshaikh OM, Asa SL, Mete O, Ezzat S. An Institutional Experience of Tumor Progression to Pituitary Carcinoma in a 15-Year Cohort of 1055 Consecutive Pituitary Neuroendocrine Tumors. Endocr Pathol 2019; 30:118-127. [PMID: 30706322 DOI: 10.1007/s12022-019-9568-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pituitary carcinoma is a rare disease, defined by the presence of cerebrospinal or distant metastasis of a pituitary neuroendocrine tumor (PitNET). To review our institutional experience of pituitary carcinoma, we searched the database of the UHN Endocrine Oncology Site group and the University Health Network pathology laboratory information system from 2001 to 2016. Among 1055 PitNETs from 1169 transsphenoidal resections, we identified 4 cases of pituitary carcinoma, indicating that pituitary carcinoma represents around 0.4% of PitNETs. All four patients were women. The age at initial presentation ranged from 23 to 54 years. Two patients had Cushing disease with corticotroph tumors; one was initially a densely granulated corticotroph tumor that evolved to become sparsely granulated, while the other was a Crooke cell tumor. One patient had a functioning sparsely granulated lactotroph tumor and one had a clinically silent poorly differentiated PIT1 lineage tumor. Apart from a relatively high Ki67 labeling index (≥ 10%) in three tumors, there were no cytomorphologic features at the time of initial presentation that could predict subsequent metastatic behavior. The time from diagnosis of the pituitary neuroendocrine tumor to the diagnosis of malignancy was 3 to 14 years. Therapies included somatostatin analogs, external beam radiotherapy, chemotherapies including capecitabine/temozolomide, everolimus, sunitinib, bevacizumab, and peptide receptor radionuclide therapy (PRRT). One patient died of disease 18 years after initial diagnosis, underscoring the protracted course of this ultimately fatal neuroendocrine malignancy.
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Affiliation(s)
- Omalkhaire M Alshaikh
- Department of Medicine, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Al Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Sylvia L Asa
- Department of Pathology, University Health Network, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ozgur Mete
- Department of Pathology, University Health Network, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Shereen Ezzat
- Department of Medicine, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada.
- Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Room 7-327, Toronto, Ontario, M5G 2M9, Canada.
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21
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Dai C, Liu X, Ma W, Wang R. The Treatment of Refractory Pituitary Adenomas. Front Endocrinol (Lausanne) 2019; 10:334. [PMID: 31191457 PMCID: PMC6548863 DOI: 10.3389/fendo.2019.00334] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 05/09/2019] [Indexed: 12/22/2022] Open
Abstract
Refractory pituitary adenomas (PAs) are defined as aggressive-invasive PAs characterized by a high Ki-67 index, rapid growth, frequent recurrence, and resistance to conventional treatments. It is notoriously difficult to manage refractory PAs because the efficacy of current therapeutic options is limited. The purpose of this review is to address currently employed and promising therapeutic strategies for the treatment of refractory PAs. Except for prolactinomas, neurosurgery is the first-line option, but most refractory PAs often recur or re-grow after initial surgery and require further treatments. Medical therapy, radiotherapy and re-operation are explored when surgery has failed to completely resect tumors; however, refractory PAs are usually resistant to these treatments. As a salvage treatment, temozolomide (TMZ) has shown promising results and is currently used for all types of refractory PAs. However, not all refractory PAs are responsive to TMZ treatment, and some of these PAs are resistant to TMZ. Although targeted therapies such as vascular endothelial growth factor, epidermal growth factor and mTOR inhibitors have also been used to treat refractory PAs, the effectiveness of these targeted therapies is still not known due to a lack of data from randomized prospective trials. As a novel therapeutic method, cancer immunotherapy is a promising strategy for the treatment of refractory PAs, but further preclinical research and clinical trials are needed to assess the efficacy of this new approach. In summary, early identification and a multidisciplinary approach are required to treat refractory PAs.
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22
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Syro LV, Rotondo F, Ortiz LD, Kovacs K. 65 YEARS OF THE DOUBLE HELIX: Treatment of pituitary tumors with temozolomide: an update. Endocr Relat Cancer 2018. [PMID: 29535142 DOI: 10.1530/erc-18-0015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Temozolomide is an alkylating chemotherapeutic agent used in malignant neuroendocrine neoplasia, melanoma, brain metastases and an essential component of adjuvant therapy in the treatment of glioblastoma multiforme and anaplastic astrocytoma. Since 2006, it has been used for the treatment of pituitary carcinomas and aggressive pituitary adenomas. Here, we discuss the current indications and results of temozolomide therapy in pituitary tumors, as well as frequently asked questions regarding temozolomide treatment, duration of therapy, dosage, tumor recurrence and resistance.
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Affiliation(s)
- Luis V Syro
- Department of NeurosurgeryHospital Pablo Tobon Uribe and Clinica Medellin, Medellin, Colombia
| | - Fabio Rotondo
- Division of PathologyDepartment of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Leon D Ortiz
- Division of Neuro-OncologyInstituto de Cancerologia, Clinica Las Americas. Medellin, Colombia
| | - Kalman Kovacs
- Division of PathologyDepartment of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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23
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Yoo F, Kuan EC, Heaney AP, Bergsneider M, Wang MB. Corticotrophic pituitary carcinoma with cervical metastases: case series and literature review. Pituitary 2018; 21:290-301. [PMID: 29404894 DOI: 10.1007/s11102-018-0872-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Pituitary tumors are the second most common intracranial tumors, however, pituitary carcinoma is a rare clinical entity which represents only 0.1-0.2% of all pituitary tumors. Diagnosis of pituitary carcinoma requires the presence of metastasis. Early identification of pituitary carcinoma is difficult, and only recently have guidelines been published for the treatment of aggressive pituitary tumors. We present two cases from our institution, with a review of other cases available in literature in order to better characterize this rare disease. METHODS A retrospective review of two patients with pituitary carcinoma treated at a tertiary medical center was performed. The MEDLINE database was searched for all cases of pituitary carcinoma. Information for age at diagnosis, sex, pituitary tumor type, latency period from pituitary tumor to presentation of carcinoma, sites of metastasis, number of surgical therapies, radiation and chemotherapy, and survival after diagnosis were collected. RESULTS A total of 69 studies were available for review for a total of 72 unique cases. The average age at diagnosis was 46.3 years. The most common tumors were ACTH-secreting (34.7%), Prolactin-secreting (23.6%), and Null Cell (15.3%). The average latency period from pituitary tumor diagnosis to metastasis was 9 years. All patients underwent surgical therapy during their treatment, with an average of 2.76 procedures. The mortality rate was 54.8% with average time to death after diagnosis of approximately 10 months. CONCLUSIONS Pituitary carcinoma is a rare disease with high mortality rate and is a diagnostic and treatment challenge. Further study is required but is difficult due to its low incidence.
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Affiliation(s)
- Frederick Yoo
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave. 62-132 CHS, Los Angeles, CA, 90095-1624, USA.
| | - Edward C Kuan
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave. 62-132 CHS, Los Angeles, CA, 90095-1624, USA
| | - Anthony P Heaney
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, USA
- Department of Medicine, Division of Endocrinology, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Marvin Bergsneider
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Marilene B Wang
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave. 62-132 CHS, Los Angeles, CA, 90095-1624, USA
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Abstract
Non-functioning pituitary carcinomas (NFPC) are defined as tumours of adenophyseal origin with craniospinal or systemic dissemination, with the absence of a hormonal hypersecretion syndrome. These are a histologically heterogenous group of tumours, comprising gonadotroph, null cell, "silent" tumours of corticotroph, somatotroph or lactotroph cell lineages as well as plurihormonal Pit-1 tumours. NFPC are exceedingly rare, and hence few cases have been described. This review has identified 38 patients with NFPC reported in the literature. Recurrent invasive non-functioning pituitary adenomas (NFPA) were observed in a majority of patients. Various factors have been identified as markers of the potential for aggressive behaviour, including rapid tumour growth, growth after radiotherapy, gain or shift of hormone secretion and raised proliferative markers. Typically, there is a latency of several years from the original presentation with an NFPA to identification of metastases and only 5 cases reported with rapidly progressive malignant disease within 1 month of presentation. Therapeutic options include debulking surgery, radiation therapy and chemotherapy with temozolomide recommended as first line systemic treatment. Although long-term survivors are described, prognosis remains generally very poor (median survival 8 months). Improvements in molecular tumour profiling may assist in predicting tumour behaviour, guide therapeutic choices and identify novel therapies.
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Affiliation(s)
- Nèle Lenders
- Garvan Institute of Medical Research, Sydney, Australia
- Department of Endocrinology, St Vincent's Hospital, University of New South Wales, Sydney, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Ann McCormack
- Garvan Institute of Medical Research, Sydney, Australia.
- Department of Endocrinology, St Vincent's Hospital, University of New South Wales, Sydney, Australia.
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25
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McCormack A, Dekkers OM, Petersenn S, Popovic V, Trouillas J, Raverot G, Burman P. Treatment of aggressive pituitary tumours and carcinomas: results of a European Society of Endocrinology (ESE) survey 2016. Eur J Endocrinol 2018; 178:265-276. [PMID: 29330228 DOI: 10.1530/eje-17-0933] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/08/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To collect outcome data in a large cohort of patients with aggressive pituitary tumours (APT)/carcinomas (PC) and specifically report effects of temozolomide (TMZ) treatment. DESIGN Electronic survey to ESE members Dec 2015-Nov 2016. RESULTS Reports on 166 patients (40 PC, 125 APT, 1 unclassified) were obtained. Median age at diagnosis was 43 (range 4-79) years. 69% of the tumours were clinically functioning, and the most frequent immunohistochemical subtype were corticotroph tumours (45%). Ki-67 index did not distinguish APT from PC, median 7% and 10% respectively. TMZ was first-line chemotherapy in 157 patients. At the end of the treatment (median 9 cycles), radiological evaluation showed complete response (CR) in 6%, partial response (PR) in 31%, stable disease (SD) in 33% and progressive disease in 30%. Response was more frequent in patients receiving concomitant radiotherapy and TMZ. CR was seen only in patients with low MGMT expression. Clinically functioning tumours were more likely to respond than non-functioning tumours, independent of MGMT status. Of patients with CR, PR and SD, 25, 40 and 48% respectively progressed after a median of 12-month follow-up. Other oncological drugs given as primary treatment and to TMZ failures resulted in PR in 20%. CONCLUSION This survey confirms that TMZ is established as first-line chemotherapeutic treatment of APT/PC. Clinically functioning tumours, low MGMT and concurrent radiotherapy were associated with a better response. The limited long-term effect of TMZ and the poor efficacy of other drugs highlight the need to identify additional effective therapies.
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Affiliation(s)
- Ann McCormack
- St Vincent's Hospital and Garvan Institute of Medical Research, Sydney, Australia
| | - Olaf M Dekkers
- Department of Internal Medicine (Section Endocrinology) & Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | - Jacqueline Trouillas
- Centre de Pathologie et de Biologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Gerald Raverot
- Fédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université de Lyon, Bron, France
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital Malmö, University of Lund, Lund, Sweden
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26
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Syro LV, Rotondo F, Camargo M, Ortiz LD, Serna CA, Kovacs K. Temozolomide and Pituitary Tumors: Current Understanding, Unresolved Issues, and Future Directions. Front Endocrinol (Lausanne) 2018; 9:318. [PMID: 29963012 PMCID: PMC6013558 DOI: 10.3389/fendo.2018.00318] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 05/28/2018] [Indexed: 01/26/2023] Open
Abstract
Temozolomide, an alkylating agent, initially used in the treatment of gliomas was expanded to include pituitary tumors in 2006. After 12 years of use, temozolomide has shown a notable advancement in pituitary tumor treatment with a remarkable improvement rate in the 5-year overall survival and 5-year progression-free survival in both aggressive pituitary adenomas and pituitary carcinomas. In this paper, we review the mechanism of action of temozolomide as alkylating agent, its interaction with deoxyribonucleic acid repair systems, therapeutic effects in pituitary tumors, unresolved issues, and future directions relating to new possibilities of targeted therapy.
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Affiliation(s)
- Luis V. Syro
- Department of Neurosurgery, Hospital Pablo Tobon Uribe and Clinica Medellin, Medellin, Colombia
- *Correspondence: Luis V. Syro,
| | - Fabio Rotondo
- Department of Laboratory Medicine, Division of Pathology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Mauricio Camargo
- Genetics, Regeneration and Cancer Laboratory, Universidad de Antioquia, Medellin, Colombia
| | - Leon D. Ortiz
- Division of Neuro-oncology, Instituto de Cancerología, Clinica Las Americas, Pharmacogenomics, Universidad CES, Medellin, Colombia
| | - Carlos A. Serna
- Laboratorio de Patologia y Citologia Rodrigo Restrepo, Department of Pathology, Clinica Las Américas, Universidad CES, Medellin, Colombia
| | - Kalman Kovacs
- Department of Laboratory Medicine, Division of Pathology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
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27
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Raverot G, Burman P, McCormack A, Heaney A, Petersenn S, Popovic V, Trouillas J, Dekkers OM. European Society of Endocrinology Clinical Practice Guidelines for the management of aggressive pituitary tumours and carcinomas. Eur J Endocrinol 2018; 178:G1-G24. [PMID: 29046323 DOI: 10.1530/eje-17-0796] [Citation(s) in RCA: 332] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pituitary tumours are common and easily treated by surgery or medical treatment in most cases. However, a small subset of pituitary tumours does not respond to standard medical treatment and presents with multiple local recurrences (aggressive pituitary tumours) and in rare occasion with metastases (pituitary carcinoma). The present European Society of Endocrinology (ESE) guideline aims to provide clinical guidance on diagnosis, treatment and follow-up in aggressive pituitary tumours and carcinomas. METHODS We decided upfront, while acknowledging that literature on aggressive pituitary tumours and carcinomas is scarce, to systematically review the literature according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The review focused primarily on first- and second-line treatment in aggressive pituitary tumours and carcinomas. We included 14 single-arm cohort studies (total number of patients = 116) most on temozolomide treatment (n = 11 studies, total number of patients = 106). A positive treatment effect was seen in 47% (95% CI: 36-58%) of temozolomide treated. Data from the recently performed ESE survey on aggressive pituitary tumours and carcinomas (165 patients) were also used as backbone for the guideline. SELECTED RECOMMENDATION: (i) Patients with aggressive pituitary tumours should be managed by a multidisciplinary expert team. (ii) Histopathological analyses including pituitary hormones and proliferative markers are needed for correct tumour classification. (iii) Temozolomide monotherapy is the first-line chemotherapy for aggressive pituitary tumours and pituitary carcinomas after failure of standard therapies; treatment evaluation after 3 cycles allows identification of responder and non-responder patients. (iv) In patients responding to first-line temozolomide, we suggest continuing treatment for at least 6 months in total. Furthermore, the guideline offers recommendations for patients who recurred after temozolomide treatment, for those who did not respond to temozolomide and for patients with systemic metastasis.
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Affiliation(s)
- Gerald Raverot
- Fédération d'Endocrinologie, Centre de Référence des Maladies Rares Hypophysaires HYPO, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
- INSERM U1052, CNRS UMR5286, Cancer Research Centre of Lyon, Lyon, France
| | - Pia Burman
- Department of Endocrinology, Skane University Hospital Malmö, University of Lund, Lund, Sweden
| | - Ann McCormack
- Garvan Institute, Sydney, Australia
- Department of Endocrinology, St Vincent's Hospital, University of New South Wales, Sydney, Australia
| | - Anthony Heaney
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Vera Popovic
- Medical Faculty, University Belgrade, Belgrade, Serbia
| | - Jacqueline Trouillas
- Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
- Centre de Pathologie et de Biologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Olaf M Dekkers
- Departments of Internal Medicine (Section Endocrinology) & Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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28
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Chen C, Yin S, Zhang S, Wang M, Hu Y, Zhou P, Jiang S. Treatment of aggressive prolactinoma with temozolomide: A case report and review of literature up to date. Medicine (Baltimore) 2017; 96:e8733. [PMID: 29381964 PMCID: PMC5708963 DOI: 10.1097/md.0000000000008733] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Aggressive pituitary adenomas and pituitary carcinomas are rare and demand multiple treatment strategies. Temozolomide, an orally active alkylating chemotherapeutic agent, has recently been recommended as a salvage medication for refractory pituitary adenomas or carcinomas. PATIENT CONCERNS A 17-year-old male presenting with aggressive prolactinoma that continued to progress despite surgery, gamma knife, and dopamine agonists. DIAGNOSES The diagnosis of refractory aggressive prolactinoma was made on the basis of clinical findings and the lack of efficacy of conventional treatment. INTERVENTIONS The patient received the most frequently recommended regimen of temozolomide treatment for 22 cycles. OUTCOMES Temozolomide resulted in a remarkable shrinkage of tumor mass and inhibition of prolactin secretion and this patient's clinical condition improved progressively. LESSONS Temozolomide can be used as a salvage treatment to refractory pituitary tumors and o(6)-methylguanine-DNA methyltransferase (MGMT) status is a significant predictor to the effectiveness of temozolomide based on the existing literature.
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Affiliation(s)
- Cheng Chen
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
| | - Senlin Yin
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
| | - Shizhen Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Mengmeng Wang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
| | - Yu Hu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
| | - Peizhi Zhou
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
| | - Shu Jiang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
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29
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Lasolle H, Cortet C, Castinetti F, Cloix L, Caron P, Delemer B, Desailloud R, Jublanc C, Lebrun-Frenay C, Sadoul JL, Taillandier L, Batisse-Lignier M, Bonnet F, Bourcigaux N, Bresson D, Chabre O, Chanson P, Garcia C, Haissaguerre M, Reznik Y, Borot S, Villa C, Vasiljevic A, Gaillard S, Jouanneau E, Assié G, Raverot G. Temozolomide treatment can improve overall survival in aggressive pituitary tumors and pituitary carcinomas. Eur J Endocrinol 2017; 176:769-777. [PMID: 28432119 DOI: 10.1530/eje-16-0979] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/20/2017] [Accepted: 03/27/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Only few retrospective studies have reported an efficacy rate of temozolomide (TMZ) in pituitary tumors (PT), all around 50%. However, the long-term survival of treated patients is rarely evaluated. We therefore aimed to describe the use of TMZ on PT in clinical practice and evaluate the long-term survival. DESIGN Multicenter retrospective study by members of the French Society of Endocrinology. METHODS Forty-three patients (14 women) treated with TMZ between 2006 and 2016 were included. Most tumors were corticotroph (n = 23) or lactotroph (n = 13), and 14 were carcinomas. Clinical/pathological characteristics of PT, as well as data from treatment evaluation and from the last follow-up were recorded. A partial response was considered as a decrease in the maximal tumor diameter by more than 30% and/or in the hormonal rate by more than 50% at the end of treatment. RESULTS The median treatment duration was 6.5 cycles (range 2-24), using a standard regimen for most and combined radiotherapy for six. Twenty-two patients (51.2%) were considered as responders. Silent tumor at diagnosis was associated with a poor response. The median follow-up after the end of treatment was 16 months (0-72). Overall survival was significantly higher among responders (P = 0.002); however, ten patients relapsed 5 months (0-57) after the end of TMZ treatment, five in whom TMZ was reinitiated without success. DISCUSSION Patients in our series showed a 51.2% response rate to TMZ, with an improved survival among responders despite frequent relapses. Our study highlights the high variability and lack of standardization of treatment protocols.
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Affiliation(s)
- Hélène Lasolle
- Fédération d'EndocrinologieGroupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Université Lyon 1Lyon, France
| | - Christine Cortet
- Service d'EndocrinologieHôpital Claude Huriez, CHRU de Lille, Lille, France
| | - Fréderic Castinetti
- Service d'EndocrinologieHôpital de La Timone, CHU de Marseille, Marseille, France
| | - Lucie Cloix
- Service d'EndocrinologieHôpital Bretonneau, CHRU de Tours, Tours, France
| | - Philippe Caron
- Service d'EndocrinologieHôpital Larrey, CHU de Toulouse, Toulouse, France
| | - Brigitte Delemer
- Service d'EndocrinologieHôpital Robert Debré, CHU de Reims, Reims, France
| | - Rachel Desailloud
- Service d'EndocrinologieHôpital Nord, CHU d'Amiens-Picardie, Amiens, France
| | - Christel Jublanc
- Service d'EndocrinologieHôpital de La Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | | | | | - Marie Batisse-Lignier
- Service d'EndocrinologieHôpital Gabriel Montpied, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Nathalie Bourcigaux
- Service d'EndocrinologieHôpital Saint Antoine, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Damien Bresson
- Service de NeurochirurgieHôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Olivier Chabre
- Service d'EndocrinologieCHU de Grenoble-Alpes, La Tronche, France
| | - Philippe Chanson
- Service d'Endocrinologie et des Maladies de la ReproductionHôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Le Kremlin Bicêtre, France
- INSERM 1185Fac Med Paris Sud, Univ Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Cyril Garcia
- Service d'EndocrinologieHôpital d'Instruction des Armées Bégin, Saint-Mandé, France
| | | | - Yves Reznik
- Service d'EndocrinologieCHU de Caen, Caen, France
| | - Sophie Borot
- Service d'EndocrinologieHôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Chiara Villa
- Service d'Anatomie et Cytologie PathologiquesHôpital Foch, Suresnes, France
- INSERM U1016 CNRS UMR 8104Paris, France
| | - Alexandre Vasiljevic
- Centre de Pathologie EstGroupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | | | - Emmanuel Jouanneau
- Université Lyon 1Lyon, France
- Service de NeurochirurgieHôpital Neurologique, Hospices Civils de Lyon, Bron, France
| | - Guillaume Assié
- Department of EndocrinologyInstitut Cochin, INSERM U1016, CNRS UMR8104, Paris Descartes University, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Gérald Raverot
- Fédération d'EndocrinologieGroupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Université Lyon 1Lyon, France
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30
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Jordan JT, Miller JJ, Cushing T, Seijo M, Batchelor TT, Arrillaga-Romany IC, Shih HA, Nachtigall LB, Loeffler JS, Dietrich J. Temozolomide therapy for aggressive functioning pituitary adenomas refractory to surgery and radiation: a case series. Neurooncol Pract 2017; 5:64-68. [PMID: 31385986 DOI: 10.1093/nop/npx013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Treatment of aggressive pituitary adenomas typically involves a multimodality approach based on histopathological features and may include pharmacotherapy, surgery, and occasionally radiation therapy. In cases of treatment-refractory tumor progression, chemotherapy may be considered; however, no standard chemotherapeutic regimen has been established. Literature review suggests that temozolomide may have a beneficial role in a subset of cases. To understand the efficacy of temozolomide in progressive pituitary tumors, we reviewed the outcomes of cases at our center. Methods We performed a retrospective chart review to report the outcome and unique features of 7 patients with aggressive functioning pituitary adenomas or carcinomas treated with temozolomide. Tumor pathology included somatotroph (n = 1), corticotroph (n = 3), and lactotroph (n = 3) tumors. Results Four of the 7 patients had at least 2 prior resections, and all had prior radiation and surgery before treatment with temozolomide. Notably, all patients showed response to therapy, defined as either stable disease (43%) or partial response (57%). Median progression-free survival was 1.66 years, and median overall survival was 4 years. Conclusion Our data suggest that temozolomide has an important role in the management of aggressive functioning pituitary tumors that are resistant to standard therapies, and that optimization of therapy with temozolomide may involve individualized regimens. Future prospective clinical trials should be considered.
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Affiliation(s)
- Justin T Jordan
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA
| | - Julie J Miller
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA
| | - Tucker Cushing
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA
| | - Marlon Seijo
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA
| | - Tracy T Batchelor
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA
| | | | - Helen A Shih
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Lisa B Nachtigall
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA.,Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA
| | - Jay S Loeffler
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Jorg Dietrich
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA
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31
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A Rapid Biochemical and Radiological Response to the Concomitant Therapy with Temozolomide and Radiotherapy in an Aggressive ACTH Pituitary Adenoma. Case Rep Endocrinol 2017; 2017:2419590. [PMID: 28357143 PMCID: PMC5357528 DOI: 10.1155/2017/2419590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/05/2017] [Accepted: 02/13/2017] [Indexed: 12/14/2022] Open
Abstract
Background and Importance. In the last eight years temozolomide (TMZ) has been used as the last-line treatment modality for aggressive pituitary tumors to be applied after the failure of surgery, medical therapy, and radiotherapy. The objective was to achieve a rapid control of tumor growth and hormone normalization with concurrent chemoradiotherapy in a patient with very aggressive ACTH pituitary adenoma. Clinical Presentation. We describe a patient with an aggressive ACTH-producing adenoma treated with concurrent temozolomide and radiotherapy. The patient suffered from an aggressive ACTH adenoma resistant to surgical and medical treatment. After two months of concurrent temozolomide and radiotherapy, cortisol normalization and significant tumor shrinkage were observed. After 22 months of follow-up, there is still no evidence of tumor recurrence. Conclusion. Concurrent treatment with temozolomide and irradiation appears to be highly effective in the achievement of the tumor volume control as well as in the control of ACTH secretion in aggressive ACTH adenoma.
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32
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Felker J, Patterson B, Wrubel D, Janss A. Successful treatment of a child with a prolactin secreting macroadenoma with temozolomide. J Pediatr Endocrinol Metab 2016; 29:1413-1415. [PMID: 27815961 DOI: 10.1515/jpem-2016-0159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 10/05/2016] [Indexed: 11/15/2022]
Abstract
Prolactinomas are a rare subset of brain tumors in pediatrics. We report a child with a prolactin secreting macroadenoma which was refractory to initial treatment with a dopamine antagonist. Given the location of her tumor she was ineligible for surgical resection. Temozolomide (200 mg/m2×5 days each month) was administered with a dramatic and prolonged response in tumor size, prolactin level, and symptoms, with no side effects from treatment. We demonstrate the benefit of temozolomide in the treatment of a pediatric patient with prolactinoma.
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33
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Kamiya-Matsuoka C, Cachia D, Waguespack SG, Crane CH, Mahajan A, Brown PD, Nam JY, McCutcheon IE, Penas-Prado M. Radiotherapy with concurrent temozolomide for the management of extraneural metastases in pituitary carcinoma. Pituitary 2016; 19:415-21. [PMID: 27106209 PMCID: PMC5215904 DOI: 10.1007/s11102-016-0721-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pituitary carcinomas (PC) are uncommon neuroendocrine tumors, accounting for 0.1 % of all pituitary tumors. The diagnosis of PC is based on the presence of metastases from a pituitary adenoma, and not by local invasion or pathological features alone. PC is typically resistant to therapy, with a median overall survival of only 31 months. There is no standard treatment for PC, but maximal safe resection and radiation are performed when possible. Encouraging preliminary data on the use of temozolomide (TMZ)-based therapy has been previously reported. METHODS We report the response to therapy and safety of radiation with concurrent temozolomide (RT/TMZ) in 2 adult patients with heavily pretreated PC and extraneural metastases. RESULTS Both patients had prior history of pituitary macroadenoma. At the time of diagnosis of PC, Ki-67 % was 24.2 and 10 %, with positive p53 staining in one case. Metastatic sites included lymph nodes, liver and bone. Case-1 received RT/TMZ to the tumor bed in the skull base and to the metastases in the cervical lymph nodes. Case-2 received RT/TMZ to recurrent tumor involving portacaval lymph nodes. Both patients achieved excellent long-term control of the sites of treated extraneural metastases, with no significant acute or delayed toxicity. CONCLUSIONS RT/TMZ was safely delivered and might provide sustained control of extraneural metastases in PC. Although this retrospective report has limitations, RT/TMZ can be considered as a therapeutic option for the management of extraneural metastases in PC.
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Affiliation(s)
- Carlos Kamiya-Matsuoka
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Blvd, Room FC7.3000, Unit 431, Houston, TX, 77030, USA.
| | - David Cachia
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anita Mahajan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul D Brown
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joo Yeon Nam
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Blvd, Room FC7.3000, Unit 431, Houston, TX, 77030, USA
| | - Ian E McCutcheon
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marta Penas-Prado
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Blvd, Room FC7.3000, Unit 431, Houston, TX, 77030, USA
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Moisi M, Cruz AS, Benkers T, Rostad S, Broyles FB, Yuen K, Mayberg M. Treatment of Aggressive Prolactin-Secreting Pituitary Adenomas with Adjuvant Temozolomide Chemotherapy: A Review. Cureus 2016; 8:e658. [PMID: 27489751 PMCID: PMC4963231 DOI: 10.7759/cureus.658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Most prolactin-secreting pituitary adenomas demonstrate slow growth and are effectively managed with medical/surgical therapy. Rarely, these tumors can behave aggressively with rapid growth and invasion of local tissues, and are refractory to medical, surgical, or radio-surgical therapies. We report a case of a prolactin-secreting adenoma in a young woman, which became progressively aggressive and refractory to usual treatment modalities, but responded to treatment with the chemotherapeutic agent temozolomide. In addition, we review the literature for treatment of refractory adenomas with temozolomide. The clinical and pathologic characteristics of aggressive prolactin-secreting adenomas are reviewed, as well as their response to dopamine agonists, surgery, radiotherapy, and chemotherapy.
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Affiliation(s)
- Marc Moisi
- Seattle Science Foundation ; Neurological Surgery, Wayne State University
| | - Aurora S Cruz
- Neurological Surgery, University of Louisville ; Neurological Surgery, University of California, Irvine ; Neurological Surgery, Swedish Neuroscience Institute
| | | | | | | | - Kevin Yuen
- Swedish Pituitary Center, Swedish Neuroscience Institute
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Lasolle H, Raverot G. Therapeutic innovations in endocrine diseases – part 3 : temozolomide and future therapeutics for aggressive pituitary tumors and carcinomas. Presse Med 2016; 45:e211-6. [DOI: 10.1016/j.lpm.2016.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Auriemma RS, Grasso LFS, Pivonello R, Colao A. The safety of treatments for prolactinomas. Expert Opin Drug Saf 2016; 15:503-12. [DOI: 10.1517/14740338.2016.1151493] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Renata S. Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
| | - Ludovica F. S. Grasso
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
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Losa M, Bogazzi F, Cannavo S, Ceccato F, Curtò L, De Marinis L, Iacovazzo D, Lombardi G, Mantovani G, Mazza E, Minniti G, Nizzoli M, Reni M, Scaroni C. Temozolomide therapy in patients with aggressive pituitary adenomas or carcinomas. J Neurooncol 2015; 126:519-25. [DOI: 10.1007/s11060-015-1991-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/03/2015] [Indexed: 12/27/2022]
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Ji Y, Vogel RI, Lou E. Temozolomide treatment of pituitary carcinomas and atypical adenomas: systematic review of case reports. Neurooncol Pract 2015; 3:188-195. [PMID: 27551432 DOI: 10.1093/nop/npv059] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Pituitary carcinomas (PC) and atypical pituitary adenomas (APA) are rare variants of pituitary tumors for which no evidence-based treatment currently exists. We sought to determine whether temozolomide represents an effective chemotherapeutic option for patients with PC and APA. METHODS A systematic review was performed using all published cases of PC and APA treated with temozolomide, and for which information on treatment regimen, clinical response, and survival could be identified. The primary goal of this analysis was to describe overall survival and progression-free survival among PC and APA patients after temozolomide treatment. Secondary goals included assessment of response rate and biomarkers of response. RESULTS We identified 57 cases and obtained follow-up data on 54 patients (31 APA and 23 PC) for analysis. Estimates of 5-year progression-free survival and overall survival were 21.9% and 57.4% for patients with APA and 36.1% and 56.2% for patients with PC. Among those who responded to temozolomide, overall survival was marginally statistically significantly greater for patients on long-term temozolomide therapy compared with those who were not (5-year overall survival 91.7% vs 54.1%, P = .08); Progression-free survival results were similar but not statistically significant. The objective response rate was 48.4% for patients with APA and 65.2% for patients with PC. Stable disease occurred in 29% of APA and 17.4% of PC patients. Neither histology nor expression of Ki-67 correlated with response; however, negative O6-methylguanine-DNA methyltransferase staining was strongly related to response to temozolomide in patients with APA (P < .001). CONCLUSIONS Temozolomide is an effective treatment of both PC and APA, and long-term treatment can be considered for particularly aggressive cases.
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Affiliation(s)
- Yan Ji
- Division of Hematology, Oncology and Transplantation , University of Minnesota , Minneapolis, MN (Y.J., E.L.); Masonic Cancer Center, Biostatistics and Bioinformatics , University of Minnesota , Minneapolis, MN (R.I.V.)
| | - Rachel Isaksson Vogel
- Division of Hematology, Oncology and Transplantation , University of Minnesota , Minneapolis, MN (Y.J., E.L.); Masonic Cancer Center, Biostatistics and Bioinformatics , University of Minnesota , Minneapolis, MN (R.I.V.)
| | - Emil Lou
- Division of Hematology, Oncology and Transplantation , University of Minnesota , Minneapolis, MN (Y.J., E.L.); Masonic Cancer Center, Biostatistics and Bioinformatics , University of Minnesota , Minneapolis, MN (R.I.V.)
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Pivonello R, De Leo M, Cozzolino A, Colao A. The Treatment of Cushing's Disease. Endocr Rev 2015; 36:385-486. [PMID: 26067718 PMCID: PMC4523083 DOI: 10.1210/er.2013-1048] [Citation(s) in RCA: 292] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Monica De Leo
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Alessia Cozzolino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
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Temozolomide-Induced Shrinkage of Invasive Pituitary Adenoma in Patient with Nelson's Syndrome: A Case Report and Review of the Literature. Case Rep Endocrinol 2015. [PMID: 26221547 PMCID: PMC4499620 DOI: 10.1155/2015/623092] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction. Invasive tumours in Nelson's syndrome need aggressive therapy. Recent reports have documented the efficacy of temozolomide (TMZ) in the treatment of adenomas resistant to conventional management. Objective. The review of the literature concerning TMZ treatment of atypical corticotroph adenomas and a case study of 56-year-old woman who developed Nelson's syndrome. Treatment Proceeding. The patient with Cushing's disease underwent transsphenoidal adenomectomy followed by a 27-month-long period of remission. Due to a regrowth of the tumor, she underwent two reoperations followed by stereotactic radiotherapy. Because of treatment failures, bilateral adrenalectomy was performed. Then she developed Nelson's syndrome. A fourth transsphenoidal adenomectomy was performed, but there was a rapid recurrence. Five months later, she underwent a right frontotemporal craniotomy. Due to a rapid regrowth of the tumour, the patient did not receive gamma-knife therapy and was treated with cabergoline and somatostatin analogue for some time. Only TMZ therapy resulted in marked clinical, biochemical, and radiological improvement. To date, this is the first case of invasive corticotroph adenoma in Nelson's syndrome treated with temozolomide in Poland. Conclusion. In our opinion, temozolomide can be an effective treatment option of invasive adenomas in Nelson's syndrome.
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Hornyak M, Couldwell WT. Multimodality Treatment for Invasive Pituitary Adenomas. Postgrad Med 2015; 121:168-76. [DOI: 10.3810/pgm.2009.03.1989] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liu JK, Patel J, Eloy JA. The role of temozolomide in the treatment of aggressive pituitary tumors. J Clin Neurosci 2015; 22:923-9. [PMID: 25772801 DOI: 10.1016/j.jocn.2014.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 12/24/2014] [Indexed: 01/09/2023]
Abstract
Pituitary tumors are amongst the most common intracranial neoplasms and are generally benign. However, some pituitary tumors exhibit clinically aggressive behavior that is characterized by tumor recurrence and continued progression despite repeated treatments with conventional surgical, radiation and medical therapies. More recently, temozolomide, a second generation oral alkylating agent, has shown therapeutic promise for aggressive pituitary adenomas and carcinomas with favorable clinical and radiographic responses. Temozolomide causes DNA damage by methylation of the O(6) position of guanine, which results in potent cytotoxic DNA adducts and consequently, tumor cell apoptosis. The degree of MGMT expression appears to be inversely related to therapeutic responsiveness to temozolomide with a significant number of temozolomide-sensitive pituitary tumors exhibiting low MGMT expression. The presence of high MGMT expression appears to mitigate the effectiveness of temozolomide and this has been used as a marker in several studies to predict the efficacy of temozolomide. Recent evidence also suggests that mutations in mismatch repair proteins such as MSH6 could render pituitary tumors resistant to temozolomide. In this article, the authors review the development of temozolomide, its biochemistry and interaction with O(6)-methylguanine-DNA methyltransferase (MGMT), its role in adjuvant treatment of aggressive pituitary neoplasms, and future works that could influence the efficacy of temozolomide therapy.
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Affiliation(s)
- James K Liu
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Suite 8100, 90 Bergen Street, Newark, NJ 07103, USA; Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA.
| | - Jimmy Patel
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Jean Anderson Eloy
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Suite 8100, 90 Bergen Street, Newark, NJ 07103, USA; Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA
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Ceccato F, Lombardi G, Manara R, Emanuelli E, Denaro L, Milanese L, Gardiman MP, Bertorelle R, Scanarini M, D’Avella D, Occhi G, Boscaro M, Zagonel V, Scaroni C. Temozolomide and pasireotide treatment for aggressive pituitary adenoma: expertise at a tertiary care center. J Neurooncol 2015; 122:189-96. [DOI: 10.1007/s11060-014-1702-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 12/19/2014] [Indexed: 10/24/2022]
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Bruno OD, Juárez-Allen L, Christiansen SB, Manavela M, Danilowicz K, Vigovich C, Gómez RM. Temozolomide Therapy for Aggressive Pituitary Tumors: Results in a Small Series of Patients from Argentina. Int J Endocrinol 2015; 2015:587893. [PMID: 26106414 PMCID: PMC4461777 DOI: 10.1155/2015/587893] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/06/2015] [Accepted: 05/06/2015] [Indexed: 02/01/2023] Open
Abstract
We evaluated results of temozolomide (TMZ) therapy in six patients, aged 34-78 years, presenting aggressive pituitary tumors. In all the patients tested O(6)-methylguanine-DNA methyltransferase (MGMT) immunoexpression in surgical specimens was absent. Patients received temozolomide 140-320 mg/day for 5 days monthly for at least 3 months. In two patients minimum time for evaluation could not be reached because of death in a 76-year-old man with a malignant prolactinoma and of severe neutro-thrombopenia in a 47-year-old woman with nonfunctioning pituitary adenoma. In two patients (a 34-year-old acromegalic woman and a 39-year-old woman with Nelson's syndrome) no response was observed after 4 and 6 months, respectively, and the treatment was stopped. Conversely, two 52- and 42-year-old women with Cushing's disease had long-term total clinical and radiological remissions which persisted after stopping temozolomide. We conclude that TMZ therapy may be of variable efficacy depending on-until now-incompletely understood factors. Cooperative work on a greater number of cases of aggressive pituitary tumors should be crucial to establish the indications, doses, and duration of temozolomide administration.
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Affiliation(s)
- Oscar D. Bruno
- Foundation of Endocrinology, 1425 Buenos Aires, Argentina
- *Oscar D. Bruno:
| | | | | | - Marcos Manavela
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, 1120 Buenos Aires, Argentina
| | - Karina Danilowicz
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, 1120 Buenos Aires, Argentina
| | - Carlos Vigovich
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, 1120 Buenos Aires, Argentina
| | - Reynaldo M. Gómez
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, 1120 Buenos Aires, Argentina
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Chatzellis E, Alexandraki KI, Androulakis II, Kaltsas G. Aggressive pituitary tumors. Neuroendocrinology 2015; 101:87-104. [PMID: 25571935 DOI: 10.1159/000371806] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 12/25/2014] [Indexed: 11/19/2022]
Abstract
Pituitary adenomas are common intracranial tumors that are mainly considered as benign. Rarely, these tumors can exhibit an aggressive behavior, characterized by gross invasion of the surrounding tissues, resistance to conventional treatment leading to early and frequent recurrences. Even more rarely, pituitary tumors can give rise to cerebrospinal or systemic metastases qualifying as pituitary carcinomas according to the latest WHO definition. In the same classification, a subset of tumors with relatively distinct histopathological features was identified and defined as atypical adenomas designated to follow a more aggressive clinical course. This classification, although clinically useful, does not provide an accurate correlation between histopathological findings and the clinical behavior of these tumors, neither is it adequate to convey the precise features of 'aggressive' tumors. Thus, 'aggressive' pituitary adenomas need to be properly defined with clinical, radiological, histological and molecular markers in order to identify patients at increased risk of early recurrence or subsequent tumor progression. At present, no single marker or classification system of pituitary tumor aggressiveness exists, and clinically useful information in the literature is insufficient to guide diagnostic and therapeutic decisions. Treatment of patients with aggressive pituitary tumors is challenging since conventional treatments often fail, necessitating multiple surgical procedures with additional radiotherapy. Although traditional chemotherapy applied in other neuroendocrine tumors has not been shown to be efficacious, newer agents, particularly temozolomide, have shown promising results and are currently used despite the lack of data from a randomized prospective trial. Molecular targeted therapies such as mTOR and epidermal growth factor inhibitors have also been applied and might prove to be useful in the management of these patients. In the present review, we provide information regarding the epidemiology and clinical, histopathological and molecular features of aggressive pituitary tumors using recent employed definitions. In addition, we review currently employed therapeutic means providing a therapeutic algorithm and highlight the need to identify more specific disease-related and prognostic markers and the necessity for central registration of these tumors.
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Affiliation(s)
- Eleftherios Chatzellis
- Endocrine Unit, Department of Pathophysiology, National University of Athens, Athens, Greece
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Zacharia BE, Gulati AP, Bruce JN, Carminucci AS, Wardlaw SL, Siegelin M, Remotti H, Lignelli A, Fine RL. High response rates and prolonged survival in patients with corticotroph pituitary tumors and refractory Cushing disease from capecitabine and temozolomide (CAPTEM): a case series. Neurosurgery 2014; 74:E447-55; discussion E455. [PMID: 24226425 DOI: 10.1227/neu.0000000000000251] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Rarely, corticotrophic pituitary tumors take on an aggressive form characterized by rapid growth, invasion into local structures, compression of cranial nerves, and possible spread to distant sites. When conventional surgery, radiation therapy, and hormones fail to control progression and symptoms, alternative therapies are needed. A novel chemotherapeutic regimen of capecitabine and temozolomide (CAPTEM), originally designed in our laboratory, demonstrated dramatic antineoplastic effects against corticotrophic pituitary tumors. CLINICAL PRESENTATION We present a case series of 4 patients with aggressive, adrenocorticotrophic hormone--producing pituitary tumors who had previously depleted all surgical, radiation, and hormonal therapies and were then treated with CAPTEM. Dramatic clinical improvements in neurological deficits and Cushing symptoms were evident in all patients after treatment was initiated. Confirmed by radiographic imaging, 2 of 4 patients demonstrated complete regression of disease, 1 patient had a 75% regression, and the fourth patient has ongoing stable disease for > 4.5 years at the time of this writing. Immunohistochemical analysis of patients' tumor samples showed low O-methyguanyl methyltransferase expression and adequate levels of mismatch repair enzymes (MLH-1, MSH-2, MSH-6, and PMS-2), which are important for the in vivo efficacy of CAPTEM. CONCLUSION This is the first report of prolonged antitumor response to and radiographic complete remissions as a result of CAPTEM in patients with aggressive pituitary tumors who had exhausted all other therapies.
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Affiliation(s)
- Brad E Zacharia
- *Department of Neurological Surgery, ‡Experimental Therapeutics Program, Department of Medicine, Division of Medical Oncology, Pancreas Center at Columbia, §Department of Medicine, Neuroendocrine Unit, and ¶Department of Pathology, Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital-Columbia University Medical Center, New York, NY
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Hirohata T, Ishii Y, Matsuno A. Treatment of pituitary carcinomas and atypical pituitary adenomas: a review. Neurol Med Chir (Tokyo) 2014; 54:966-73. [PMID: 25446382 PMCID: PMC4533354 DOI: 10.2176/nmc.ra.2014-0178] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Atypical pituitary adenomas (APAs) are aggressive tumors, harboring a Ki-67 (MIB-1) staining index of 3% or more, and positive immunohistochemical staining for p53 protein, according to the World Health Organization (WHO) classification in 2004. Pituitary carcinomas (PC) usually develop from progressive APAs and predominantly consist of hormone-generating tumors, defined by the presence of disseminations in the cerebrospinal system or systemic metastases. Most of the cases with these malignant pituitary adenomas underwent surgeries, irradiations and adjuvant medical treatments, nevertheless, the therapies are mainly palliative. Recently, the efficacy of temozolomide (TMZ), an orally administered alkylating agent, has been reported as an alternative medical treatment. However, some recent studies have demonstrated a significant recurrence rate after effective response to TMZ. Further clinical and pathological researches of malignant pituitary adenomas will be required to improve the outcome of patients with these tumors.
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Mendola M, Passeri E, Ambrosi B, Corbetta S. Multiple cerebral hemorrhagic foci from metastases during temozolomide treatment in a patient with corticotroph pituitary carcinoma. J Clin Endocrinol Metab 2014; 99:2623-4. [PMID: 24823463 DOI: 10.1210/jc.2014-1183] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- Marco Mendola
- Endocrinology and Diabetology Unit, Department of Biomedical Sciences for Health, University of Milan, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, 20097 San Donato Milanese, Italy
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Wang Y, Li J, Tohti M, Hu Y, Wang S, Li W, Lu Z, Ma C. The expression profile of Dopamine D2 receptor, MGMT and VEGF in different histological subtypes of pituitary adenomas: a study of 197 cases and indications for the medical therapy. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2014; 33:56. [PMID: 25027022 PMCID: PMC4223393 DOI: 10.1186/s13046-014-0056-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/27/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND To study the expression of D2R, MGMT and VEGF for clinical significance in pituitary adenomas, and to predict the potential curative medical therapy of dopamine agonists, temozolomide and bevacizumab on pituitary adenomas. METHODS Immunohistochemistry and western blot were performed to detect the expression of expression of D2R, MGMT and VEGF in pituitary adenoma tissue samples. The ratio of high expression of D2R, MGMT or VEGF in different subtypes of PA was compared by the use of chi-squared tests. The relationships between D2R, MGMT and VEGF expression were assessed by the Spearman rank correlation test. The association between their expression and clinical parameters was analyzed using a chi-squared test, or Fisher's exact probability test when appropriate. RESULTS The data showed that in 197 different histological subtypes of pituitary adenomas (PAs), 64.9% of them were D2R high expression, 86.3% were MGMT low expression and 58.9% were VEGF high expression. D2R high expression existed more frequently in PRL- and GH- secreting PAs. MGMT low expression existed in all PA subtypes. VEGF high expression existed more frequently in PRL, ACTH, FSH secreting and non-functioning PAs. The data of western blot also support the results. Spearman's rank correlation analysis showed that expression of MGMT was positively associated with D2R (r = 0.154, P = 0.031) and VEGF (r = 0.161, P = 0.024) in PAs, but no correlation was showed between D2R and VEGF expression (r = -0.025, P = 0.725 > 0.05). The association between their expression and clinical parameters was analyzed using a chi-squared test, or Fisher's exact probability test when appropriate, but the result showed no significant association. CONCLUSIONS PRL-and GH-secreting PAs exist high expression of D2R, responding to dopamine agonists; Most PAs exist low expression of MGMT and high expression of VEGF, TMZ or bevacizumab treatment could be applied under the premise of indications.
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50
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Ferone D, Pivonello C, Vitale G, Zatelli MC, Colao A, Pivonello R. Molecular basis of pharmacological therapy in Cushing's disease. Endocrine 2014; 46:181-98. [PMID: 24272603 DOI: 10.1007/s12020-013-0098-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/19/2013] [Indexed: 01/16/2023]
Abstract
Cushing's disease (CD) is a severe endocrine condition caused by an adrenocorticotropin (ACTH)-producing pituitary adenoma that chronically stimulates adrenocortical cortisol production and with potentially serious complications if not or inadequately treated. Active CD may produce a fourfold increase in mortality and is associated with significant morbidities. Moreover, excess mortality risk may persist even after CD treatment. Although predictors of risk in treated CD are not fully understood, the importance of early recognition and adequate treatment is well established. Surgery with resection of a pituitary adenoma is still the first line therapy, being successful in about 60-70 % of patients; however, recurrence within 2-4 years may often occur. When surgery fails, medical treatment can reduce cortisol production and ameliorate clinical manifestations while more definitive therapy becomes effective. Compounds that target hypothalamic-pituitary axis, glucocorticoid synthesis or adrenocortical function are currently used to control the deleterious effects of chronic glucocorticoid excess. In this review we describe and analyze the molecular basis of the drugs targeting the disease at central level, suppressing ACTH secretion, as well as at peripheral level, acting as adrenal inhibitors, or glucocorticoid receptor antagonists. Understanding of the underlying molecular mechanisms in CD and of glucocorticoid biology should promote the development of new targeted and more successful therapies in the future. Indeed, most of the drugs discussed have been tested in limited clinical trials, but there is potential therapeutic benefit in compounds with better specificity for the class of receptors expressed by ACTH-secreting tumors. However, long-term follow-up with management of persistent comorbidities is needed even after successful treatment of CD.
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Affiliation(s)
- Diego Ferone
- Endocrinology, Department of Internal Medicine and Medical Specialties & Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Viale Benedetto XV, 6, 16132, Genoa, Italy,
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