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Seibold J, Hönemann M, Tönjes A, Sandner B. Safe long-term therapy of Cushing's syndrome over 37 years with mitotane. Front Endocrinol (Lausanne) 2024; 15:1294415. [PMID: 38440784 PMCID: PMC10911286 DOI: 10.3389/fendo.2024.1294415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/29/2024] [Indexed: 03/06/2024] Open
Abstract
While suggested, surgery is not always possible as a first-line treatment of Cushing's Disease (CD). In such cases, patients require medical therapy in order to prevent complications resulting from hypercortisolism. Although there has been a wide expansion in pharmacological options in recent years, mitotane was the agent of choice for treating hypercortisolism decades ago. Due to the introduction of other therapies, long-term experience with mitotane remains limited. Here, we report the case of a woman with CD who was treated with mitotane for 37 years. During the treatment period, biochemical and clinical disease control was achieved and the patient had two uncomplicated pregnancies. Drug-related side effects remained moderate and could be controlled by several dose adjustments. Our case highlights the ability of mitotane to allow an effective control of hypercortisolism and to represent a safe treatment option in special situations where CD requires an alternative therapeutic approach. Furthermore, we provide a literature review of the long-term use of mitotane and reported cases of pregnancy in the context of mitotane therapy.
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Affiliation(s)
- Jonas Seibold
- Medical Department III - Endocrinology, Nephrology, Rheumatology, University of Leipzig Medical Center, Leipzig, Germany
| | - Mario Hönemann
- Institute of Medical Microbiology and Virology, University of Leipzig Medical Center, Leipzig, Germany
| | - Anke Tönjes
- Medical Department III - Endocrinology, Nephrology, Rheumatology, University of Leipzig Medical Center, Leipzig, Germany
| | - Benjamin Sandner
- Medical Department III - Endocrinology, Nephrology, Rheumatology, University of Leipzig Medical Center, Leipzig, Germany
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Altieri B, Kimpel O, Megerle F, Detomas M, Chifu I, Fuss CT, Quinkler M, Kroiss M, Fassnacht M. Recovery of adrenal function after stopping mitotane in patients with adrenocortical carcinoma. Eur J Endocrinol 2024; 190:139-150. [PMID: 38244214 DOI: 10.1093/ejendo/lvae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/21/2023] [Accepted: 12/28/2023] [Indexed: 01/22/2024]
Abstract
OBJECTIVE Mitotane is the standard therapy of adrenocortical carcinoma (ACC) due to its relative selectivity of its cytotoxic effects toward adrenocortical cells. Therefore, it virtually always leads to adrenal insufficiency. Frequency and characteristics of hypothalamic-pituitary-adrenal axis recovery after discontinuation are ill-defined. METHODS This was a retrospective study of patients with ACC adjuvantly treated with mitotane for ≥12 months who were disease-free at mitotane stop and had a minimum follow-up ≥1 year. Primary endpoint was adrenal recovery. Cox regression analyses were used to identify predictive factors. Moreover, mitotane plasma elimination rate and hormonal changes after mitotane stop were investigated. RESULTS Fifty-six patients (36 women) treated with mitotane for a median time of 25 months and an average daily dose of 2.8 g were included. Median time after discontinuation until mitotane levels dropped below 5 and 2 mg/L, and the detection limit was 152 days (interquartile range: 114-202), 280 days (192-370), and 395 days (227-546), respectively. Full adrenal recovery was documented in 32 (57%) patients after a median time of 26 months (95% confidence interval [CI] = 19.6-32.4). In 4 patients (7.1%), adrenal insufficiency persisted >5 years after discontinuation. Mitotane peak ≥ 27 mg/L significantly correlated with longer time to adrenal recovery (hazard ratio [HR] = 0.2, 95% CI = 0.1-0.8, P = .03). Twenty-seven of 38 patients (71%) followed in reference centers achieved adrenal recovery compared with only 5/18 (28%) followed up in non-reference centers (HR = 4.51, 95% CI = 1.71-11.89, P = .002). Other investigated factors were not associated with adrenal function after discontinuation. CONCLUSIONS Our study demonstrates that adrenal recovery occurs in most patients after stopping mitotane, particularly when followed up in specialized centers, but not in all. Elimination time of mitotane after treatment discontinuation is very long but individually quite variable.
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Affiliation(s)
- Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Otilia Kimpel
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Felix Megerle
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Mario Detomas
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Irina Chifu
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Carmina Teresa Fuss
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Marcus Quinkler
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, 10627 Berlin, Germany
| | - Matthias Kroiss
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
- Department of Internal Medicine IV, University Hospital, Ludwig-Maximilians-University Munich, Ziemssenstrasse 1, 80336 Munich, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Josef-Schneider-Strasse 6, 97080 Würzburg, Germany
- Central Laboratory, University Hospital Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
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Poirier J, Godemel S, Mourot A, Grunenwald S, Olney HJ, Le XK, Lacroix A, Caron P, Bourdeau I. Central Hypothyroidism is Frequent During Mitotane Therapy in Adrenocortical Cancer Patients: Prevalence and Timeline. J Clin Endocrinol Metab 2023; 108:2336-2342. [PMID: 36856782 DOI: 10.1210/clinem/dgad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/15/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023]
Abstract
CONTEXT Central hypothyroidism was described previously in mitotane-treated patients but data on its prevalence and time of occurrence are limited. OBJECTIVE To better characterize thyroid hormone insufficiency in patients exposed to mitotane. METHODS We reviewed medical records of patients from 2 academic centers in Montreal (Canada) and Toulouse (France) with exposure to mitotane therapy for adrenocortical cancer between 1995 and 2020. We analyzed the thyroid function parameters during and after treatment. RESULTS In our cohort of 83 patients, 17 were excluded because of preexisting primary hypothyroidism or drug-induced hypothyroidism. During follow-up, 3/66 patients maintained a normal thyroid function and 63/66 developed central hypothyroidism. Among those 63 patients, 56 presented with an inappropriately normal or low TSH and 7 with a mildly elevated TSH. The onset of hypothyroidism was: <3 months in 33.3%, 3 to 6 months in 19.1%, 6 to 9 months in 14.3%, and 9 to 12 months in 9.5%. At least 14.3% of cases occurred after 12 months of exposure, and 6 patients had an undetermined time of occurrence. Over time, 27 patients stopped mitotane and partial (42.3%) or complete (23.1%) recovery from hypothyroidism was observed, mainly in the first 2 years after mitotane discontinuation. CONCLUSION Mitotane therapy is frequently associated with new onset of central hypothyroidism with a prevalence of 95.5%. Most cases occurred in the first year of treatment. Partial or full recovery of thyroid function occurs in 65.4% of cases. This study supports the importance of systematic monitoring of TSH and free T4 levels during and following discontinuation of mitotane therapy.
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Affiliation(s)
- Jonathan Poirier
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 3E4, Canada
| | - Sophie Godemel
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, Centre Hospitalo-Universitaire de Toulouse, 31059 Toulouse Cedex, France
| | - Aurélie Mourot
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 3E4, Canada
| | - Solange Grunenwald
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, Centre Hospitalo-Universitaire de Toulouse, 31059 Toulouse Cedex, France
| | - Harold J Olney
- Oncology Division, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 3E4, Canada
| | - Xuan Kim Le
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 3E4, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 3E4, Canada
| | - Philippe Caron
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, Centre Hospitalo-Universitaire de Toulouse, 31059 Toulouse Cedex, France
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 3E4, Canada
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Poirier J, Bonnet-Serrano F, Thomeret L, Bouys L, Bertherat J. Prolonged adrenocortical blockade following discontinuation of Osilodrostat. Eur J Endocrinol 2023; 188:K29-K32. [PMID: 37300549 DOI: 10.1093/ejendo/lvad060] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/19/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Osilodrostat is the newest approved steroidogenic inhibitor drug for the treatment of hypercortisolism. In this article, we describe 3 patients who experienced a previously undescribed adverse event: a prolonged adrenocortical blockade following treatment cessation. METHODS Patient records showing a history of successful hypercortisolism control with Osilodrostat followed by at least 4 weeks of treatment interruption were reviewed. Patient characteristics and hormonal dosage were analyzed. RESULTS Persistence of adrenocortical blockade was found in 3 patients and lasted from 6 weeks to 9 months depending on patients. This phenomenon manifested in patients regardless of lower or higher daily Osilodrostat doses (2-10 mg) and total treatment duration did not seem to predict the severity of the blockade. CONCLUSION The finding of this previously undescribed side effect highlights the importance of continuing adrenal function monitoring after Osilodrostat interruption to prevent adrenal crisis in patients at risk.
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Affiliation(s)
- Jonathan Poirier
- Assistance Publique-Hôpitaux de Paris, Service d'Endocrinologie et Maladies Métaboliques -Hôpitaux universitaires Paris-Centre, Paris F-75014, France
| | - Fidéline Bonnet-Serrano
- Assistance Publique-Hôpitaux de Paris, UF d'hormonologie-Hôpitaux universitaires Paris-Centre, Paris F-75014, France
- Institut Cochin, Inserm U1016-CNRS UMR8104-Université Paris-Cité, Paris F-75014, France
| | - Louis Thomeret
- Institut Cochin, Inserm U1016-CNRS UMR8104-Université Paris-Cité, Paris F-75014, France
| | - Lucas Bouys
- Assistance Publique-Hôpitaux de Paris, Service d'Endocrinologie et Maladies Métaboliques -Hôpitaux universitaires Paris-Centre, Paris F-75014, France
- Assistance Publique-Hôpitaux de Paris, UF d'hormonologie-Hôpitaux universitaires Paris-Centre, Paris F-75014, France
- Institut Cochin, Inserm U1016-CNRS UMR8104-Université Paris-Cité, Paris F-75014, France
| | - Jérôme Bertherat
- Assistance Publique-Hôpitaux de Paris, Service d'Endocrinologie et Maladies Métaboliques -Hôpitaux universitaires Paris-Centre, Paris F-75014, France
- Assistance Publique-Hôpitaux de Paris, UF d'hormonologie-Hôpitaux universitaires Paris-Centre, Paris F-75014, France
- Institut Cochin, Inserm U1016-CNRS UMR8104-Université Paris-Cité, Paris F-75014, France
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Treatment of adrenocortical carcinoma: oncological and endocrine outcomes. Curr Opin Urol 2023; 33:50-58. [PMID: 36444650 DOI: 10.1097/mou.0000000000001045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Adrenocortical carcinoma (ACC) is a rare, aggressive disease with a paucity of data and great variability between published studies regarding its treatment. This review provides information on current clinical management and oncological and endocrine outcomes. RECENT FINDINGS Complete surgical resection is the only potentially curative treatment for adrenocortical carcinoma (ACC). Adjuvant mitotane treatment is recommended in patients with favourable/intermediate prognosis. As part of the endocrine follow-up, steroid hormones and thyroid hormones may be decreased or increased and may need to be substituted or suppressed. Recurrences are common. If the disease-free interval is more than 12 months, surgery is a treatment if complete resection is feasible. In advanced/metastatic ACC patients, the prognosis is poor. Mitotane monotherapy is only appropriate for patients with low tumour burden and indolent disease. Patients with unfavourable prognosis should be treated with aggressive cytotoxic therapy. Patients requiring third-line treatment should be considered for clinical trials. Immunotherapy and targeted therapy are currently being investigated, but have so far yielded only unsatisfactory results. SUMMARY There is scarce evidence for the treatment of ACC, which often complicates clinical decision-making. Patients who progress on EDP-M should be treated in clinical trials.
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Kimball A, Sertic M, Saylor PJ, Kamran SC, Boyraz B. Case 38-2022: A 21-Year-Old Woman with Fatigue and Weight Gain. N Engl J Med 2022; 387:2269-2277. [PMID: 36516093 DOI: 10.1056/nejmcpc2201250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Allison Kimball
- From the Departments of Medicine (A.K., P.J.S.), Radiology (M.S.), Radiation Oncology (S.C.K.), and Pathology (B.B.), Massachusetts General Hospital, and the Departments of Medicine (A.K., P.J.S.), Radiology (M.S.), Radiation Oncology (S.C.K.), and Pathology (B.B.), Harvard Medical School - both in Boston
| | - Madeleine Sertic
- From the Departments of Medicine (A.K., P.J.S.), Radiology (M.S.), Radiation Oncology (S.C.K.), and Pathology (B.B.), Massachusetts General Hospital, and the Departments of Medicine (A.K., P.J.S.), Radiology (M.S.), Radiation Oncology (S.C.K.), and Pathology (B.B.), Harvard Medical School - both in Boston
| | - Philip J Saylor
- From the Departments of Medicine (A.K., P.J.S.), Radiology (M.S.), Radiation Oncology (S.C.K.), and Pathology (B.B.), Massachusetts General Hospital, and the Departments of Medicine (A.K., P.J.S.), Radiology (M.S.), Radiation Oncology (S.C.K.), and Pathology (B.B.), Harvard Medical School - both in Boston
| | - Sophia C Kamran
- From the Departments of Medicine (A.K., P.J.S.), Radiology (M.S.), Radiation Oncology (S.C.K.), and Pathology (B.B.), Massachusetts General Hospital, and the Departments of Medicine (A.K., P.J.S.), Radiology (M.S.), Radiation Oncology (S.C.K.), and Pathology (B.B.), Harvard Medical School - both in Boston
| | - Baris Boyraz
- From the Departments of Medicine (A.K., P.J.S.), Radiology (M.S.), Radiation Oncology (S.C.K.), and Pathology (B.B.), Massachusetts General Hospital, and the Departments of Medicine (A.K., P.J.S.), Radiology (M.S.), Radiation Oncology (S.C.K.), and Pathology (B.B.), Harvard Medical School - both in Boston
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Shirley M. Mitotane in adrenocortical carcinoma: a profile of its use. DRUGS & THERAPY PERSPECTIVES 2022. [DOI: 10.1007/s40267-022-00958-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Metabolic and Endocrine Toxicities of Mitotane: A Systematic Review. Cancers (Basel) 2021; 13:cancers13195001. [PMID: 34638485 PMCID: PMC8508479 DOI: 10.3390/cancers13195001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/29/2021] [Accepted: 10/02/2021] [Indexed: 12/05/2022] Open
Abstract
Simple Summary This is, to our knowledge, the first systematic review conducted on the endocrine effects of mitotane, which aims to collect all available evidence in the literature and provide complete and useful information regarding the management of the endocrine and metabolic side effects of mitotane in clinical practice. Abstract Despite the pivotal role of mitotane in adrenocortical carcinoma (ACC) management, data on the endocrine toxicities of this treatment are lacking. The aim of this systematic review is to collect the available evidence on the side effects of mitotane on the endocrine and metabolic systems in both children and adults affected by adrenal carcinoma. Sixteen articles on 493 patients were included. Among the adrenal insufficiency, which is an expected side effect of mitotane, 24.5% of patients increased glucocorticoid replacement therapy. Mineralocorticoid insufficiency usually occurred late in treatment in 36.8% of patients. Thyroid dysfunction is characterized by a decrease in FT4, which occurs within 3–6 months of treatment in 45.4% of patients, while TSH seems to not be a reliable marker. Dyslipidemia is characterized by an increase in both LDL-c and HDL-c (54.2%). Few studies have found evidence of hypertriglyceridemia. In males, gynecomastia and hypogonadism can occur after 3–6 months of treatment (38.4% and 35.6%, respectively), while in pre-menopausal women, mitotane can cause ovarian cysts and, less frequently, menstrual disorders. Most of these side effects appear to be reversible after mitotane discontinuation. We finally suggest an algorithm that could guide metabolic and endocrine safety assessments in patients treated with mitotane for ACC.
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Abstract
Resident progenitor and/or stem cell populations in the adult adrenal cortex enable cortical cells to undergo homeostatic renewal and regeneration after injury. Renewal occurs predominantly in the outer layers of the adrenal gland but newly formed cells undergo centripetal migration, differentiation and lineage conversion in the process of forming the different functional steroidogenic zones. Over the past 10 years, advances in the genetic characterization of adrenal diseases and studies of mouse models with altered adrenal phenotypes have helped to elucidate the molecular pathways that regulate adrenal tissue renewal, several of which are fine-tuned via complex paracrine and endocrine influences. Moreover, the adrenal gland is a sexually dimorphic organ, and testicular androgens have inhibitory effects on cell proliferation and progenitor cell recruitment in the adrenal cortex. This Review integrates these advances, including the emerging role of sex hormones, into existing knowledge on adrenocortical cell renewal. An in-depth understanding of these mechanisms is expected to contribute to the development of novel therapies for severe endocrine diseases, for which current treatments are unsatisfactory.
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Affiliation(s)
- Rodanthi Lyraki
- Université Côte d'Azur, INSERM, CNRS, Institut de Biologie Valrose, Nice, France
| | - Andreas Schedl
- Université Côte d'Azur, INSERM, CNRS, Institut de Biologie Valrose, Nice, France.
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Kastelan D, Muzurovic E, Dusek T. Approach to patients with European Network for the Study of Adrenal Tumor stages I and II adrenocortical carcinomas. Curr Opin Endocrinol Diabetes Obes 2021; 28:265-270. [PMID: 33709971 DOI: 10.1097/med.0000000000000626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Adrenocortical carcinoma (ACC) is a rare tumor with variable prognosis depending mostly on the disease stage and tumor grade. The staging system proposed by the European Network for the Study of Adrenal Tumors has a reliable prognostic potential and defines ACC stages I-IV. Due to the absence of extraadrenal tissue invasion, patients with stage I-II have a lower recurrence rate and better prognosis. This article elaborates on the current understanding of the clinical approach to this group of patients. RECENT FINDINGS Concerning the treatment, complete surgical resection of the tumor provides the only chance for cure. However, even after tumor removal, the risk of recurrence remains high and the main predictors of recurrence include tumor stage, grade (measured by Ki-67 proliferative index), and the tumor resection status. Adjuvant mitotane and/or adjuvant radiotherapy should be considered in patients with high risk of recurrence taking into account potential harmful effects of such treatment. Accordingly, careful selection of patients who may benefit from adjuvant treatment is of the utmost importance both for improving disease outcome and for avoiding potential overtreatment in patients who are at low risk of disease recurrence. SUMMARY Many aspects of the management of patients with ACC stages I and II are not entirely evidence-based, and treatment decisions rely mostly on expert opinions and data from retrospective studies. Therefore, the treatment of these patients should be restricted to specialized centers with high expertise in ACC.
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Affiliation(s)
- Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb University School of Medicine, Zagreb, Croatia
| | - Emir Muzurovic
- Department of Internal Medicine, Endocrinology Section, Clinical Centre of Montenegro, Faculty of Medicine, University of Montenegro, Podgorica, Montenegro
| | - Tina Dusek
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb University School of Medicine, Zagreb, Croatia
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Abstract
Adrenocortical carcinoma (ACC) is an extremely rare disease, the incidence of which is 0 [...].
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Vikner ME, Krogh J, Daugaard G, Andreassen M. Metabolic and hormonal side effects of mitotane treatment for adrenocortical carcinoma: A retrospective study in 50 Danish patients. Clin Endocrinol (Oxf) 2021; 94:141-149. [PMID: 32996176 DOI: 10.1111/cen.14345] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Mitotane is used in the treatment of adrenocortical carcinoma (ACC). Metabolic and hormonal side effects of mitotane, the effect of subsequent treatment with statins and hormones and the effects of discontinuation of mitotane were assessed. PATIENTS AND METHODS Fifty patients were included. Lipid profiles, thyroid hormones, sex hormones and adrenal function from first year of mitotane treatment and after cessation were evaluated. RESULTS After 6 months of mitotane treatment total cholesterol increased from (median) 5.1 (IQR 4.3 to 5.8) to 7.4 (6.2-9.0) mmol/L, p < .001. LDL, HDL and triglyceride also increased, all p ≤ .03. Three months of treatment with statins decreased total and LDL-cholesterol, and cessation of mitotane led to further reduction in lipids. Plasma thyroxine decreased from 90 (78-111) to 57 (47-63) nmol/L and free thyroxine from 16.0 (13.0-18.3) to 11.7 (10.5-12.6) pmol/L on mitotane, both p < .001, while TSH remained unchanged. Treatment with thyroxin significantly increased plasma thyroxine and free thyroxine and decreased TSH. Cessation of mitotane increased total T4 (p < .001). Mitotane increased plasma SHBG from 36 (22-51) to 189 (85-259) nmol/L and LH from 4.6 (1.6-8.1) to 20.0 (10.0-34.9) IU/L, both p < .001. In males the changes were accompanied by an increase in testosterone from 9.8 (7.2-14.5) to 27.0 (15.3-34.8) nmol/L, p < .03. Fifteen of 24 tested patients regained normal adrenal function 6 (3-16) months after cessation of mitotane. CONCLUSIONS Mitotane treatment exerts multiple severe side effects involving both the metabolic and endocrine systems that may require treatment, but the effect appears to be partially reversible.
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Affiliation(s)
- Malene Elbaek Vikner
- Department of Endocrinology, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark
| | - Jesper Krogh
- Department of Endocrinology, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark
| | - Gedske Daugaard
- Department of Oncology, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark
| | - Mikkel Andreassen
- Department of Endocrinology, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark
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Paragliola RM, Corsello A, Locantore P, Papi G, Pontecorvi A, Corsello SM. Medical Approaches in Adrenocortical Carcinoma. Biomedicines 2020; 8:biomedicines8120551. [PMID: 33260476 PMCID: PMC7760807 DOI: 10.3390/biomedicines8120551] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/15/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
Adrenocortical carcinoma (ACC) represents one of the most aggressive endocrine tumors. In spite of a correct therapeutic strategy based on a multidisciplinary approach between endocrinologist, surgeon and oncologist, the prognosis is often poor. Surgery is the mainstay treatment in ACC. Mitotane, a dichloro-diphenyl-trichloro-ethane derivate, represents the main medical treatment of ACC in consideration of its adrenocytolitic activity and it is mainly employed as adjuvant treatment after complete surgical resection and for the treatment of advanced ACC. However, the use of mitotane as adjuvant therapy is still controversial, also in consideration of the retrospective nature of several studies. The recurrence of disease is frequent, especially in advanced disease at the diagnosis. Therefore, in these contexts, conventional chemotherapy must be considered in association with mitotane, being the combination etoposide, doxorubicin and cisplatin (EDP) the standard of care in this setting. A more modern therapeutic approach, based on the need of a salvage therapy for advanced ACC that progresses through first-line EDP, is focused on molecular-targeted therapies. However, robust clinical trials are necessary to assess the real efficacy of these treatments.
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Pivonello R, Ferrigno R, De Martino MC, Simeoli C, Di Paola N, Pivonello C, Barba L, Negri M, De Angelis C, Colao A. Medical Treatment of Cushing's Disease: An Overview of the Current and Recent Clinical Trials. Front Endocrinol (Lausanne) 2020; 11:648. [PMID: 33363514 PMCID: PMC7753248 DOI: 10.3389/fendo.2020.00648] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/07/2020] [Indexed: 12/20/2022] Open
Abstract
Cushing's disease (CD) is a serious endocrine disorder characterized by chronic hypercortisolism, or Cushing's syndrome (CS), caused by a corticotroph pituitary tumor, which induces an excessive adrenocorticotropic hormone (ACTH) and consequently cortisol secretion. CD presents a severe clinical burden, with impairment of the quality of life and increase in mortality. Pituitary surgery represents the first-line therapy, but it is non-curative in one third of patients, requiring additional treatments. Among second-line treatments, medical therapy is gradually gaining importance, although the current medical treatments are unable to reach optimal efficacy and safety profile. Therefore, new drugs and new formulations of presently available drugs are currently under clinical investigation in international clinical trials, in order to assess their efficacy and safety in CD, or in the general population of CS. Among pituitary-directed agents, pasireotide, in the twice-daily subcutaneous formulation, has been demonstrated to be an effective treatment both in clinical trials and in real-world studies, and extension studies of the phase II and III clinical trials reported evidence of long-term efficacy with general good safety profile, although associated with frequent hyperglycemia, which requires monitoring of glucose metabolism. Moreover, the most recent once-monthly intramuscular formulation, pasireotide long-acting release (LAR), showed similar efficacy and safety, but associated with potential better compliance profile in CD. Roscovitine is an experimental drug currently under investigation. Among adrenal-directed agents, metyrapone is the only historical agent currently under investigation in a prospective, multicenter, international clinical trial, that would likely clarify its efficacy and safety in a large population of patients with CS. Osilodrostat, a novel agent with a mechanism of action similar to metyrapone, seems to offer a rapid, sustained, and effective disease control of CD, according to recently completed clinical trials, whereas levoketoconazole, a different chemical formulation of the historical agent ketoconazole, is still under investigation in clinical trials, with preliminary evidences showing an effective and safe control of CS. ATR-101 is an experimental drug currently under investigation. Among glucocorticoid receptor-directed drugs, mifepristone has been demonstrated to improve clinical syndrome and comorbidities, especially hypertension and impairment of glucose metabolism, but the occurrence of hypokalemia and in women uterine disorders, due to the concomitant action on progestin receptor, requires caution, whereas the preliminary evidence on relacorilant, characterized by high selectivity for glucocorticoid receptor, suggested good efficacy in the control of hypertension and impairment of glucose metabolism, as well as a good safety profile, in CS. Finally, a limited experience has demonstrated that combination therapy might be an interesting approach in the management of CD. The current review provides a summary of the available evidences from current and recent clinical trials on CD, with a specific focus on preliminary data.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Maria Cristina De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Nicola Di Paola
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Livia Barba
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Mariarosaria Negri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Cristina De Angelis
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
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