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Riedmeier M, Antonini SRR, Brandalise S, Costa TEJB, Daiggi CM, de Figueiredo BC, de Krijger RR, De Sá Rodrigues KE, Deal C, Del Rivero J, Engstler G, Fassnacht M, Fernandes Luiz Canali GC, Molina CAF, Gonc EN, Gültekin M, Haak HR, Guran T, Hendriks Allaird EJ, Idkowiak J, Kuhlen M, Malkin D, Meena JP, Pamporaki C, Pinto E, Puglisi S, Ribeiro RC, Thompson LDR, Yalcin B, Van Noesel M, Wiegering V. International consensus on mitotane treatment in pediatric patients with adrenal cortical tumors: indications, therapy, and management of adverse effects. Eur J Endocrinol 2024; 190:G15-G24. [PMID: 38552173 DOI: 10.1093/ejendo/lvae038] [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: 11/21/2023] [Revised: 01/17/2024] [Accepted: 02/19/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE Mitotane is an important cornerstone in the treatment of pediatric adrenal cortical tumors (pACC), but experience with the drug in the pediatric age group is still limited and current practice is not guided by robust evidence. Therefore, we have compiled international consensus statements from pACC experts on mitotane indications, therapy, and management of adverse effects. METHODS A Delphi method with 3 rounds of questionnaires within the pACC expert consortium of the international network groups European Network for the Study of Adrenal Tumors pediatric working group (ENSAT-PACT) and International Consortium of pediatric adrenocortical tumors (ICPACT) was used to create 21 final consensus statements. RESULTS We divided the statements into 4 groups: environment, indications, therapy, and adverse effects. We reached a clear consensus for mitotane treatment for advanced pACC with stages III and IV and with incomplete resection/tumor spillage. For stage II patients, mitotane is not generally indicated. The timing of initiating mitotane therapy depends on the clinical condition of the patient and the setting of the planned therapy. We recommend a starting dose of 50 mg/kg/d (1500 mg/m²/d) which can be increased up to 4000 mg/m2/d. Blood levels should range between 14 and 20 mg/L. Duration of mitotane treatment depends on the clinical risk profile and tolerability. Mitotane treatment causes adrenal insufficiency in virtually all patients requiring glucocorticoid replacement shortly after beginning. As the spectrum of adverse effects of mitotane is wide-ranging and can be life-threatening, frequent clinical and neurological examinations (every 2-4 weeks), along with evaluation and assessment of laboratory values, are required. CONCLUSIONS The Delphi method enabled us to propose an expert consensus statement, which may guide clinicians, further adapted by local norms and the individual patient setting. In order to generate evidence, well-constructed studies should be the focus of future efforts.
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Affiliation(s)
- Maria Riedmeier
- University Hospital Würzburg, Department of Pediatrics, Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Wuerzburg, Wuerzburg 97080, Germany
| | - Sonir R R Antonini
- Department of Pediatrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo 14051-200, Brazil
| | - Silvia Brandalise
- Boldrini Children's Hospital, Department of Pediatrics, São Paulo 13083-210, Brazil
| | - Tatiana El Jaick B Costa
- Service of Pediatric Oncology, Hospital Infantil Joana de Gusmão, Florianópolis, SC 88025-301, Brazil
| | - Camila M Daiggi
- Boldrini Children's Hospital, Department of Pediatrics, São Paulo 13083-210, Brazil
| | | | - Ronald R de Krijger
- Department of Pathology, University Medical Center Utrecht, Utrecht 3584 CS, The Netherlands
| | | | - Cheri Deal
- Research Center, CHU Sainte-Justine and University of Montreal, Montreal, Québec H3T 1C5, Canada
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, United States
| | - Gernot Engstler
- St. Anna Kinderspital, Department of Pediatrics, Medical University Vienna, Vienna 1090, Austria
| | - Martin Fassnacht
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg 97080, Germany
| | | | - Carlos A Fernandes Molina
- Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao 15 Paulo, Ribeirao Preto, Sao Paulo 14049-900, Brazil
| | - Elmas Nazli Gonc
- Department of Pediatric Endocrinology, Faculty of Medicine, Hacettepe University, Ankara 06230, Turkey
| | - Melis Gültekin
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
| | - Harm R Haak
- Department of Internal Medicine, Máxima MC, Eindhoven 5631 BM/Veldhoven 5504 DB, The Netherlands
- CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht University, Maastricht 616 6200 MD, The Netherlands
| | - Tulay Guran
- Department of Paediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul 34722, Turkey
| | - Emile J Hendriks Allaird
- Department of Paediatrics, University of Cambridge, Cambridge CB20QQ, United Kingdom
- Department of Paediatric Endocrinology and Diabetes, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB20QQ, United Kingdom
| | - Jan Idkowiak
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B152TT, United Kingdom
- Department of Endocrinology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B46NH, United Kingdom
| | - Michaela Kuhlen
- Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Augsburg 86135, Germany
| | - David Malkin
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario M5G1X8, Canada
| | - Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, Mother & Child Block, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, TU Dresden, Dresden 01307, Germany
| | - Emilia Pinto
- St. Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Soraya Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano 10043, Italy
| | - Raul C Ribeiro
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Lester D R Thompson
- Pathology, Head and Neck Pathology Consultations, Woodland Hills, CA 91364, United States
| | - Bilgehan Yalcin
- Department of Pediatric Oncology, Faculty of Medicine, Hacettepe University, Ankara 06230, Turkey
| | - Max Van Noesel
- Pediatric Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht 3584 CS, The Netherlands
- Division Imaging & Cancer, University Medical Center Utrecht, Utrecht 3584 CS, The Netherlands
| | - Verena Wiegering
- University Hospital Würzburg, Department of Pediatrics, Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Wuerzburg, Wuerzburg 97080, Germany
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Stadler G, de Almeida Veiga A, Rita Corso C, Bach de Assis C, de Toledo Nogueira B, Regina Rocha Martins L, Cruz Bonk B, Lada Degaut Pontes F, Cavalcante de Figueiredo B, Mera de Souza L. Two-dimensional chromatography for enantiomeric analysis of mitotane and its metabolite o,p'-DDA in patients with adrenocortical carcinoma indicates enantioselective metabolism. Bioorg Chem 2023; 141:106835. [PMID: 37713949 DOI: 10.1016/j.bioorg.2023.106835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/21/2023] [Accepted: 09/02/2023] [Indexed: 09/17/2023]
Abstract
Mitotane is a chiral drug used to treat adrenocortical carcinoma, being metabolized to the o,p'-dichlorodiphenyl acetic acid (o,p'-DDA), also a chiral compound. Despite of its therapeutic significance, the overall ratios and enantiomers have not been known. In this study, we analyzed the enantiomers of mitotane and o,p'-DDA in the plasma of patients by a newly developed chiral-phase method employed in two-dimensional chromatography. Important differences were observed in the ratio of (S)/(R)-mitotane, which varied substantially from 1:1.2 to 1:10 whereas the (S)/(R)-o,p'-DDA ratio was relatively conserved, at approximately 2:1. These findings provide evidence for the enantioselective metabolism and provide a method for further analyses of mitotane and metabolites, which can explain the variation in the therapeutic response.
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Affiliation(s)
- Gabriela Stadler
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Alan de Almeida Veiga
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Claudia Rita Corso
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Camila Bach de Assis
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Beatriz de Toledo Nogueira
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | | | - Beatriz Cruz Bonk
- Universidade Tecnológica Federal do Paraná, Curitiba 81280-340, Brazil
| | - Flávia Lada Degaut Pontes
- Departamento de Bioquímica e Biologia Molecular, Universidade Federal do Paraná, Curitiba 81531-990, Brazil
| | - Bonald Cavalcante de Figueiredo
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Lauro Mera de Souza
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil.
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Schiavon A, Saba L, Catucci G, Petiti J, Puglisi S, Borin C, Reimondo G, Gilardi G, Giachino C, Terzolo M, Lo Iacono M. Albumin/Mitotane Interaction Affects Drug Activity in Adrenocortical Carcinoma Cells: Smoke and Mirrors on Mitotane Effect with Possible Implications for Patients' Management. Int J Mol Sci 2023; 24:16701. [PMID: 38069023 PMCID: PMC10706292 DOI: 10.3390/ijms242316701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 11/22/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Mitotane is the only drug approved for the treatment of adrenocortical carcinoma (ACC). Although it has been used for many years, its mechanism of action remains elusive. H295R cells are, in ACC, an essential tool to evaluate drug mechanisms, although they often lead to conflicting results. METHODS Using different in vitro biomolecular technologies and biochemical/biophysical experiments, we evaluated how the presence of "confounding factors" in culture media and patient sera could reduce the pharmacological effect of mitotane and its metabolites. RESULTS We discovered that albumin, the most abundant protein in the blood, was able to bind mitotane. This interaction altered the effect of the drug by blocking its biological activity. This blocking effect was independent of the albumin source or methodology used and altered the assessment of drug sensitivity of the cell lines. CONCLUSIONS In conclusion, we have for the first time demonstrated that albumin does not only act as an inert drug carrier when mitotane or its metabolites are present. Indeed, our experiments clearly indicated that both albumin and human serum were able to suppress the pharmacological effect of mitotane in vitro. These experiments could represent a first step towards the individualization of mitotane treatment in this rare tumor.
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Affiliation(s)
- Aurora Schiavon
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (A.S.); (L.S.); (S.P.); (C.B.); (G.R.); (C.G.); (M.T.)
| | - Laura Saba
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (A.S.); (L.S.); (S.P.); (C.B.); (G.R.); (C.G.); (M.T.)
| | - Gianluca Catucci
- Department of Life Sciences and Systems Biology, University of Turin, 10123 Turin, Italy; (G.C.); (G.G.)
| | - Jessica Petiti
- Division of Advanced Materials Metrology and Life Sciences, Istituto Nazionale di Ricerca Metrologica (INRiM), 10135 Turin, Italy;
| | - Soraya Puglisi
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (A.S.); (L.S.); (S.P.); (C.B.); (G.R.); (C.G.); (M.T.)
| | - Chiara Borin
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (A.S.); (L.S.); (S.P.); (C.B.); (G.R.); (C.G.); (M.T.)
| | - Giuseppe Reimondo
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (A.S.); (L.S.); (S.P.); (C.B.); (G.R.); (C.G.); (M.T.)
| | - Gianfranco Gilardi
- Department of Life Sciences and Systems Biology, University of Turin, 10123 Turin, Italy; (G.C.); (G.G.)
| | - Claudia Giachino
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (A.S.); (L.S.); (S.P.); (C.B.); (G.R.); (C.G.); (M.T.)
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (A.S.); (L.S.); (S.P.); (C.B.); (G.R.); (C.G.); (M.T.)
| | - Marco Lo Iacono
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (A.S.); (L.S.); (S.P.); (C.B.); (G.R.); (C.G.); (M.T.)
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