Outcome of Immunotherapy in Adrenocortical Carcinoma - A retrospective cohort study

OBJECTIVE

Clinical trials with immune checkpoint inhibitors (ICI) in adrenocortical carcinoma (ACC) have yielded contradictory results. We aimed to evaluate treatment response and safety of ICI in ACC in a real-life setting.

DESIGN

Retrospective cohort study of 54 patients with advanced ACC receiving ICI as compassionate use at six German reference centres between 2016 and 2022.

METHODS

Objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), overall survival (OS) and treatment-related adverse events (TRAE) were assessed.

RESULTS

In 52 patients surviving at least 4 weeks after initiation of ICI, ORR was 13.5% (6-26) and DCR 24% (16-41). PFS was 3.0 months (95%CI 2.3-3.7). In all patients, median OS was 10.4 months (3.8-17). 17 TRAE occurred in 15 patients, which was associated with a longer PFS of 5.5 (1.9-9.2) vs. 2.5 (2.0- 3.0) months (HR 0.29, 95%CI 0.13-0.66, p=0.001) and OS of 28.2 (9.5-46.8) vs. 7.0 (4.1-10.2) months (HR 0.34, 95%CI 0.12-0.93). Positive tissue staining for programmed cell death ligand 1 (PD-L1) was associated with a longer PFS of 3.2 (2.6-3.8) vs. 2.3 (1.6-3.0, p<0.05) months. Adjusted for concomitant mitotane use, treatment with nivolumab was associated with lower risk of progression (HR 0.36, 0.15-0.90) and death (HR 0.20, 0.06-0.72) compared to pembrolizumab.

CONCLUSIONS

In the real-life setting we observe a response comparable to other second-line therapies and an acceptable safety profile in ACC patients receiving different ICI. The relevance of PD-L1 as a marker of response and the potentially more favourable outcome in nivolumab treated patients require confirmation.

Fertility and Pregnancy in Primary Adrenal Insufficiency in Germany

Autoimmune adrenalitis (AA) and congenital adrenal hyperplasia (CAH) are the most common reasons for acquired and monogenetic primary adrenal insufficiency. Both concern women in their fertile years. The aim of the work was to examine fertility rates, pregnancy outcome, and children's characteristics in AA and CAH patients in 2 German endocrine centers. One hundred and fifty-eight women were contacted. Thirty-nine patients with CAH due to 21-hydroxlase deficiency and 54 AA patients agreed and were included. Information about course and outcome of pregnancies was obtained by questionnaire and telephone interview. Fertility rates were calculated and compared to expected values from the German general population. Twelve CAH patients (30.8%) had 25 pregnancies, which resulted in 16 children. In AA patients, 93 pregnancies in 42 women (75%) were reported resulting in 73 childbirths. Fertility rates were normal in nonclassic CAH and in AA-only patients, but significantly reduced in classic CAH and autoimmune polyendocrine syndrome type 2 (APS-2). Rates of miscarriages were high in all CAH (36%) and APS-2 (22%) patients. The majority of children in both groups were born at term, but rates of cesarean section were elevated in classic CAH and in AA patients<5 years before or after diagnosis. Children born to CAH patients weighed significantly less than expected and 33.3% of them were born small for gestational age. Fertility seems not to be reduced in general, but specific in classic CAH and APS 2 patients. Nevertheless all CAH and AA patients seem to be at risk of miscarriages and cesarean section.

Glucose Metabolism in Primary Aldosteronism

In recent years, an increasing number of studies have revealed deleterious effects of aldosterone via the mineralocorticoid receptor (MR). Especially in patients with primary aldosteronism (PA) a significant higher estimated risk of developing cardiovascular comorbidities and comortalities compared to essential hypertensives was reported. As diabetes mellitus and the metabolic syndrome are one of the major contributors to cardiovascular morbidity and mortality their connection to aldosterone excess became a focus of research in PA patients. Several studies assessed the effect of PA on glucose metabolism, the prevalence of diabetes mellitus, and the effect of PA treatment on both revealing different results. Therefore, we performed an extensive literature research. This review focuses on the current knowledge of the connection between aldosterone excess, glucose homeostasis, and diabetes mellitus in patients with PA. We have highlighted this topic from a pro and contra perspective followed by a summarizing concluding remark. Additionally, we have briefly reviewed the data on possible underlying mechanisms and indicated future considerations on the possible impact of cortisol co-secretion in PA.

Changes in pulmonary mechanics after fiberoptic bronchoalveolar lavage in mechanically ventilated patients

OBJECTIVE

We prospectively assessed the impact of bronchoalveolar lavage (BAL) on respiratory mechanics in critically ill, mechanically ventilated patients.

STUDY DESIGN

Mechanically ventilated patients underwent BAL of one lung segment using 5 x 20 ml of sterile, physiologic saline with a temperature of 25-28 degrees C. The fractional inspired oxygen was increased to 1.0, but ventilator settings were otherwise left unchanged. Static pulmonary compliance, pulmonary resistance, alveolar ventilation, and serial dead space were measured 60 min and 2 min before and 8, 60, and 180 min after BAL to assess the consequences of the procedure. In addition, blood gases [partial pressure of carbon dioxide in arterial blood (PaCO2) and arterial oxygen tension (PaO2)], hemodynamic variables (heart rate, systolic and diastolic blood pressure), and body temperature were recorded at the same time points.

SETTING

Intensive care unit of a university hospital.

PATIENTS

18 consecutive critically ill, mechanically ventilated patients.

RESULTS

Pulmonary compliance decreased by 23% (p < 0.05) and pulmonary resistance increased by 22% (p < 0.05) shortly after BAL. The changes in pulmonary compliance and resistance were more than 30% in one third of the patient population. One hour after the procedure, PaO2 was significantly lower and PaCO2 significantly higher than before the procedure. Three hours after the procedure, pulmonary resistance returned to pre-BAL values but compliance remained 10% below baseline values (p < 0.05).

CONCLUSION

BAL in mechanically ventilated patients is associated with deterioration of pulmonary mechanics and function.