Immunotherapy for endocrine tumours: a clinician's perspective

Immunotherapy has revolutionised the treatment of oncological patients, but its application in various endocrine tumours is rather limited and is mainly used when conventional therapies have failed. Immune checkpoint inhibitors (ICIs) have been employed in progressive adrenocortical carcinoma, primarily utilizing the anti-PD-L1 agent pembrolizumab, obtaining overall response rates ranging between 14% and 23%. In contrast, the response rate in phaeochromocytoma/paraganglioma was substantially less at 9%, considering the small number of patients treated. Similarly, the response rate in advanced differentiated thyroid carcinomas treated with pembrolizumab was also low at 9%, although the combination of ICIs with tyrosine kinase inhibitors showed higher efficacy. Low response rates to ICIs have also been observed in progressive medullary thyroid cancer, except in tumours with a high mutation burden (TMB). Pembrolizumab or spartalizumab can be utilized in patients with high TMB anaplastic thyroid cancer, obtaining better response rates, particularly in patients with high PD-L1 expression. Immunotherapy has also been used in a few cases of parathyroid carcinoma, showing limited antitumour effect. Pituitary carcinomas may exhibit a more favourable response to ICIs compared to aggressive pituitary tumours, particularly corticotroph tumours. Patients with advanced neuroendocrine tumours achieve an overall response rate of 15%, which varies according to the primary tumour site of origin, degree of differentiation, and therapeutic regimen utilised. Future research is needed to evaluate the potential role of immunohistochemical biomarkers, such as programmed death 1/programmed death ligand 1 and TMB, as predictors for the response to immunotherapy. Furthermore, randomised prospective studies could provide more robust data on the efficacy and side effects of ICIs.

Clinical course of patients with adrenal incidentalomas and cortisol autonomy: a German retrospective single center cohort study

Background

Adrenal incidentalomas with cortisol autonomy are associated with increased cardiovascular morbidity and mortality. Specific data on the clinical and biochemical course of affected patients are lacking.

Methods

Retrospective study from a tertiary referral centre in Germany. After exclusion of overt hormone excess, malignancy and glucocorticoid medication, patients with adrenal incidentalomas were stratified according to serum cortisol after 1 mg dexamethasone: autonomous cortisol secretion (ACS), >5.0; possible ACS (PACS), 1.9-5.0; non-functioning adenomas (NFA), ≤1.8 µg/dl.

Results

A total of 260 patients were enrolled (147 women (56.5%), median follow-up 8.8 (2.0-20.8) years). At initial diagnosis, median age was 59.5 (20-82) years, and median tumour size was 27 (10-116) mm. Bilateral tumours were more prevalent in ACS (30.0%) and PACS (21.9%) than in NFA (8.1%). Over time, 40/124 (32.3%) patients had a shift of their hormonal secretion pattern (NFA to PACS/ACS, n=15/53; PACS to ACS, n=6/47; ACS to PACS, n=11/24; PACS to NFA, n=8/47). However, none of the patients developed overt Cushing's syndrome. Sixty-one patients underwent adrenalectomy (NFA, 17.9%; PACS, 24.0%; ACS, 39.0%). When non-operated patients with NFA were compared to PACS and ACS at last follow-up, arterial hypertension (65.3% vs. 81.9% and 92.0%; p<0.05), diabetes (23.8% vs. 35.6% and 40.0%; p<0.01), and thromboembolic events (PACS: HR 3.43, 95%-CI 0.89-13.29; ACS: HR 5.96, 95%-CI 1.33-26.63; p<0.05) were significantly less frequent, along with a trend towards a higher rate of cardiovascular events in case of cortisol autonomy (PACS: HR 2.23, 95%-CI 0.94-5.32; ACS: HR 2.60, 95%-CI 0.87-7.79; p=0.1). Twenty-five (12.6%) of the non-operated patients died, with higher overall mortality in PACS (HR 2.6, 95%-CI 1.0-4.7; p=0.083) and ACS (HR 4.7, 95%-CI 1.6-13.3; p<0.005) compared to NFA. In operated patients, prevalence of arterial hypertension decreased significantly (77.0% at diagnosis to 61.7% at last follow-up; p<0.05). The prevalence of cardiovascular events and mortality did not differ significantly between operated and non-operated patients, whereas thromboembolic events were significantly less frequent in the surgical treatment group.

Conclusion

Our study confirms relevant cardiovascular morbidity in patients with adrenal incidentalomas (especially those with cortisol autonomy). These patients should therefore be monitored carefully, including adequate treatment of typical cardiovascular risk factors. Adrenalectomy was associated with a significantly decreased prevalence of hypertension. However, more than 30% of patients required reclassification according to repeated dexamethasone suppression tests. Thus, cortisol autonomy should ideally be confirmed before making any relevant treatment decision (e.g. adrenalectomy).

Efficacy and safety of radiation therapy in advanced adrenocortical carcinoma

BACKGROUND

International guidelines emphasise the role of radiotherapy (RT) for the management of advanced adrenocortical carcinoma (ACC). However, the evidence for this recommendation is very low.

METHODS

We retrospectively analysed all patients who received RT for advanced ACC in five European centres since 2000.

PRIMARY ENDPOINT

time to progression of the treated lesion (tTTP). Secondary endpoints: best objective response, progression-free survival (PFS), overall survival (OS), adverse events, and the establishment of predictive factors by Cox analyses.

RESULTS

In total, 132 tumoural lesions of 80 patients were treated with conventional RT (cRT) of 50-60 Gy (n = 20) or 20-49 Gy (n = 69), stereotactic body RT of 35-50 Gy (SBRT) (n = 36), or brachytherapy of 12-25 Gy (BT) (n = 7). Best objective lesional response was complete (n = 6), partial (n = 52), stable disease (n = 60), progressive disease (n = 14). Median tTTP was 7.6 months (1.0-148.6). In comparison to cRT20-49Gy, tTTP was significantly longer for cRT50-60Gy (multivariate adjusted HR 0.10; 95% CI 0.03-0.33; p < 0.001) and SBRT (HR 0.31; 95% CI 0.12-0.80; p = 0.016), but not for BT (HR 0.66; 95% CI 0.22-1.99; p = 0.46). Toxicity was generally mild and moderate with three grade 3 events. No convincing predictive factors could be established.

CONCLUSIONS

This largest published study on RT in advanced ACC provides clear evidence that RT is effective in ACC.

Single-nuclei and bulk-tissue gene-expression analysis of pheochromocytoma and paraganglioma links disease subtypes with tumor microenvironment

Pheochromocytomas (PC) and paragangliomas (PG) are rare neuroendocrine tumors associated with autonomic nerves. Here we use single-nuclei RNA-seq and bulk-tissue gene-expression data to characterize the cellular composition of PCPG and normal adrenal tissues, refine tumor gene-expression subtypes and make clinical and genotypic associations. We confirm seven PCPG gene-expression subtypes with significant genotype and clinical associations. Tumors with mutations in VHL, SDH-encoding genes (SDHx) or MAML3-fusions are characterized by hypoxia-inducible factor signaling and neoangiogenesis. PCPG have few infiltrating lymphocytes but abundant macrophages. While neoplastic cells transcriptionally resemble mature chromaffin cells, early chromaffin and neuroblast markers are also features of some PCPG subtypes. The gene-expression profile of metastatic SDHx-related PCPG indicates these tumors have elevated cellular proliferation and a lower number of non-neoplastic Schwann-cell-like cells, while GPR139 is a potential theranostic target. Our findings therefore clarify the diverse transcriptional programs and cellular composition of PCPG and identify biomarkers of potential clinical significance.

International consensus on initial screening and follow-up of asymptomatic SDHx mutation carriers

Approximately 20% of patients diagnosed with a phaeochromocytoma or paraganglioma carry a germline mutation in one of the succinate dehydrogenase (SDHx) genes (SDHA, SDHB, SDHC and SDHD), which encode the four subunits of the SDH enzyme. When a pathogenic SDHx mutation is identified in an affected patient, genetic counselling is proposed for first-degree relatives. Optimal initial evaluation and follow-up of people who are asymptomatic but might carry SDHx mutations have not yet been agreed. Thus, we established an international consensus algorithm of clinical, biochemical and imaging screening at diagnosis and during surveillance for both adults and children. An international panel of 29 experts from 12 countries was assembled, and the Delphi method was used to reach a consensus on 41 statements. This Consensus Statement covers a range of topics, including age of first genetic testing, appropriate biochemical and imaging tests for initial tumour screening and follow-up, screening for rare SDHx-related tumours and management of elderly people who have an SDHx mutation. This Consensus Statement focuses on the management of asymptomatic SDHx mutation carriers and provides clinicians with much-needed guidance. The standardization of practice will enable prospective studies in the near future.

Acromegaly and late-onset primary hyperparathyroidism in a female with a rare MEN1 gene variant of yet undetermined clinical significance (p.Val167Ala)

Not required for Clinical Vignette.

Robotic adrenalectomy: evaluation of cost-effectiveness

Laparoscopic adrenalectomy (LA) is the preferred treatment option for adrenal lesions, considering the improved patients outcomes, due to the reduced postoperative morbidity and postoperative pain, the faster recovery and the shorter length of hospital stay. The widespread diffusion of robotic technology led to the development and standardization of robot-assisted approach to adrenalectomy. However, to date, no clear benefit from the use of the robot-assisted approach has been found. The higher costs remain an important drawback and limit the implementation of robot-assisted adrenalectomy (RA) programs. This review summarizes the current available data regarding RA including its operative outcomes, advantages and drawbacks in comparison with conventional LA, evaluating its cost-effectiveness.

Laparoscopic adrenalectomy

In the last three decades, endoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal diseases. Gagner et al., first reported in 1992, the lateral trans-abdominal laparoscopic approach to adrenalectomy. Afterwards, several retrospective and comparative studies addressed the advantages of minimally invasive adrenalectomy specifically consistent in less postoperative pain, improved patients' satisfaction, shorter hospital stay and recovery time when compared to open adrenalectomy. The lateral transabdominal approach to the adrenals is currently one of the most widely used, since it allows an optimal comprehensive view of the adrenal region and surrounding structures, and provides and adequate working space. On the other hand, from a technical point of view, essential requirements for a successful laparoscopic adrenalectomy are an appropriate knowledge of retroperitoneal anatomy, a gentle tissue manipulation and a precise haemostasis technique in order to identify appropriately the structures of interest and avoid the troublesome 'oozing' that could complicate the surgical procedure.

Laparoscopic hand-assisted adrenalectomy for tumours larger than 5 cm

OBJECTIVE

Adrenal surgery remains a distinct surgical challenge. Technical challenges associated with laparoscopic adrenalectomy are tumour size, haemorrhage control and oncological compromise. Hand-assisted laparoscopic (HAL) adrenalectomy, utilizing a hand-port device, offers minimally invasive surgery with the advantages and safety of tactile feedback. We aimed to assess the efficacy of HAL for patients requiring adrenalectomy for tumours over 5 cm in size.

CONTEXT

Hand-assisted laparoscopic surgery is used in several surgical specialities over totally laparoscopic surgery to manage sizeable pathology, reduce operating time and conversion rates. HAL adrenalectomy is demonstrated in this series as a safe alternative to laparoscopic adrenalectomy for large adrenal tumours.

DESIGN

A retrospective analysis of all HAL adrenalectomies performed over 8 years (October 2006-May 2015) by a single surgeon was performed. This case series is the largest study of this technique.

PATIENTS

All patients who were fit for surgery with adrenal tumours (over 5 cm) were included.

ANALYSIS

Primary endpoints were overall mortality, operating time, hospital stay, complications and conversion to open surgery.

RESULTS

A total of 56 patients underwent the procedure. A total of 43 had unilateral and 13 bilateral lesions. Most lesions (45) were histologically benign. These included functioning and non-functioning tumours. Median tumour size was 8 cm (range 5-19 cm). There was one (1.8%) intra-operative conversion and no peri-operative mortality. Postoperative complications occurred in 8 (14%) patients, all self-limiting. The median length of stay was 6 days (range 2-21). There was one recurrence of pathology with repeat surgery.

CONCLUSION

Hand-assisted laparoscopic surgery offers a safe reproducible approach to adrenal surgery combining minimally invasive surgery with tactile integration. Although previously described in small numbers, this represents the largest case series to date. HAL is a safe minimally invasive surgical option for larger tumours, including malignancies. The HAL technique may additionally offer a shorter learning curve for trainee adrenal surgeons.

Luteinizing hormone and insulin resistance in menopausal patients with adrenal incidentalomas: The cause-effect relationship?

OBJECTIVE

A high prevalence of insulin resistance (IR) has proven to manifest in patients with adrenal incidentalomas (AI). It has been demonstrated that an increase in IR is related to the size of tumourous masses; additionally, luteinizing hormone (LH)-dependent adrenal pathologies are well documented in patients with LH-responsive adrenal tumours occurring under conditions of physiologically elevated LH. We hypothesized that an association between LH and insulin might play a role in adrenal tumourigenesis and steroidogenesis.

DESIGN

The aim of our study was to investigate the association between LH and IR; adrenal tumour size (ATS) and IR; LH and cortisol after the 1 mg overnight dexamethasone test (1 mg DST); and ATS and 1 mg DST cortisol in AI patients. This was a case-control study conducted in the Clinic for Endocrinology, Diabetes and Metabolic Diseases in Belgrade, Serbia. The total study group consisted of 105 menopausal women: 75 AI patients [27 with nonfunctional AI (NAI) and 48 with (possible) autonomous cortisol secretion ((P)ACS)] and 30 age-, BMI-, LH- and menopause duration-matched healthy control (HC) women. To estimate IR, we used homeostasis model assessment (HOMA-IR).

RESULTS

Luteinizing hormone and ATS are in a significant positive correlation with HOMA-IR and 1 mg DST cortisol in menopausal patients with AI and (P)ACS.

CONCLUSIONS

Our data point to a possible cause-effect relationship between LH and insulin in patients with AI and (P)ACS adding to the body of evidence of their involvement in adrenal tumourigenesis and steroidogenesis.

Laparoscopic treatment of adrenal cysts--own research and literature review

MATERIAL AND METHODS

Over the last 18 months we operated on six patients with large adrenal gland cysts in our centre. This consisted of 8.2% of all patients treated in said period due to adrenal gland pathologies. On ruling out malignancy or parasitic nature of the lesions, all patients were surgically treated in order to excise the cysts while leaving the gland untouched. In five patients the cysts were resected but the adrenal gland was spared. However, in one patient the adrenal gland coated the entire cystic mass, which imposed performance of adrenalectomy in addition to cystectomy. During surgeries we tried not to clip the suprarenal vein, which we managed to do in four out of six cases.

RESULTS

A one-year remote follow-up period revealed no cyst recurrence in ultrasound or CT, and it was possible to visualise the remaining part of the adrenal gland in all cases.

CONCLUSION

Thus, in our opinion resection of benign cysts is well justified and recommendable.

Videoscopic adrenalectomy - when does retroperitoneal seem better?

Introduction

Videoscopic adrenalectomy is the gold standard for the surgical treatment of benign adrenal tumours. The two most common approaches are the lateral transperitoneal approach (LTA) and the posterior retroperitoneal approach (PRA). So far it has not been established which is the preferable one. The choice depends primarily on the surgeon's preference and contraindications for a particular approach in individual cases.

Aim

To compare the two most common approaches for videoscopic adrenalectomy, LTA and PRA, based on a literature review and our own experience.

Material and methods

We reviewed the literature (PubMed and Cochrane 1990 – current) and analysed retrospectively our own patients who underwent videoscopic adrenalectomy between 2009 and 2013. The analysis covered patient features, tumour characteristics, reasons for qualification for each approach, operative time and postoperative complications.

Results

Out of 71 videoscopic adrenalectomies, 50 were performed using PRA and 21 using LTA. Patients in the PRA group on average were older, but had smaller tumours. There was no significant difference in perioperative morbidity between PRA and LTA. Mean blood loss and total operative time were smaller/shorter for the PRA group in comparison to the LTA group. Time to first oral intake and the average postoperative hospital stay were shorter for PRA than LTA.

Conclusions

Videoscopic adrenalectomy is a safe and efficient technique performed using both LTA and PRA approaches. The choice of technique should be guided, most of all, by surgeon experience, patient characteristics, tumour size and location. Our preferable approach is PRA, especially for small (< 6 cm) benign tumours. We find LTA advantageous for tumours of larger size, with suspected malignant character (either primary or secondary), in ectopic position, as well as in patients lacking an ipsilateral kidney or when a simultaneous abdominal operation is planned.

Adrenal cortical carcinoma masquerading as pheochromocytoma: a case report

Adrenocortical carcinoma (ACC) is a malignant tumour arising from the adrenal cortex, while pheochromocytoma is a catecholamine secreting tumour of the adrenal medulla or extra adrenal sites. Both conditions are very rare, with incidence of approximately 1–2 cases per million adults annually. Most adrenocortical tumours are functioning. ACC can be associated with clinical Cushing syndrome and virilisation due to excessive production of cortisol and androgens, respectively. However, it is rare for ACC to present clinically as pheochromocytoma. We report a case of a 28-year-old lady who presented with paroxysmal hypertension and palpitations associated with raised urinary vanillyl mandelic acid. On examination, there was postural hypotension and ballotable mass in right lumbar region with no obvious features suggestive of Cushing syndrome or virilisation. A huge right suprarenal mass with areas of necrosis and calcification was noted on the abdomen CT. A right adrenalectomy was done. The histology was consistent with ACC. There are reported cases of ACC presenting with clinical features of pheochromocytoma but limited in number, accounting for barely a dozen cases in the literature. This pseudopheochromocytoma may be due to the presence of neuroendocrine features in ACC.