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Feelders RA, Fleseriu M, Kadioglu P, Bex M, González-Devia D, Boguszewski CL, Yavuz DG, Patino H, Pedroncelli AM, Maamari R, Chattopadhyay A, Biller BMK, Pivonello R. Long-term efficacy and safety of subcutaneous pasireotide alone or in combination with cabergoline in Cushing's disease. Front Endocrinol (Lausanne) 2023; 14:1165681. [PMID: 37876540 PMCID: PMC10593462 DOI: 10.3389/fendo.2023.1165681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 08/11/2023] [Indexed: 10/26/2023] Open
Abstract
Objective This study evaluated short- and long-term efficacy and safety of the second-generation somatostatin receptor ligand pasireotide alone or in combination with dopamine agonist cabergoline in patients with Cushing's disease (CD). Study design This is an open-label, multicenter, non-comparative, Phase II study comprising 35-week core phase and an optional extension phase. All patients started with pasireotide, and cabergoline was added if cortisol remained elevated. Eligible patients had active CD, with or without prior surgery, were pasireotide naïve at screening or had discontinued pasireotide for reasons other than safety. Primary endpoint was proportion of patients with a mean urinary free cortisol (mUFC) level not exceeding the upper limit of normal (ULN) at week 35 with missing data imputed using last available post-baseline assessments. Results Of 68 patients enrolled, 26 (38.2%) received pasireotide monotherapy and 42 (61.8%) received pasireotide plus cabergoline during the core phase. Thirty-four patients (50.0%; 95% CI 37.6-62.4) achieved the primary endpoint, of whom 17 (50.0%) received pasireotide monotherapy and 17 (50.0%) received combination therapy. Proportion of patients with mUFC control remained stable during the extension phase up to week 99. Treatment with either mono or combination therapy provided sustained improvements in clinical symptoms of hypercortisolism up to week 99. Hyperglycemia and nausea (51.5% each), diarrhea (44.1%) and cholelithiasis (33.8%) were the most frequent adverse events. Conclusion Addition of cabergoline in patients with persistently elevated mUFC on maximum tolerated doses of pasireotide is an effective and well-tolerated long-term strategy for enhancing control of hypercortisolism in some CD patients. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT01915303, identifier NCT01915303.
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Affiliation(s)
- Richard A. Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Maria Fleseriu
- Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
| | - Pinar Kadioglu
- Division of Endocrinology, Metabolism and Diabetes, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Türkiye
| | - Marie Bex
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Deyanira González-Devia
- Departamento de Medicina Interna, Sección de Endocrinologia, Hospital Universitario Fundación Santa Fé de Bogotá, Bogota, Colombia
| | - Cesar Luiz Boguszewski
- Department of Internal Medicine, Endocrine Division (SEMPR), Federal University of Paraná, Curitiba, Parana, Brazil
| | - Dilek Gogas Yavuz
- Section of Endocrinology and Metabolism, Marmara University School of Medicine, Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Türkiye
| | - Heather Patino
- Global Medical Affairs, Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Alberto M. Pedroncelli
- Recordati AG, Basel, Switzerland
- Global Medical Affairs, Novartis Pharma AG, Basel, Switzerland
| | - Ricardo Maamari
- Global Medical Affairs, Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Arghya Chattopadhyay
- Global Medical Affairs, Novartis Healthcare Private Limited, Hyderabad, Telangana, India
| | - Beverly M. K. Biller
- Neuroendocrine & Pituitary Tumor Clinical Center, Massachusetts General Hospital, Boston, MA, United States
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
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2
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Fleseriu M, Varlamov EV, Hinojosa-Amaya JM, Langlois F, Melmed S. An individualized approach to the management of Cushing disease. Nat Rev Endocrinol 2023; 19:581-599. [PMID: 37537306 DOI: 10.1038/s41574-023-00868-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
Cushing disease caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary corticotroph adenoma leads to hypercortisolaemia with high mortality due to metabolic, cardiovascular, immunological, neurocognitive, haematological and infectious conditions. The disorder is challenging to diagnose because of its common and heterogenous presenting features and the biochemical pitfalls of testing levels of hormones in the hypothalamic-pituitary-adrenal axis. Several late-night salivary cortisol and 24-h urinary free cortisol tests are usually required as well as serum levels of cortisol after a dexamethasone suppression test. MRI might only identify an adenoma in 60-75% of patients and many adenomas are small. Therefore, inferior petrosal sinus sampling remains the gold standard for confirmation of ACTH secretion from a pituitary source. Initial treatment is usually transsphenoidal adenoma resection, but preoperative medical therapy is increasingly being used in some countries and regions. Other management approaches are required if Cushing disease persists or recurs following surgery, including medications to modulate ACTH or block cortisol secretion or actions, pituitary radiation, and/or bilateral adrenalectomy. All patients require lifelong surveillance for persistent comorbidities, clinical and biochemical recurrence, and treatment-related adverse effects (including development of treatment-associated hypopituitarism). In this Review, we discuss challenges in the management of Cushing disease in adults and provide information to guide clinicians when planning an integrated and individualized approach for each patient.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Elena V Varlamov
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Jose M Hinojosa-Amaya
- Division of Endocrinology, Department of Medicine, Hospital Universitario "Dr. José E. González", Autonomous University of Nuevo León, Monterrey, Mexico
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Pivonello R, Scaroni C, Polistena B, Migliore A, Giustina A. Unmet needs on the current medical management of Cushing's syndrome: results from a Delphi panel of Italian endocrinologists. J Endocrinol Invest 2023:10.1007/s40618-023-02058-8. [PMID: 37076758 PMCID: PMC10115381 DOI: 10.1007/s40618-023-02058-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 03/02/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Cushing's syndrome (CS) is a rare clinical condition caused by excessive cortisol secretion from adrenal glands. CS is associated with increased mortality and morbidity; therefore, a prompt diagnosis and an effective therapeutic approach are strongly necessary to improve the patient's clinical management. The first-line treatment for CS is surgery, while medical treatment has historically played a minor role. However, thanks to the availability of novel compounds, the possibility of improving hypercortisolism control using different drug combinations emerged. PURPOSE No absolute recommendations are available to guide the therapeutic choice for patients with CS and, consequently, the awareness of unmet needs in CS management is growing. Although new data from clinical trials are needed to better define the most appropriate management of CS, an expert consensus approach can help define unmet needs and optimize the current CS management and treatment. METHODS Twenty-seven endocrinologists from 12 Italian regions, working among the main Italian referral centers for hospital endocrinology where they take care of CS patients, were involved in a consensus process and used the Delphi method to reach an agreement on 24 statements about managing CS patients. RESULTS In total, 18 statements reached a consensus. Some relevant unmet needs in the management of CS were reported, mainly related to the lack of a pharmacological treatment successful for the majority of patients. CONCLUSION While acknowledging the difficulty in achieving complete disease control, a significant change in CS management requires the availability of medical treatment with improved efficacy and safety over available therapeutic options at the time of the current study.
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Affiliation(s)
- R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Via Sergio Pansini, 5, 80131, Naples, Italy.
| | - C Scaroni
- Endocrinology Unit, Department of Medicine, DIMED, Hospital-University of Padova, Padua, Italy
| | | | | | - A Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan, Italy
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Martino M, Aboud N, Lucchetti B, Salvio G, Arnaldi G. An evaluation of pharmacological options for Cushing's disease: what are the state-of-the-art options? Expert Opin Pharmacother 2023; 24:557-576. [PMID: 36927238 DOI: 10.1080/14656566.2023.2192349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Untreated Cushing's syndrome (CS) is associated with significant morbidity and mortality. Cortisol normalization is a key goal to treatment. Pituitary surgery remains the first-line approach for Cushing's disease, but sometimes it is impracticable, unsuccessful, or complicated by recurrence. Medical therapy has been historically considered a palliative. However, in the latest years, interest on this topic has grown due to both the availability of new drugs and the reevaluation of the old, commonly used drugs in clinical practice. AREAS COVERED In this article, we will discuss the current options and future directions of medical therapy for CS, aiming at fitting best patients' features. An extensive literature search regarding already approved and investigational principles was conducted (PubMed, ClinicalTrials.gov. Available drugs include inhibitors of ACTH secretion, steroidogenesis inhibitors, and glucocorticoid receptor antagonists; drugs acting at different levels can be also combined in uncontrolled patients. EXPERT OPINION Since there is still no standardized pharmacological approach and the superiority of one drug over another has not been established yet in the absence of comparative studies, each time clinicians' choices should be patient-tailored. Age, gender, tumor features, severity of hypercortisolism, comorbidities/complications, rapidity of action, side effects, drug-drug interactions, contraindications, availability, patients' preferences, and costs should be all considered.
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Affiliation(s)
- Marianna Martino
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Nairus Aboud
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Beatrice Lucchetti
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Gianmaria Salvio
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Giorgio Arnaldi
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
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Sabahi M, Ghasemi-Nesari P, Maroufi SF, Shahbazi T, Yousefi O, Shahtaheri SA, Bin-Alamer O, Dabecco R, Velasquez N, Arce KM, Adada B, Benjamin CG, Borghei-Razavi H. Recurrent Cushing Disease: An Extensive Review on Pros and Cons of Different Therapeutic Approaches. World Neurosurg 2023; 172:49-65. [PMID: 36739900 DOI: 10.1016/j.wneu.2023.01.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Recurrent Cushing disease (CD) is characterized by the reappearance of clinical and hormonal aspects of hypercortisolism that occur more than 6 months after an initial post-treatment remission. METHODS We performed a systematic review and meta-analysis to synthesize the evidence about remission and complication rates after transsphenoidal surgery (TSS) radiotherapy (RT) and medical therapy (MT) in recurrent CD patients. A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), and Cochrane electronic bibliographic databases through 2020. RESULTS We noted 61 articles described therapeutic management of recurrent CD patients with representative outcome. A total of 723 patients received different therapeutic modality for their recurrent CD. The remission rates were 0.65 (95% confidence interval [CI] 0.60-0.70), 0.57 (95% CI 0.51-0.63), and 0.75 (95% CI 0.60-0.86) in the TSS, RT, and MT subgroups, respectively. The total remission rate after therapeutic approaches on recurrent CD patients was 0.64 (95% CI 0.60-0.68). A test for subgroup differences revealed there was a statistically significant difference between different subgroups (P = 0.01). The post hoc test showed that in comparison with RT, TSS (P = 0.0344) and MT (P = 0.0149) had a higher rate of remission. However, there was no statistically significant difference between separate therapeutic modalities in terms of complications including diabetes insipidus (P = 1.0) and hypopituitarism (P = 0.28). CONCLUSIONS Compared MT and TSS, RT has a statistically lower rate of remission. Although there is robust superiority of surgery over RT, interpretation of MT data must considered with caution due to the small number of included cases and wide CI range.
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Affiliation(s)
- Mohammadmahdi Sabahi
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paniz Ghasemi-Nesari
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Taha Shahbazi
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Yousefi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Alireza Shahtaheri
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Othman Bin-Alamer
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rocco Dabecco
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Nathalia Velasquez
- Department of Otolaryngology/Head and Neck Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Karla M Arce
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Florida, Weston, Florida, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA.
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6
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Mehlich A, Bolanowski M, Mehlich D, Witek P. Medical treatment of Cushing's disease with concurrent diabetes mellitus. Front Endocrinol (Lausanne) 2023; 14:1174119. [PMID: 37139336 PMCID: PMC10150952 DOI: 10.3389/fendo.2023.1174119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/03/2023] [Indexed: 05/05/2023] Open
Abstract
Cushing's disease (CD) is a severe endocrine disorder characterized by chronic hypercortisolaemia secondary to an overproduction of adrenocorticotropic hormone (ACTH) by a pituitary adenoma. Cortisol excess impairs normal glucose homeostasis through many pathophysiological mechanisms. The varying degrees of glucose intolerance, including impaired fasting glucose, impaired glucose tolerance, and Diabetes Mellitus (DM) are commonly observed in patients with CD and contribute to significant morbidity and mortality. Although definitive surgical treatment of ACTH-secreting tumors remains the most effective therapy to control both cortisol levels and glucose metabolism, nearly one-third of patients present with persistent or recurrent disease and require additional treatments. In recent years, several medical therapies demonstrated prominent clinical efficacy in the management of patients with CD for whom surgery was non-curative or for those who are ineligible to undergo surgical treatment. Cortisol-lowering medications may have different effects on glucose metabolism, partially independent of their role in normalizing hypercortisolaemia. The expanding therapeutic landscape offers new opportunities for the tailored therapy of patients with CD who present with glucose intolerance or DM, however, additional clinical studies are needed to determine the optimal management strategies. In this article, we discuss the pathophysiology of impaired glucose metabolism caused by cortisol excess and review the clinical efficacy of medical therapies of CD, with particular emphasis on their effects on glucose homeostasis.
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Affiliation(s)
- Anna Mehlich
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Marek Bolanowski
- Chair and Department of Endocrinology, Diabetes, and Isotope Treatment, Wroclaw Medical University, Wroclaw, Poland
| | - Dawid Mehlich
- Laboratory of Molecular OncoSignalling, International Institute of Molecular Mechanisms and Machines (IMol) Polish Academy of Sciences, Warsaw, Poland
- Doctoral School of Medical University of Warsaw, Medical University of Warsaw, Warsaw, Poland
- Laboratory of Experimental Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Przemysław Witek,
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Abstract
First-line treatment for Cushing´s disease is transsphenoidal surgery. But in cases of persistent or recurrent disease after surgery, contraindications to surgery, severe hypercortisolism control before surgery, or for patients waiting for radiotherapy effects, medical therapy may be indicated. Pituitary-directed agents include cabergoline and pasireotide. Both drugs present similar potential for biochemical control and pasireotide has additionally been proved to reduce tumor volume. Moreover, pasireotide was evaluated in high quality studies. In respect to safety, both drugs are well tolerated and safe, but special attention should be given for cardiac valve disease and psychiatric disorder for cabergoline, and hyperglycemia for pasireotide.
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Affiliation(s)
- Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
- Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
- , Rua Prof. Rodolpho Paulo Rocco, 255, 9th floor, Ilha do Fundão, 21941-913, Rio de Janeiro, Brazil.
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Ilan Shimon
- Institute of Endocrinology, Petach Tikva, and Sackler School of Medicine, Beilinson Hospital, Tel-Aviv University, Tel-Aviv, Israel
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Albani A, Perez-Rivas LG, Tang S, Simon J, Lucia KE, Colón-Bolea P, Schopohl J, Roeber S, Buchfelder M, Rotermund R, Flitsch J, Thorsteinsdottir J, Herms J, Stalla G, Reincke M, Theodoropoulou M. Improved pasireotide response in USP8 mutant corticotroph tumours in vitro. Endocr Relat Cancer 2022; 29:503-511. [PMID: 35686696 DOI: 10.1530/erc-22-0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/10/2022] [Indexed: 12/13/2022]
Abstract
Cushing's disease is a rare but devastating and difficult to manage condition. The somatostatin analogue pasireotide is the only pituitary-targeting pharmaceutical approved for the treatment of Cushing's disease but is accompanied by varying efficacy and potentially severe side effects. Finding means to predict which patients are more likely to benefit from this treatment may improve their management. More than half of corticotroph tumours harbour mutations in the USP8 gene, and there is evidence of higher somatostatin receptor 5 (SSTR5) expression in the USP8-mutant tumours. Pasireotide has a high affinity for SSTR5, indicating that these tumours may be more sensitive to treatment. To test this hypothesis, we examined the inhibitory action of pasireotide on adrenocorticotrophic hormone synthesis in primary cultures of human corticotroph tumour with assessed USP8 mutational status and in immortalized murine corticotroph tumour cells overexpressing human USP8 mutants frequent in Cushing's disease. Our in vitro results demonstrate that pasireotide exerts a higher antisecretory response in USP8-mutant corticotroph tumours. Overexpressing USP8 mutants in a murine corticotroph tumour cell model increased endogenous somatostatin receptor 5 (Sstr5) transcription. The murine Sstr5 promoter has two binding sites for the activating protein 1 (AP-1) and USP8 mutants possibly to mediate their action by stimulating AP-1 transcriptional activity. Our data corroborate the USP8 mutational status as a potential marker of pasireotide response and describe a potential mechanism through which USP8 mutants may regulate SSTR5 gene expression.
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Affiliation(s)
- Adriana Albani
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Sicheng Tang
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Julia Simon
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Kristin Elisabeth Lucia
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Paula Colón-Bolea
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Sigrun Roeber
- Center for Neuropathology and Prion Research, LMU Munich, Munich, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Roman Rotermund
- Department of Neurosurgery, Universitätskrankenhaus Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, Universitätskrankenhaus Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jochen Herms
- Center for Neuropathology and Prion Research, LMU Munich, Munich, Germany
| | - Günter Stalla
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
- Medicover Neuroendocrinology, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
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Bolanowski M, Kałużny M, Witek P, Jawiarczyk-Przybyłowska A. Pasireotide-a novel somatostatin receptor ligand after 20 years of use. Rev Endocr Metab Disord 2022; 23:601-620. [PMID: 35067849 PMCID: PMC9156514 DOI: 10.1007/s11154-022-09710-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 11/03/2022]
Abstract
Pasireotide, a novel multireceptor-targeted somatostatin receptor ligand (SRL) is characterized by a higher affinity to somatostatin receptor type 5 than type 2, unlike first-generation SRLs. Because of the broader binding profile, pasireotide has been suggested to have a greater clinical efficacy in acromegaly than first-generation SRLs and to be efficacious in Cushing's disease. The consequence of this binding profile is the increased blood glucose level in some patients. This results from the inhibition of both insulin secretion and the incretin effect and only a modest suppression of glucagon. A monthly intramuscular formulation of long-acting release pasireotide has been approved for both acromegaly and Cushing's disease treatment. This review presents data on the efficacy and safety of pasireotide treatment mostly in patients with acromegaly and Cushing's disease. Moreover, other possible therapeutic applications of pasireotide are mentioned.
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Affiliation(s)
- Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wrocław Medical University, Wrocław, Poland.
| | - Marcin Kałużny
- Department of Endocrinology, Diabetes and Isotope Therapy, Wrocław Medical University, Wrocław, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Bródno Hospital, Medical University of Warsaw, Warsaw, Poland
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Mondin A, Manara R, Voltan G, Tizianel I, Denaro L, Ferrari M, Barbot M, Scaroni C, Ceccato F. Pasireotide-Induced Shrinkage in GH and ACTH Secreting Pituitary Adenoma: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2022; 13:935759. [PMID: 35846311 PMCID: PMC9283714 DOI: 10.3389/fendo.2022.935759] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/06/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Pasireotide (PAS) is a novel somatostatin receptor ligands (SRL), used in controlling hormonal hypersecretion in both acromegaly and Cushing's Disease (CD). In previous studies and meta-analysis, first-generation SRLs were reported to be able to induce significant tumor shrinkage only in somatotroph adenomas. This systematic review and meta-analysis aim to summarize the effect of PAS on the shrinkage of the pituitary adenomas in patients with acromegaly or CD. MATERIALS AND METHODS We searched the Medline database for original studies in patients with acromegaly or CD receiving PAS as monotherapy, that assessed the proportion of significant tumor shrinkage in their series. After data extraction and analysis, a random-effect model was used to estimate pooled effects. Quality assessment was performed with a modified Joanna Briggs's Institute tool and the risk of publication bias was addressed through Egger's regression and the three-parameter selection model. RESULTS The electronic search identified 179 and 122 articles respectively for acromegaly and CD. After study selection, six studies considering patients with acromegaly and three with CD fulfilled the eligibility criteria. Overall, 37.7% (95%CI: [18.7%; 61.5%]) of acromegalic patients and 41.2% (95%CI: [22.9%; 62.3%]) of CD patients achieved significant tumor shrinkage. We identified high heterogeneity, especially in acromegaly (I2 of 90% for acromegaly and 47% for CD), according to the low number of studies included. DISCUSSION PAS treatment is effective in reducing tumor size, especially in acromegalic patients. This result strengthens the role of PAS treatment in pituitary adenomas, particularly in those with an invasive behavior, with progressive growth and/or extrasellar extension, with a low likelihood of surgical gross-total removal, or with large postoperative residual tissue. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022328152, identifier CRD42022328152.
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Affiliation(s)
- Alessandro Mondin
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Renzo Manara
- Department of Neuroscience (DNS), University of Padova, Padova, Italy
- Neuroradiology Unit, University-Hospital of Padova, Padova, Italy
| | - Giacomo Voltan
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Irene Tizianel
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Luca Denaro
- Department of Neuroscience (DNS), University of Padova, Padova, Italy
- Neurosurgery Unit, University-Hospital of Padova, Padova, Italy
| | - Marco Ferrari
- Department of Neuroscience (DNS), University of Padova, Padova, Italy
- Section of Otorhinolaryngology-Head and Neck Surgery, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- *Correspondence: Filippo Ceccato,
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Fleseriu M, Auchus R, Bancos I, Ben-Shlomo A, Bertherat J, Biermasz NR, Boguszewski CL, Bronstein MD, Buchfelder M, Carmichael JD, Casanueva FF, Castinetti F, Chanson P, Findling J, Gadelha M, Geer EB, Giustina A, Grossman A, Gurnell M, Ho K, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Kelly DF, Lacroix A, McCormack A, Melmed S, Molitch M, Mortini P, Newell-Price J, Nieman L, Pereira AM, Petersenn S, Pivonello R, Raff H, Reincke M, Salvatori R, Scaroni C, Shimon I, Stratakis CA, Swearingen B, Tabarin A, Takahashi Y, Theodoropoulou M, Tsagarakis S, Valassi E, Varlamov EV, Vila G, Wass J, Webb SM, Zatelli MC, Biller BMK. Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet Diabetes Endocrinol 2021; 9:847-875. [PMID: 34687601 PMCID: PMC8743006 DOI: 10.1016/s2213-8587(21)00235-7] [Citation(s) in RCA: 265] [Impact Index Per Article: 88.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/22/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
Cushing's disease requires accurate diagnosis, careful treatment selection, and long-term management to optimise patient outcomes. The Pituitary Society convened a consensus workshop comprising more than 50 academic researchers and clinical experts to discuss the application of recent evidence to clinical practice. In advance of the virtual meeting, data from 2015 to present about screening and diagnosis; surgery, medical, and radiation therapy; and disease-related and treatment-related complications of Cushing's disease summarised in recorded lectures were reviewed by all participants. During the meeting, concise summaries of the recorded lectures were presented, followed by small group breakout discussions. Consensus opinions from each group were collated into a draft document, which was reviewed and approved by all participants. Recommendations regarding use of laboratory tests, imaging, and treatment options are presented, along with algorithms for diagnosis of Cushing's syndrome and management of Cushing's disease. Topics considered most important to address in future research are also identified.
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Affiliation(s)
| | | | | | | | - Jerome Bertherat
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares de la Surrénale, Service d'Endocrinologie, Hôpital Cochin, Paris, France
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | | | | | | | - John D Carmichael
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Felipe F Casanueva
- Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM, Marseille, France; Assistance Publique Hopitaux de Marseille, Marseille, France; Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Mônica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliza B Geer
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Ashley Grossman
- University of London, London, UK; University of Oxford, Oxford, UK
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK; NIHR Cambridge Biomedical Research Center, Cambridge, UK; Addenbrooke's Hospital, Cambridge, UK
| | - Ken Ho
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Ursula B Kaiser
- Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - André Lacroix
- Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Ann McCormack
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Alberto M Pereira
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | | | - Hershel Raff
- Medical College of Wisconsin, Milwaukee, WI, USA; Advocate Aurora Research Institute, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Martin Reincke
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | | | - Ilan Shimon
- Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | | | | | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | | | - Marily Theodoropoulou
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital General de Catalunya, Barcelona, Spain; Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- Churchill Hospital, Oxford, United Kingdom
| | - Susan M Webb
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
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12
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Elsarrag M, Patel PD, Chatrath A, Taylor D, Jane JA. Genomic and molecular characterization of pituitary adenoma pathogenesis: review and translational opportunities. Neurosurg Focus 2021; 48:E11. [PMID: 32480367 DOI: 10.3171/2020.3.focus20104] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Innovations in genomics, epigenomics, and transcriptomics now lay the groundwork for therapeutic interventions against neoplastic disease. In the past 30 years, the molecular pathogenesis of pituitary adenomas has been characterized. This enhanced understanding of the biology of pituitary tumors has potential to impact current treatment paradigms, and there exists significant translational potential for these results. In this review the authors summarize the results of genomics and molecular biology investigations into pituitary adenoma pathogenesis and behavior and discuss opportunities to translate basic science findings into clinical benefit. METHODS The authors searched the PubMed and MEDLINE databases by using combinations of the keywords "pituitary adenoma," "genomics," "pathogenesis," and "epigenomics." From the initial search, additional articles were individually evaluated and selected. RESULTS Pituitary adenoma growth is primarily driven by unrestrained cell cycle progression, deregulation of growth and proliferation pathways, and abnormal epigenetic regulation of gene expression. These pathways may be amenable to therapeutic intervention. A significant number of studies have attempted to establish links between gene mutations and tumor progression, but a thorough mechanistic understanding remains elusive. CONCLUSIONS Although not currently a prominent aspect in the clinical management of pituitary adenomas, genomics and epigenomic studies may become essential in refining patient care and developing novel pharmacological agents. Future basic science investigations should aim at elucidating mechanistic understandings unique to each pituitary adenoma subtype, which will facilitate rational drug design.
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13
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Barbot M, Regazzo D, Mondin A, Zilio M, Lizzul L, Zaninotto M, Plebani M, Arnaldi G, Ceccato F, Scaroni C. Is pasireotide-induced diabetes mellitus predictable? A pilot study on the effect of a single dose of pasireotide on glucose homeostasis. Pituitary 2020; 23:534-542. [PMID: 32524277 DOI: 10.1007/s11102-020-01055-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Pasireotide (PAS) is an effective treatment for Cushing's disease (CD) but its use is burdened by an associated high incidence of diabetes mellitus (DM). The aim of this study was to examine the effect of a single subcutaneous injection of PAS on glucose metabolism in CD, and to identify predictors of DM onset. METHODS Fifteen patients with CD (13 females, 2 males; median age 43 years [IQR 34-50]) were submitted to an acute PAS test (600 µg s.c.), measuring glucose, insulin, C-peptide, GIP, glucagon, GLP-1, ACTH, and cortisol at the baseline and every 30 min for 2 h. Then they were treated twice daily with PAS 600 µg, and followed up with clinical and hormone assessments for a median of 6 months [2-13]. RESULTS PAS prompted a significant decrease in all hormonal parameters considered except for glycemia, which increased (as expected), reaching the highest value at 120' (p < 0.0001). Overall, 9/15 patients developed DM within 2 months of starting PAS therapy. There were no differences in age, weight, visceral adiposity, HOMA index, fasting glucose or severity of CD between patients who developed DM and those who did not. Baseline fasting glucagon levels were higher in the DM patients (17.95 [12.45-20.54] vs. 10.53 [8.11-12.33] pmol/L, p = 0.0256), and so were GIP and HbA1c levels (37 [5.5-39.5] vs. 29 [27-31.8] mmol/mol, p = 0.0008). Glucose at 120' was also significantly higher in the DM patients (9.5 [8.65-11.95] vs. 6.85 [4.48-9] mmol/L, p = 0.012). CONCLUSIONS PAS was rapidly able to suppress insulin and incretin secretion, with a subsequent rise in glucose levels into the diabetic range. It also induced a significant inhibition of glucagon production. The patients at higher risk of DM during PAS therapy were those with higher glucagon levels, HbA1c > 34.5 mmol/mol, and a glucose peak after PAS administration > 9 mmol/L. CD patients with these features given PAS therapy should therefore be monitored more carefully.
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Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy.
| | - Daniela Regazzo
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| | - Alessandro Mondin
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| | - Laura Lizzul
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Giorgio Arnaldi
- Endocrinology Division, Department of Clinical and Molecular Sciences (DISCLIMO), Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
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14
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Albani A, Theodoropoulou M. Persistent Cushing's Disease after Transsphenoidal Surgery: Challenges and Solutions. Exp Clin Endocrinol Diabetes 2020; 129:208-215. [PMID: 32838436 DOI: 10.1055/a-1220-6056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Transsphenoidal surgery remains the primary treatment for Cushing's disease (CD). However, despite the vast improvements in pituitary surgery, successful treatment of CD remains a great challenge. Although selective transsphenoidal removal of the pituitary tumor is a safe and effective procedure, the disease persists in around 22% of CD patients due to incomplete tumor resection. The persistence of hypercortisolism after pituitary surgery may also be the consequence of a misdiagnosis, as can occur in case of ectopic ACTH secretion or pseudo-Cushing. Considering the elevated mortality and morbidity characterizing the disease, a multidisciplinary approach is needed to minimize potential pitfalls occurring during the diagnosis, avoid surgical failure and provide the best care in those patients who have undergone unsuccessful surgery. In this review, we analyze the factors that could predict remission or persistence of CD after pituitary surgery and revise the therapeutic options in case of surgical failure.
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Affiliation(s)
- Adriana Albani
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
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15
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Polowczyk B, Kałużny M, Bolanowski M. Somatostatin analogues in the therapy of neuroendocrine tumors: Indications, contraindications, side-effects. POSTEP HIG MED DOSW 2020. [DOI: 10.5604/01.3001.0014.3056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The presence of somatostatin receptors (SSTRs) is crucial in planning the therapy of patients with neuroendocrine tumors. This applies especially to patients in whom surgery has proven unsuccessful or there are contraindications for it. Increased SSTR expression has been observed in many cancers originating in the neuroendocrine system. Among them we distinguish anterior pituitary adenomas producing GH in excess and leading to the development of acromegaly, adenocorticotropic adenomas that autonomously synthesize ACTH, which leads to the development of ACTH-dependent Cushing’s syndrome (Cushing’s disease), as well as
adenomas of the anterior pituitary from thyrotropic cells. Rich expression of these receptors
has been confirmed in epithelial tumors of neuroendocrine origin in the gastrointestinal
tract, pancreas and lungs. Somatostatin analogues, also called somatostatin receptor ligands,
are effective in symptomatic therapy; they enable disease control, exhibit anti-proliferative
effects and allow hormonal balance, which reduces mortality among patients and improves
their quality of life. The antitumor effect of somatostatin analogues has been proven in in
vitro and in vivo studies. In therapy they are usually well tolerated and safe. For many years,
somatostatin analogues have maintained an important place in the treatment of neuroendocrine
tumors and are still the subject of many studies. The aim of the study is to analyze,
based on available literature, therapeutic indications for the use of somatostatin analogues,
taking into account contraindications for therapy and its possible side effects.
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Affiliation(s)
- Beata Polowczyk
- Katedra i Klinika Endokrynologii, Diabetologii i Leczenia Izotopami, Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu
| | - Marcin Kałużny
- Katedra i Klinika Endokrynologii, Diabetologii i Leczenia Izotopami, Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu
| | - Marek Bolanowski
- Katedra i Klinika Endokrynologii, Diabetologii i Leczenia Izotopami, Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu
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16
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Castellnou S, Vasiljevic A, Lapras V, Raverot V, Alix E, Borson-Chazot F, Jouanneau E, Raverot G, Lasolle H. SST5 expression and USP8 mutation in functioning and silent corticotroph pituitary tumors. Endocr Connect 2020; 9:EC-20-0035.R1. [PMID: 32101529 PMCID: PMC7077525 DOI: 10.1530/ec-20-0035] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/25/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Somatostatin receptor type 5 (SST5) is inconsistently expressed by corticotroph tumors, with higher expression found in corticotropinomas having ubiquitin-specific protease 8 (USP8) mutations. Aims were to study the correlation between characteristics of corticotropinomas and SST5 expression/USP8 mutation status and to describe the response to pasireotide in 5 patients. DESIGN Retrospective cohort study. METHODS Clinico-biochemical, radiological and pathological data of 62 patients, operated for a functioning or silent corticotropinoma between 2013 and 2017, were collected. SST5 expression was measured by immunohistochemistry (clone UMB-4, Abcam, IRS>1 being considered positive) and Sanger sequencing was performed on 50 tumors to screen for USP8 mutations. RESULTS SST5 expression was positive in 26/62 pituitary tumors. A moderate or strong IRS was found in 15/58 corticotropinomas and in 13/35 functioning corticotropinomas. Among functioning tumors, those expressing SST5 were more frequent in women (22/24 vs 9/15, P=0.04) and had a lower grade (P=0.04) compared to others. USP8 mutations were identified in 13/50 pituitary tumors and were more frequent in functioning compared to silent tumors (11/30 vs 2/20, P=0.05). SST5 expression was more frequent in USP8mut vs USP8wt tumors (10/11 vs 7/19, P=0.007). Among treated patients, normal urinary free cortisol levels were obtained in 3 patients (IRS 0, 2, 6) while a 4-fold decrease was observed in one patient (IRS 4). CONCLUSION SST5 expression appears to be associated with functioning, USP8mut and lower grade corticotropinomas. A correlation between SST5 expression or USP8mut and response to pasireotide remains to be confirmed.
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Affiliation(s)
- Solène Castellnou
- Service d’Endocrinologie, Centre de Référence des Maladies Rares de l’Hypophyse HYPO, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Université Lyon 1, Villeurbanne, France
| | - Alexandre Vasiljevic
- Université Lyon 1, Villeurbanne, France
- Centre de Biologie et Pathologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- INSERM U1052, CNRS, UMR5286, Centre de Recherche en Cancérologie de Lyon, Lyon, France
| | - Véronique Lapras
- Service de Radiologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Véronique Raverot
- Laboratoire d’Hormonologie, Centre de Biologie et Pathologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Eudeline Alix
- Département de Cytogénétique, Centre de Biologie et Pathologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Françoise Borson-Chazot
- Service d’Endocrinologie, Centre de Référence des Maladies Rares de l’Hypophyse HYPO, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Université Lyon 1, Villeurbanne, France
| | - Emmanuel Jouanneau
- Université Lyon 1, Villeurbanne, France
- INSERM U1052, CNRS, UMR5286, Centre de Recherche en Cancérologie de Lyon, Lyon, France
- Service de Neurochirurgie, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Gérald Raverot
- Service d’Endocrinologie, Centre de Référence des Maladies Rares de l’Hypophyse HYPO, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Université Lyon 1, Villeurbanne, France
- INSERM U1052, CNRS, UMR5286, Centre de Recherche en Cancérologie de Lyon, Lyon, France
| | - Hélène Lasolle
- Service d’Endocrinologie, Centre de Référence des Maladies Rares de l’Hypophyse HYPO, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Université Lyon 1, Villeurbanne, France
- INSERM U1052, CNRS, UMR5286, Centre de Recherche en Cancérologie de Lyon, Lyon, France
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17
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Solari D, Pivonello R, Caggiano C, Guadagno E, Chiaramonte C, Miccoli G, Cavallo LM, Del Basso De Caro M, Colao A, Cappabianca P. Pituitary Adenomas: What Are the Key Features? What Are the Current Treatments? Where Is the Future Taking Us? World Neurosurg 2020; 127:695-709. [PMID: 31266132 DOI: 10.1016/j.wneu.2019.03.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
Abstract
Pituitary tumors are a heterogeneous group of lesions (usually benign) and proper understanding of the anatomy, physiology, and pathology of the hypothalamic/pituitary region is essential to make an accurate diagnosis and define the essential treatment options (i.e., surgery, medical therapies, and radiotherapy, alone or in combination). Surgery is the primary treatment for acromegaly, Cushing disease, thyroid-stimulating hormone-secreting adenomas, resistant prolactinomas, and nonfunctioning pituitary adenomas causing mass effect. Medical and radiation therapy are reserved in cases in which surgery is not possible or does not provide a complete cure. In the last decades, tremendous innovations (i.e., targeted drugs and refined surgical tools and techniques) have expanded the treatment strategies for pituitary adenomas. We herein report the current indications for and depiction of the surgical techniques in pituitary surgery, review current medical treatments, and provide a glimpse of future possibilities.
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Affiliation(s)
- Domenico Solari
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy.
| | - Rosario Pivonello
- Division of Endocrinology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Chiara Caggiano
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Elia Guadagno
- Department of Advanced Biomedical Sciences, Section of Pathology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Carmela Chiaramonte
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giovanni Miccoli
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Marialaura Del Basso De Caro
- Department of Advanced Biomedical Sciences, Section of Pathology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Annamaria Colao
- Division of Endocrinology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
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18
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Simeoli C, Ferrigno R, De Martino MC, Iacuaniello D, Papa F, Angellotti D, Pivonello C, Patalano R, Negri M, Colao A, Pivonello R. The treatment with pasireotide in Cushing's disease: effect of long-term treatment on clinical picture and metabolic profile and management of adverse events in the experience of a single center. J Endocrinol Invest 2020; 43:57-73. [PMID: 31313243 PMCID: PMC6952330 DOI: 10.1007/s40618-019-01077-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 06/18/2019] [Indexed: 12/13/2022]
Abstract
PURPOSES Pasireotide is the first medical therapy officially approved for adult patients with Cushing's disease (CD) experiencing failure of pituitary surgery or not candidates for surgery. The current study aimed at investigating pasireotide effects on clinical picture and metabolic profile in patients enrolled in the phase III CSOM230B2305 trial at Naples center. In addition, the current study focused on safety issues encountered during the study, detailing the management of the different adverse events associated with the treatment with pasireotide in Naples center. METHODS Fourteen patients entered the study; eight patients, receiving pasireotide for at least 6 months, were considered for the efficacy analysis, whereas the entire cohort of 14 patients was considered for the safety analysis. RESULTS Full or partial disease control was obtained in 85.7% of patients, according to a "per-protocol" methodology analysis, and in 42.9% of patients, according to an "intention-to-treat" methodology analysis, after 12 months of treatment. A relevant improvement in clinical signs and symptoms, mainly in facial rubor, supraclavicular fat pad, bruising, hirsutism, and muscle strength was observed; body weight, body mass index, and waist circumference significantly reduced, and a slight non-significant reduction was observed in the prevalence of visceral obesity, hypercholesterolemia, and hypertriglyceridemia. Deterioration of glucose metabolism represented the most common adverse event, occurring in 71.4% of patients, and requiring a dietary regimen as first step, metformin therapy and/or long-acting insulin as second step, and short-acting insulin, as third step; no patients discontinued treatment for hyperglycaemia. Additional adverse events of interest were nausea (21.4%), and vomiting (14.3%), spontaneously resolved in few weeks or some months, except in one patient unsuccessfully treated with metoclopramide and ondansetron, and diarrhoea (14.3%), improved with loperamide treatment. Millimetric gallstones and biliary sludge (7.1%) were managed with ursodeoxycholic acid, inducing lithiasis and biliary sludge resolution, whereas hypocortisolism-related adverse events (7.1%) were resolved with a reduction in the pasireotide dose. CONCLUSIONS The current study on a limited series of patients contributes to confirm that pasireotide may be considered a valid option for treatment of patients with CD, although it requires an appropriate management of adverse events, especially hyperglycaemia.
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Affiliation(s)
- C Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - R Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - M C De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - D Iacuaniello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - F Papa
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - D Angellotti
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - C Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - R Patalano
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - M Negri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - A Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy.
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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: 48] [Impact Index Per Article: 12.0] [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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20
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Fleseriu M, Petersenn S, Biller BMK, Kadioglu P, De Block C, T'Sjoen G, Vantyghem M, Tauchmanova L, Wojna J, Roughton M, Lacroix A, Newell‐Price J. Long-term efficacy and safety of once-monthly pasireotide in Cushing's disease: A Phase III extension study. Clin Endocrinol (Oxf) 2019; 91:776-785. [PMID: 31465533 PMCID: PMC6899900 DOI: 10.1111/cen.14081] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/16/2019] [Accepted: 08/27/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Many patients with Cushing's disease (CD) require chronic pharmacotherapy to control their hypercortisolism. We evaluated the efficacy and safety of long-acting pasireotide during a long-term extension study in patients with CD. DESIGN Open-label extension to a 12-month Phase III study of long-acting pasireotide in CD (N = 150; NCT01374906). PATIENTS Patients with mean urinary free cortisol (mUFC) ≤ upper limit of normal (ULN) or receiving clinical benefit at core study end could continue long-acting pasireotide during the extension. RESULTS Eighty-one of 150 (54.0%) enrolled patients entered the extension. Median overall exposure to pasireotide at study end was 23.9 months; 39/81 (48.1%) patients completed the extension (received ≥ 12 months' treatment during the extension and could transit to a separate pasireotide safety study). mUFC was ≤ULN in 42/81 (51.9%), 13/81 (16.0%) and 43/81 (53.1%) patients at extension baseline, month (M) 36 and last assessment. Median mUFC remained within normal limits. Median late-night salivary cortisol was 2.6 × ULN at core baseline and 1.3 × ULN at M36. Clinical improvements were sustained over time. Forty-two (51.9%) patients discontinued during the extension: 25 (30.9%) before M24 and 17 (21.0%) after M24. Hyperglycaemia-related AEs occurred in 39.5% of patients. Mean fasting glucose (FPG) and glycated haemoglobin (HbA1c ) were stable during the extension, with antidiabetic medication initiated/escalated in some patients. Sixty-six (81.5%) and 71 (88.9%) patients were classified as having diabetes (HbA1c ≥ 6.5%, FPG ≥ 7.0 mmol/L, antidiabetic medication use, or history of diabetes) at extension baseline and last assessment. CONCLUSIONS Long-acting pasireotide provided sustained biochemical and clinical improvements, with no new safety signals emerging, supporting its use as an effective long-term therapy for CD.
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Affiliation(s)
- Maria Fleseriu
- Northwest Pituitary CenterOregon Health & Science UniversityPortlandORUSA
| | | | | | | | - Christophe De Block
- Department of Endocrinology, Diabetology and MetabolismAntwerp University HospitalAntwerpBelgium
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and GenderGhent University HospitalGhentBelgium
| | | | | | - Judi Wojna
- Novartis Pharmaceuticals CorporationEast HanoverNJUSA
| | | | - André Lacroix
- Centre hospitalier de l'Université de MontréalMontrealQCCanada
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Nishioka H, Yamada S. Cushing's Disease. J Clin Med 2019; 8:jcm8111951. [PMID: 31726770 PMCID: PMC6912360 DOI: 10.3390/jcm8111951] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022] Open
Abstract
In patients with Cushing's disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients' quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary surgery, Toranomon Hospital, Tokyo 1058470, Japan;
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
| | - Shozo Yamada
- Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo 1340081, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
- Correspondence: ; Tel.: +81-336-751-211
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Bhattacharya S, Kalra S, Dutta D, Khandelwal D, Singla R. The Interplay Between Pituitary Health and Diabetes Mellitus - The Need for 'Hypophyseo-Vigilance'. EUROPEAN ENDOCRINOLOGY 2019; 16:25-31. [PMID: 32595766 DOI: 10.17925/ee.2020.16.1.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/12/2019] [Indexed: 12/16/2022]
Abstract
The anterior and posterior hypophyseal hormones alter glucose metabolism in health and disease. Secondary diabetes may occur due to hypersecretion of anterior pituitary hormones like adrenocorticotrophic hormone in Cushing's disease and growth hormone in acromegaly. Other hormones like prolactin, gonadotropins, oxytocin and vasopressin, though not overtly associated with causation of diabetes, have important physiological role in maintaining glucose homeostasis. Hypoglycaemia is not an unusual occurrence in hypopituitarism. Many of the medications that are used for treatment of hypophyseal diseases alter glucose metabolism. Agents like pasireotide should be used with caution in the setting of diabetes, whereas pegvisomant should be given preference. Diabetes mellitus itself, on the other hand, can alter the functioning of hypothalamic pituitary axis; this is documented in both type 1 and type 2 diabetes. This review focuses on the clinically relevant interplay of hypophyseal hormones and glucose homeostasis. The authors define 'hypophyseo-vigilance' as an approach which keeps the bidirectional, multifaceted interactions between the pituitary and glucose metabolism in mind while managing diabetes and pituitary disease.
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Affiliation(s)
| | | | - Deep Dutta
- Cedar Superspeciality Clinics, Dwarka, New Delhi, India
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Manetti L, Deutschbein T, Schopohl J, Yuen KCJ, Roughton M, Kriemler-Krahn U, Tauchmanova L, Maamari R, Giordano C. Long-term safety and efficacy of subcutaneous pasireotide in patients with Cushing's disease: interim results from a long-term real-world evidence study. Pituitary 2019; 22:542-551. [PMID: 31440946 PMCID: PMC6728293 DOI: 10.1007/s11102-019-00984-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Clinical trials have demonstrated the favorable efficacy/safety profile of pasireotide in patients with Cushing's disease (CD). We report interim long-term results of an ongoing real-world evidence study of subcutaneous pasireotide in patients with CD. METHODS Adults with CD receiving pasireotide, initiated before (prior-use) or at study entry (new-use), were monitored for ≤ 3 years during a multicenter observational study ( http://clinicaltrials.gov identifier NCT02310269). Primary objective was to assess long-term safety of pasireotide alone or with other CD therapies. RESULTS At the time of this interim analysis, 127 patients had received pasireotide (new-use, n = 31; prior-use, n = 96). Eight patients had completed the 3-year observation period, 53 were ongoing, and 66 had discontinued. Among 31 new-use and 92 prior-use patients with ≥ 1 safety assessment, respectively: 24 (77%) and 37 (40%) had drug-related adverse events (AEs); 7 (23%) and 10 (11%) had serious drug-related AEs. Most common drug-related AEs were nausea (14%), hyperglycemia (11%) and diarrhea (11%); these were more frequently reported in new users and mostly of mild-to-moderate severity. 14 (45%) new-use and 15 (16%) prior-use patients experienced hyperglycemia-related AEs. Mean urinary free cortisol (mUFC) was within normal range at baseline and months 1, 12 and 24, respectively, in: 1/16 (6%), 9/18 (50%), 1/3 (33%) and 0/0 new users; 28/43 (65%), 15/27 (56%), 27/33 (82%) and 12/19 (63%) prior users. CONCLUSIONS Pasireotide is well tolerated and provides sustained reductions in mUFC during real-world treatment of CD. The lower rate of hyperglycemia-related AEs in prior users suggests that hyperglycemia tends not to deteriorate if effectively managed soon after onset. CLINICAL TRIAL REGISTRATION NUMBER NCT02310269.
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Affiliation(s)
- Luca Manetti
- Azienda Ospedaliero-Universitaria Pisana, Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, UO Endocrinologia 2 Ospedale Cisanello Via Paradisa 2, 56124, Pisa, Italy.
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Kevin C J Yuen
- Swedish Pituitary Center, Swedish Neuroscience Institute, Seattle, WA, USA
- Barrow Neurological Institute, Phoenix, AZ, USA
| | | | | | | | | | - Carla Giordano
- Section of Endocrinology, Diabetology and Metabolism, Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialities (PROMISE), University of Palermo, Palermo, Italy
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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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25
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Fleseriu M, Iweha C, Salgado L, Mazzuco TL, Campigotto F, Maamari R, Limumpornpetch P. Safety and Efficacy of Subcutaneous Pasireotide in Patients With Cushing's Disease: Results From an Open-Label, Multicenter, Single-Arm, Multinational, Expanded-Access Study. Front Endocrinol (Lausanne) 2019; 10:436. [PMID: 31379734 PMCID: PMC6646464 DOI: 10.3389/fendo.2019.00436] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/18/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction: The efficacy and safety of subcutaneous (sc) pasireotide have been evaluated in a Phase III trial. Here, we report safety and efficacy results from a multinational, expanded-access study of pasireotide sc in patients with Cushing's disease (CD) in a real-world setting (clinicaltrials.gov, identifier: NCT01582061). Methods: Adults with active CD previously untreated with pasireotide were enrolled; pasireotide sc was initiated at 600 μg twice daily (bid; EU countries) or 900 μg bid (non-EU countries; 600 μg bid in patients with impaired glucose metabolism). Pasireotide dose could be adjusted in 300 μg increments/decrements to a maximum of 900 μg bid or minimum of 300 μg bid for sustained urinary free cortisol (UFC) normalization/tolerability issues. Primary objective: document the safety of pasireotide sc in patients with CD. Key secondary objectives: assess the proportion of patients with mean UFC (mUFC) not exceeding the upper limit of normal (ULN) and changes from baseline in clinical signs/symptoms and quality of life (QoL) to weeks 12, 24, and 48. Results: One hundred and four patients received pasireotide: female, n = 84 (80.8%); median duration of pasireotide exposure, 25.1 weeks; median (range) baseline mUFC, 321.2 nmol/24 h (142-10,920; 2.3 × ULN [1.0-79.2]). Forty (38.5%) patients completed the study. The most common reasons for premature discontinuation of pasireotide were unsatisfactory therapeutic effect (n = 26, 25.0%) and adverse events (AEs; n = 20, 19.2%). Drug-related grade 3/4 AEs or drug-related serious AEs (primary endpoint) were documented in 42 (40.4%) patients, most commonly diabetes mellitus (n = 12, 11.5%) and hyperglycemia (n = 8, 7.7%). All patients experienced ≥1 AE and most (n = 102; 98.1%) reported ≥1 drug-related AE; six (5.8%) patients discontinued treatment because of hyperglycemia-related AEs. At weeks 12, 24, and 48, respectively, 36/66 (54.5%), 22/46 (47.8%), and 9/21 (42.9%) evaluable patients had normalized mUFC levels. Clinical signs/symptoms and QoL were also improved. Conclusions: In an international, real-world, clinical-practice setting, pasireotide sc was generally well-tolerated (no new safety signals were identified), effectively reduced UFC (normalization in ~50% of evaluable patients) and improved clinical signs and QoL in patients with CD. While hyperglycemia-related AEs were common, consistent with previous studies, most were manageable, with <6% of patients discontinuing treatment because of these events.
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Affiliation(s)
- Maria Fleseriu
- Departments of Medicine and Neurological Surgery, Northwest Pituitary Center, Oregon Health and Science University, Portland, OR, United States
- *Correspondence: Maria Fleseriu
| | - Chioma Iweha
- Panda Medical Associates, Peoria, AZ, United States
| | - Luiz Salgado
- General Internal Medicine Service, Hospital das Clinicas da Faculdade de Medicina FMUSP, São Paulo, Brazil
| | - Tania Longo Mazzuco
- Division of Endocrinology of Medical Clinical Department, University Hospital, UEL, Londrina, Brazil
| | | | - Ricardo Maamari
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Padiporn Limumpornpetch
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
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Albani A, Ferraù F, Ciresi A, Pivonello R, Scaroni C, Iacuaniello D, Zilio M, Guarnotta V, Alibrandi A, Messina E, Boscaro M, Giordano C, Colao A, Cannavo S. Pasireotide treatment reduces cardiometabolic risk in Cushing's disease patients: an Italian, multicenter study. Endocrine 2018; 61:118-124. [PMID: 29383677 DOI: 10.1007/s12020-018-1524-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 01/09/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Patients with Cushing's disease (CD) experience metabolic alterations leading to increased cardiovascular mortality. Recently, the visceral adiposity index (VAI) has been proposed as a marker of visceral adipose tissue dysfunction (ATD) and of the related cardiometabolic risk. We aimed to evaluate the impact of 12-month pasireotide treatment on cardiometabolic risk in CD patients. METHODS This is a multicentre, prospective, and observational study. Sixteen CD patients, referred to the Endocrine Units of the University Hospitals of Messina, Napoli, Padova, and Palermo (Italy), successfully treated with pasireotide for 12 month have been enrolled. In all patients, we assessed anthropometric, clinical, and biochemical parameters and calculated VAI, ATD severity, Framingham, and atherosclerotic cardiovascular disease (ASCVD) risk scores, before and after 6 and 12 months of treatment with pasireotide (1200-1800 mcg/daily). RESULTS Before starting pasireotide treatment, ATD was present in 7/16 patients (mild in 2/16, moderate in 3/16, and severe 2/16). After 12 months of treatment: (i) 24h-urinary free cortisol levels (p = 0.003), BMI (p < 0.001), waist circumference (p = 0.001), LDL-cholesterol (p = 0.033), total-cholesterol (p = 0.032), triglycerides (p = 0.030), VAI (p = 0.015), and ATD severity (p = 0.026) were significantly decreased as compared to baseline; (ii) ATD was present in only 1/16 patients; (iii) prevalence of diabetes mellitus (p = 0.015) and HbA1c levels (p = 0.001) were significantly increased as compared to baseline; (iv) Framingham and ASCVD risk scores were not significantly different from pre-treatment values. CONCLUSIONS Twelve-month pasireotide treatment significantly reduces VAI and ATD in CD patients. These positive effects on cardiometabolic risk occur despite no change in Framingham and ASCVD risk scores and the increase in the prevalence of diabetes mellitus.
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Affiliation(s)
- A Albani
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - F Ferraù
- Department of Human Pathology of Adulthood and Childhood 'G. Barresi', University of Messina, Messina, Italy.
| | - A Ciresi
- Section of Endocrinology, Diabetology and Metabolism, DIBIMIS, University of Palermo, Palermo, Italy
| | - R Pivonello
- Department of Clinical Medicine and Surgery, Endocrinology Unit, University of Naples Federico II, Naples, Italy
| | - C Scaroni
- Department of Medicine (DIMED), Endocrinology Unit, University-Hospital of Padua, Padova, Italy
| | - D Iacuaniello
- Department of Clinical Medicine and Surgery, Endocrinology Unit, University of Naples Federico II, Naples, Italy
| | - M Zilio
- Department of Medicine (DIMED), Endocrinology Unit, University-Hospital of Padua, Padova, Italy
| | - V Guarnotta
- Section of Endocrinology, Diabetology and Metabolism, DIBIMIS, University of Palermo, Palermo, Italy
| | - A Alibrandi
- Department of Economics, University of Messina, Messina, Italy
| | - E Messina
- Unit of Endocrinology, University Hospital 'G. Martino', Messina, Italy
| | - M Boscaro
- Department of Medicine (DIMED), Endocrinology Unit, University-Hospital of Padua, Padova, Italy
| | - C Giordano
- Section of Endocrinology, Diabetology and Metabolism, DIBIMIS, University of Palermo, Palermo, Italy
| | - A Colao
- Department of Clinical Medicine and Surgery, Endocrinology Unit, University of Naples Federico II, Naples, Italy
| | - S Cannavo
- Department of Human Pathology of Adulthood and Childhood 'G. Barresi', University of Messina, Messina, Italy
- Unit of Endocrinology, University Hospital 'G. Martino', Messina, Italy
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27
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Fuertes M, Tkatch J, Rosmino J, Nieto L, Guitelman MA, Arzt E. New Insights in Cushing Disease Treatment With Focus on a Derivative of Vitamin A. Front Endocrinol (Lausanne) 2018; 9:262. [PMID: 29881371 PMCID: PMC5976796 DOI: 10.3389/fendo.2018.00262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/07/2018] [Indexed: 12/19/2022] Open
Abstract
Cushing's disease (CD) is an endocrine disorder originated by a corticotroph tumor. It is linked with high mortality and morbidity due to chronic hypercortisolism. Treatment goals are to control cortisol excess and achieve long-term remission, therefore, reducing both complications and patient's mortality. First-line of treatment for CD is pituitary's surgery. However, 30% of patients who undergo surgery experience recurrence in long-term follow-up. Persistent or recurrent CD demands second-line treatments, such as pituitary radiotherapy, adrenal surgery, and/or pharmacological therapy. The latter plays a key role in cortisol excess control. Its targets are inhibition of adrenocorticotropic hormone (ACTH) production, inhibition of adrenal steroidogenesis, or antagonism of cortisol action at its peripheral receptor. Retinoic acid (RA) is a metabolic product of vitamin A (retinol) and has been studied for its antiproliferative effects on corticotroph tumor cells. It has been shown that this drug regulates the expression of pro-opiomelanocortin (POMC), ACTH secretion, and tumor growth in corticotroph tumor mouse cell lines and in the nude mice experimental model, via inhibition of POMC transcription. It has been shown to result in tumor reduction, normalization of cortisol levels and clinical improvement in dogs treated with RA for 6 months. The orphan nuclear receptor COUP-TFI is expressed in normal corticotroph cells, but not in corticotroph tumoral cells, and inhibits RA pathways. A first clinical human study demonstrated clinical and biochemical effectiveness in 5/7 patients treated with RA for a period of up to 12 months. In a recent second clinical trial, 25% of 16 patients achieved eucortisolemia, and all achieved a cortisol reduction after 6- to 12-month treatment. The goal of this review is to discuss in the context of the available and future pharmacological treatments of CD, RA mechanisms of action on corticotroph tumor cells, and future perspectives, focusing on potential clinical implementation.
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Affiliation(s)
- Mariana Fuertes
- Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) – CONICET – Partner Institute of the Max Planck Society, Buenos Aires, Argentina
| | - Julieta Tkatch
- División Endocrinología, Hospital General de Agudos “Carlos G. Durand”, Buenos Aires, Argentina
| | - Josefina Rosmino
- División Endocrinología, Hospital General de Agudos “Carlos G. Durand”, Buenos Aires, Argentina
| | - Leandro Nieto
- Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) – CONICET – Partner Institute of the Max Planck Society, Buenos Aires, Argentina
| | | | - Eduardo Arzt
- Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) – CONICET – Partner Institute of the Max Planck Society, Buenos Aires, Argentina
- Departamento de Fisiología y Biología Molecular y Celular, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Buenos Aires, Argentina
- *Correspondence: Eduardo Arzt,
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Langlois F, Chu J, Fleseriu M. Pituitary-Directed Therapies for Cushing's Disease. Front Endocrinol (Lausanne) 2018; 9:164. [PMID: 29765354 PMCID: PMC5938400 DOI: 10.3389/fendo.2018.00164] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 03/27/2018] [Indexed: 12/30/2022] Open
Abstract
Cushing's disease (CD) is caused by a pituitary corticotroph neuroendocrine tumor inducing uncontrolled hypercortisolism. Transsphenoidal surgery is the first-line treatment in most cases. Nonetheless, some patients will not achieve cure even in expert hands, others may not be surgical candidates and a significant percentage will experience recurrence. Many patients will thus require medical therapy to achieve disease control. Pharmacologic options to treat CD have increased in recent years, with an explosion in knowledge related to pathophysiology at the molecular level. In this review, we focus on medications targeting specifically pituitary adrenocorticotropic hormone-secreting tumors. The only medication in this group approved for the treatment of CD is pasireotide, a somatostatin receptor ligand. Cabergoline and temozolomide may also be used in select cases. Previously studied and abandoned medical options are briefly discussed, and emphasis is made on upcoming medications. Mechanism of action and available data on efficacy and safety of cell cycle inhibitor roscovitine, epidermal growth factor receptor inhibitor gefitinib, retinoic acid, and silibinin, a heat shock protein 90 inhibitor are also presented.
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Affiliation(s)
- Fabienne Langlois
- Department of Endocrinology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jennifer Chu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, United States
| | - Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, United States
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
- *Correspondence: Maria Fleseriu,
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