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Marazuela M, Martínez-Hernandez R, Marques-Pamies M, Biagetti B, Araujo-Castro M, Puig-Domingo M. Predictors of biochemical response to somatostatin receptor ligands in acromegaly. Best Pract Res Clin Endocrinol Metab 2024:101893. [PMID: 38575404 DOI: 10.1016/j.beem.2024.101893] [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] [Indexed: 04/06/2024]
Abstract
Although predictors of response to first-generation somatostatin receptor ligands (fg-SRLs), and to a lesser extent to pasireotide, have been studied in acromegaly for many years, their use is still not recommended in clinical guidelines. Is there insufficient evidence to use them? Numerous biomarkers including various clinical, functional, radiological and molecular markers have been identified. The first ones are applicable pre-surgery, while the molecular predictors are utilized for patients not cured after surgery. In this regard, factors predicting a good response to fg-SRLs are specifically: low basal GH, a low GH nadir in the acute octreotide test, T2 MRI hypointensity, a densely granulated pattern, high immunohistochemistry staining for somatostatin receptor 2 (SSTR2), and E-cadherin. However, there is still a lack of consensus regarding which of these biomarkers is more useful or how to integrate them into clinical practice. With classical statistical methods, it is complex to define reliable and generalizable cut-off values for a single biomarker. The potential solution to the limitations of traditional methods involves combining systems biology with artificial intelligence, which is currently providing answers to such long-standing questions that may eventually be finally included into the clinical guidelines and make personalized medicine a reality. The aim of this review is to describe the current knowledge of the main fg-SRLs and pasireotide response predictors, discuss their current usefulness, and point to future directions in the research of this field.
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Affiliation(s)
- Mónica Marazuela
- Department of Endocrinology and Nutrition Hospital Universitario La Princesa, Universidad Autónoma de Madrid,Instituto de Investigación Princesa, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER GCV14/ER/12), Madrid, Spain.
| | | | | | - Betina Biagetti
- Endocrinology & Nutrition Service, Vall d'Hebron University Hospital and Vall d'Hebron Research Institute (VHIR), Department of Medicine, Autonomous University of Barcelona, Reference Networks (ERN), 08035 Barcelona, Spain
| | - Marta Araujo-Castro
- Endocrinology & Nutrition Department. Hospital Universitario Ramón y Cajal, Spain & Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Manel Puig-Domingo
- Department of Endocrinology and Nutrition, Department of Medicine, Germans Trias i Pujol Research Institute and Hospital, Universitat Autònoma de Barcelona, Spain and Centro de Investigación Biomédica en Red de Enfermedades Raras CIBERER G747, Badalona, Spain
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Regazzo D, Avallone S, MacSweeney CP, Sergeev E, Howe D, Godwood A, Bennett KA, Brown AJH, Barnes M, Occhi G, Barbot M, Faggian D, Tropeano MP, Losa M, Lasio G, Scaroni C, Pecori Giraldi F. A novel somatostatin receptor ligand for human ACTH - and GH -secreting pituitary adenomas. Eur J Endocrinol 2024; 190:K8-K16. [PMID: 38123488 DOI: 10.1093/ejendo/lvad171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/11/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Somatostatin receptor ligands have come to play a pivotal role in the treatment of both ACTH- and GH-secreting pituitary adenomas. Clinical efficacy averages 30-50%, thus a considerable number of patients with Cushing's disease or acromegaly remain unresponsive to this therapeutic approach. HTL0030310 is a new somatostatin receptor ligand selective for subtype 5 over subtype 2, thus with a different receptor profile compared to clinical somatostatin receptor ligands. DESIGN Assessment of the effect of HTL0030310 on hormone secretion in human ACTH- and GH-secreting pituitary adenomas in vitro. METHODS Primary cultures from 3 ACTH-secreting and 5 GH-secreting pituitary adenomas were treated with 1, 10 and 100 nM HTL0030310 alone or with 10 nM CRH or GHRH, respectively. Parallel incubations with 10 nM pasireotide were also carried out. ACTH and GH secretion were assessed after 4 and 24 hour incubation; SSTR2, SSTR3, SSTR5, GH and POMC expression were evaluated after 24 hours. RESULTS HTL0030310 reduced unchallenged ACTH and POMC levels up to 50% in 2 ACTH-secreting adenomas and blunted CRH-stimulated ACTH/POMC by 20-70% in all 3 specimens. A reduction in spontaneous GH secretion was observed in 4 GH-secreting adenomas and in 2 specimens during GHRH co-incubation. SSTRs expression was detected in all specimens. CONCLUSIONS This first study on a novel somatostatin receptor 5-preferring ligand indicates that HTL0030310 can inhibit hormonal secretion in human ACTH- and GH-secreting pituitary adenomas. These findings suggest a potential new avenue for somatostatin ligands in the treatment of Cushing's disease and acromegaly.
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Affiliation(s)
- Daniela Regazzo
- Endocrinology Unit, University Hospital of Padova, Padua 35143
| | - Serena Avallone
- Endocrinology Unit, University Hospital of Padova, Padua 35143
- Department of Clinical and Molecular Science, Università Politecnica delle Marche, Ancona 60126
| | | | | | - David Howe
- Sosei Heptares, Cambridge, CB21 6DG, United Kingdom
| | - Alex Godwood
- Sosei Heptares, Cambridge, CB21 6DG, United Kingdom
| | | | | | - Matt Barnes
- Sosei Heptares, Cambridge, CB21 6DG, United Kingdom
| | - Gianluca Occhi
- Department of Biology, University of Padova, Padua 35143
| | - Mattia Barbot
- Endocrinology Unit, University Hospital of Padova, Padua 35143
| | - Diego Faggian
- Laboratory Medicine, Department of Medicine, University Hospital of Padova, Padua 35143
| | - Maria Pia Tropeano
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano 20089
| | - Marco Losa
- Department of Neurosurgery, Ospedale San Raffaele, Milan 20132
| | - Giovanni Lasio
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano 20089
| | - Carla Scaroni
- Endocrinology Unit, University Hospital of Padova, Padua 35143
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Marques-Pamies M, Gil J, Jordà M, Puig-Domingo M. Predictors of Response to Treatment with First-Generation Somatostatin Receptor Ligands in Patients with Acromegaly. Arch Med Res 2023; 54:102924. [PMID: 38042683 DOI: 10.1016/j.arcmed.2023.102924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/27/2023] [Accepted: 11/17/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND AND AIMS Predictors of first-generation somatostatin receptor ligands (fgSRLs) response in acromegaly have been studied for over 30 years, but they are still not recommended in clinical guidelines. Is there not enough evidence to support their use? This systematic review aims to describe the current knowledge of the main predictors of fgSRLs response and discuss their current usefulness, as well as future research directions. METHODS A systematic search was performed in the Scopus and PubMed databases for functional, imaging, and molecular predictive factors. RESULTS A total of 282 articles were detected, of which 64 were included. Most of them are retrospective studies performed between 1990 and 2023 focused on the predictive response to fgSRLs in acromegaly. The usefulness of the predictive factors is confirmed, with good response identified by the most replicated factors, specifically low GH nadir in the acute octreotide test, T2 MRI hypointensity, high Somatostatin receptor 2 (SSTR2) and E-cadherin expression, and a densely granulated pattern. Even if these biomarkers are interrelated, the association is quite heterogeneous. With classical statistical methods, it is complex to define reliable and generalizable cut-off values worth recommending in clinical guidelines. Machine-learning models involving omics are a promising approach to achieve the highest accuracy values to date. CONCLUSIONS This survey confirms a sufficiently robust level of evidence to apply knowledge of predictive factors for greater efficiency in the treatment decision process. The irruption of artificial intelligence in this field is providing definitive answers to such long-standing questions that may change clinical guidelines and make personalized medicine a reality.
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Affiliation(s)
| | - Joan Gil
- Endocrine Research Unit, Germans Trias i Pujol Research Institute, Badalona, Spain; Network Research Center for Rare Diseases, CIBERER, Unit 747, Instituto de Salud Carlos III, Madrid, Spain; Department of Endocrinology, Research Center for Pituitary Diseases, Hospital Sant Pau, IIB-SPau, Barcelona, Spain
| | - Mireia Jordà
- Endocrine Research Unit, Germans Trias i Pujol Research Institute, Badalona, Spain
| | - Manel Puig-Domingo
- Endocrine Research Unit, Germans Trias i Pujol Research Institute, Badalona, Spain; Network Research Center for Rare Diseases, CIBERER, Unit 747, Instituto de Salud Carlos III, Madrid, Spain; Department of Endocrinology and Nutrition, Germans Trias i Pujol University Hospital, Badalona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Marques-Pamies M, Gil J, Valassi E, Hernández M, Biagetti B, Giménez-Palop O, Martínez S, Carrato C, Pons L, Villar-Taibo R, Araujo-Castro M, Blanco C, Simón I, Simó-Servat A, Xifra G, Vázquez F, Pavón I, García-Centeno R, Zavala R, Hanzu FA, Mora M, Aulinas A, Vilarrasa N, Librizzi S, Calatayud M, de Miguel P, Alvarez-Escola C, Picó A, Sampedro M, Salinas I, Fajardo-Montañana C, Cámara R, Bernabéu I, Jordà M, Webb SM, Marazuela M, Puig-Domingo M. Revisiting the usefulness of the short acute octreotide test to predict treatment outcomes in acromegaly. Front Endocrinol (Lausanne) 2023; 14:1269787. [PMID: 38027102 PMCID: PMC10654626 DOI: 10.3389/fendo.2023.1269787] [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: 07/30/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction We previously described that a short version of the acute octreotide test (sAOT) can predict the response to first-generation somatostatin receptor ligands (SRLs) in patients with acromegaly. We have prospectively reassessed the sAOT in patients from the ACROFAST study using current ultra-sensitive GH assays. We also studied the correlation of sAOT with tumor expression of E-cadherin and somatostatin receptor 2 (SSTR2) . Methods A total of 47 patients treated with SRLs for 6 months were evaluated with the sAOT at diagnosis and correlated with SRLs' response. Those patients whose IGF1 decreased to <3SDS from normal value were considered responders and those whose IGF1 was ≥3SDS, were considered non-responders. The 2 hours GH value (GH2h) after s.c. administration of 100 mcg of octreotide was used to define predictive cutoffs. E-cadherin and SSTR2 immunostaining in somatotropinoma tissue were investigated in 24/47 and 18/47 patients, respectively. Results In all, 30 patients were responders and 17 were non-responders. GH2h was 0.68 (0.25-1.98) ng/mL in responders vs 2.35 (1.59-9.37) ng/mL in non-responders (p<0.001). GH2h = 1.4ng/mL showed the highest ability to identify responders (accuracy of 81%, sensitivity of 73.3%, and specificity of 94.1%). GH2h = 4.3ng/mL was the best cutoff for non-response prediction (accuracy of 74%, sensitivity of 35.3%, and specificity of 96.7%). Patients with E-cadherin-positive tumors showed a lower GH2h than those with E-cadherin-negative tumors [0.9 (0.3-2.1) vs 3.3 (1.5-12.1) ng/mL; p<0.01], and patients with positive E-cadherin presented a higher score of SSTR2 (7.5 ± 4.2 vs 3.3 ± 2.1; p=0.01). Conclusion The sAOT is a good predictor tool for assessing response to SRLs and correlates with tumor E-cadherin and SSTR2 expression. Thus, it can be useful in clinical practice for therapeutic decision-making in patients with acromegaly.
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Affiliation(s)
| | - Joan Gil
- Endocrine Research Unit, Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Elena Valassi
- Endocrine Research Unit, Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Department of Endocrinology and Nutrition, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Marta Hernández
- Department of Endocrinology and Nutrition, Arnau de Vilanova University Hospital, Lleida, Spain
- Endocrine Research Unit, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Lleida, Spain
| | - Betina Biagetti
- Department of Endocrinology and Nutrition, Vall Hebron University Hospital, Barcelona, Spain
| | - Olga Giménez-Palop
- Department of Endocrinology and Nutrition, Parc Taulí University Hospital, Sabadell, Spain
| | - Silvia Martínez
- Department Hormonal Laboratory, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Cristina Carrato
- Department of Pathology, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Laura Pons
- Department of Pathology, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Rocío Villar-Taibo
- Department of Endocrinology and Nutrition, Clínico de Santiago University Hospital, Santiago de Compostela, Spain
| | - Marta Araujo-Castro
- Department of Endocrinology and Nutrition, Ramón y Cajal University Hospital, Madrid, Spain
| | - Concepción Blanco
- Department of Endocrinology and Nutrition, Príncipe de Asturias University Hospital, Madrid, Spain
| | - Inmaculada Simón
- Department of Endocrinology and Nutrition, Joan XXIII University Hospital, Tarragona, Spain
| | - Andreu Simó-Servat
- Department of Endocrinology and Nutrition, Mutua de Terrassa University Hospital, Terrassa, Spain
| | - Gemma Xifra
- Department of Endocrinology and Nutrition, Josep Trueta University Hospital, Girona, Spain
| | - Federico Vázquez
- Department of Endocrinology and Nutrition, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Isabel Pavón
- Department of Endocrinology and Nutrition, Getafe University Hospital, Madrid, Spain
| | - Rogelio García-Centeno
- Department of Endocrinology and Nutrition, Gregorio Marañón University Hospital, Madrid, Spain
| | - Roxana Zavala
- Department of Endocrinology and Nutrition, Joan XXIII University Hospital, Tarragona, Spain
| | - Felicia Alexandra Hanzu
- Department of Endocrinology and Nutrition, Hospital Clinic University Hospital, Barcelona, Spain
- Endocrine Research Unit, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Mireia Mora
- Department of Endocrinology and Nutrition, Hospital Clinic University Hospital, Barcelona, Spain
- Endocrine Research Unit, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Anna Aulinas
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Departament de Medicina, Barcelona, Spain
| | - Nuria Vilarrasa
- Department of Endocrinology and Nutrition, Bellvitge University Hospital, Bellvitge, Spain
- Endocrine Research Unit, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Soledad Librizzi
- Department of Endocrinology and Nutrition, 12 de Octubre University Hospital, Madrid, Spain
| | - María Calatayud
- Department of Endocrinology and Nutrition, 12 de Octubre University Hospital, Madrid, Spain
| | - Paz de Miguel
- Department of Endocrinology and Nutrition, Clínico San Carlos University Hospital, Madrid, Spain
| | | | - Antonio Picó
- Department of Endocrinology and Nutrition, General University Hospital Dr Balmis, Miguel Hernández University, Alicante, Spain
- Endocrine Research Unit, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Miguel Sampedro
- Department of Endocrinology and Nutrition, La Princesa University Hospital, Madrid, Spain
| | - Isabel Salinas
- Department of Endocrinology and Nutrition, Germans Trias i Pujol University Hospital, Badalona, Spain
| | | | - Rosa Cámara
- Department of Endocrinology and Nutrition, La Fe University Hospital, Valencia, Spain
| | - Ignacio Bernabéu
- Department of Endocrinology and Nutrition, Clínico de Santiago University Hospital, Santiago de Compostela, Spain
| | - Mireia Jordà
- Endocrine Research Unit, Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain
| | - Susan M. Webb
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Departament de Medicina, Barcelona, Spain
| | - Mónica Marazuela
- Department of Endocrinology and Nutrition, La Princesa University Hospital, Madrid, Spain
| | - Manel Puig-Domingo
- Endocrine Research Unit, Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Department of Endocrinology and Nutrition, Germans Trias i Pujol University Hospital, Badalona, Spain
- Universitat Autònoma de Barcelona (UAB), Departament de Medicina, Barcelona, Spain
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Herkenhoff CGB, Trarbach EB, Batista RL, Soares IC, Frassetto FP, do Nascimento FBP, Grande IPP, Silva PPB, Duarte FHG, Bronstein MD, Jallad RS. Survivin: A Potential Marker of Resistance to Somatostatin Receptor Ligands. J Clin Endocrinol Metab 2023; 108:876-887. [PMID: 36273993 DOI: 10.1210/clinem/dgac610] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 09/19/2022] [Indexed: 02/13/2023]
Abstract
CONTEXT Invasive and somatostatin receptor ligand (SRL)-resistant pituitary tumors represent a challenge in the clinical practice of endocrinologists. Efforts have been made to elucidate reliable makers for both. Survivin and eukaryotic translation initiation factor-binding protein 1 (4EBP1) are upregulated in several cancers and involved in apoptosis and cell proliferation. OBJECTIVE We explored the role of these markers in somatotropinomas. METHODS Immunostains for survivin and 4EBP1, and also for somatostatin receptor type 2 (SSTR2), Ki-67, and cytokeratin 18, were analyzed in tissue microarrays containing 52 somatotropinoma samples. Tumor invasiveness was evaluated in all samples while drug resistance was evaluated in 34 patients who received SRL treatment. All these parameters were correlated with first-generation SRL (fg-SRL) responsiveness and tumor invasiveness. RESULTS Low survivin expression (P = 0.04), hyperintense signal on T2 weighted image (T2WI) (P = 0.01), younger age (P = 0.01), sparsely granular adenomas (SGA) (P = 0.04), high postoperative growth hormone (GH) and insulin-like growth factor-1 (IGF-1) levels (P = 0.049 and P < 0.001, respectively), and large postoperative tumor size (P = 0.02) were associated with resistance to fg-SRL. Low survivin and SSTR2 expression and high 4EBP1 expression were associated with SGA (P = 0.04, P = 0.01, and P = 0.001, respectively). Younger age (P = 0.03), large tumor pre- and postoperative (P = 0.04 and P = 0.006, respectively), low SSTR2 expression (P = 0.03), and high baseline GH and IGF-1 (P = 0.01 and P = 0.02, respectively) were associated with tumor invasiveness. However, survivin, 4EBP1, Ki-67, and granulation patterns were not associated with tumor invasion. CONCLUSION This study suggests that low survivin expression is predictive of resistance to fg-SRL in somatotropinomas, but not of tumor invasiveness.
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Affiliation(s)
- Clarissa G Borba Herkenhoff
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
| | - Ericka B Trarbach
- Laboratory of Cellular and Molecular Endocrinology/LIM25 Division of Endocrinology and Metabology, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
| | - Rafael Loch Batista
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
- Service of Endocrine Oncology, Cancer Institute of the State of São Paulo (ICESP), Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
| | - Iberê Cauduro Soares
- Department of Pathology, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
| | - Fernando Pereira Frassetto
- Department of Pathology, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
| | | | - Isabella Pacetti Pajaro Grande
- Laboratory of Cellular and Molecular Endocrinology/LIM25 Division of Endocrinology and Metabology, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
| | - Paula P B Silva
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
| | - Felipe H G Duarte
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
| | - Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
- Laboratory of Cellular and Molecular Endocrinology/LIM25 Division of Endocrinology and Metabology, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
| | - Raquel S Jallad
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
- Laboratory of Cellular and Molecular Endocrinology/LIM25 Division of Endocrinology and Metabology, Clinics Hospital, University of São Paulo Medical School, São Paulo, CEP 05403-010, Brazil
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Labadzhyan A, Melmed S. Molecular targets in acromegaly. Front Endocrinol (Lausanne) 2022; 13:1068061. [PMID: 36545335 PMCID: PMC9760705 DOI: 10.3389/fendo.2022.1068061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/18/2022] [Indexed: 12/10/2022] Open
Abstract
Molecular therapeutic targets in growth hormone (GH)-secreting adenomas range from well-characterized surface receptors that recognize approved drugs, to surface and intracellular markers that are potential candidates for new drug development. Currently available medical therapies for patients with acromegaly bind to somatostatin receptors, GH receptor, or dopamine receptors, and lead to attainment of disease control in most patients. The degree of control is variable: however, correlates with both disease aggressiveness and tumor factors that predict treatment response including somatostatin receptor subtype expression, granulation pattern, kinases and their receptors, and other markers of proliferation. A better understanding of the mechanisms underlying these molecular markers and their relationship to outcomes holds promise for expanding treatment options as well as a more personalized approach to treating patients with acromegaly.
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Affiliation(s)
- Artak Labadzhyan
- Department of Medicine, Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Ilie MD, Tabarin A, Vasiljevic A, Bonneville JF, Moreau-Grangé L, Schillo F, Delemer B, Barlier A, Figarella-Branger D, Bisot-Locard S, Santos A, Chanson P, Raverot G. Predictive Factors of Somatostatin Receptor Ligand Response in Acromegaly-A Prospective Study. J Clin Endocrinol Metab 2022; 107:2982-2991. [PMID: 36136828 DOI: 10.1210/clinem/dgac512] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Somatostatin receptor ligands (SRLs) are the cornerstone medical treatments for acromegaly; however, many patients remain unresponsive to SRLs. Well-established predictive markers of response are needed. OBJECTIVE We aimed to explore the relationship between responsiveness to SRLs relative to somatostatin (SST)2A and 5 receptor expression, adenoma granularity, and T2-weighted magnetic resonance imaging (MRI) signal intensity (T2WSI). METHODS We conducted a multicentric, prospective, observational cohort study, in France. Forty-nine naïve patients (ie, patients without preoperative SRL treatment) with active acromegaly following surgery were treated with octreotide (group 1; n = 47), or pasireotide if uncontrolled under first-generation SRLs (group 2; n = 9). Data were collected at baseline and months 3 and 6. Biochemical measurements, immunohistochemistry studies, and MRI readings were centralized. RESULTS In group 1, IGF-I decrease from baseline to month 6 positively correlated with SST2A immunoreactive score (IRS), P = 0.01. Densely granulated/intermediate adenomas had a greater IGF-I and GH decrease under octreotide compared with sparsely granulated adenomas (P = 0.02 and P = 0.006, respectively), and expressed greater levels of SST2A (P < 0.001), coupled with lower levels of SST5 (P = 0.004). T2WSI changed between preoperative MRI and month 6 MRI in one-half of the patients. Finally, SST5 IRS was higher in preoperative hyperintense compared with preoperative hypointense adenomas (P = 0.04), and most sparsely granulated and most hyperintense adenomas expressed high SST5 levels. CONCLUSION We prospectively confirm that SST2A and adenoma granularity are good predictors of response to octreotide. We propose the IRS for scoring system harmonization. MRI sequences must be optimized to be able to use the T2WSI as a predictor of treatment response.
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Affiliation(s)
- Mirela-Diana Ilie
- Inserm U1052, CNRS UMR5286, Claude Bernard Lyon 1 University, Cancer Research Center of Lyon, Lyon 69001, France
- Endocrinology Department, "C.I. Parhon" National Institute of Endocrinology, Bucharest 011863, Romania
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, Bordeaux University Hospital, Pessac 33600, France
| | - Alexandre Vasiljevic
- Inserm U1052, CNRS UMR5286, Claude Bernard Lyon 1 University, Cancer Research Center of Lyon, Lyon 69001, France
- Pathology Department, "Groupement Hospitalier Est" Hospices Civils de Lyon, Bron 69500, France
| | - Jean-François Bonneville
- Departments of Medical Imaging and Endocrinology, Liège University Hospital, Liège 4000, Belgium
| | - Lucile Moreau-Grangé
- Department of Endocrinology, Diabetes and Metabolic Disorders, Rouen University Hospital, Rouen 76000, France
| | - Franck Schillo
- Department of Diabetes, Endocrinology and Nutrition, Besançon University Hospital, Besançon 25030, France
| | - Brigitte Delemer
- Department of Endocrinology, Diabetes and Nutrition, Reims University Hospital, Reims 51092, France
| | - Anne Barlier
- Laboratory of Molecular Biology, Conception University Hospital, AP-HM, Marseille 13005, France
- Aix-Marseille University, Inserm, MMG, Marseille 13011, France
| | | | | | | | - Philippe Chanson
- Department of Endocrinology and Reproduction Disorders, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre 94270, France
- Paris-Saclay University, Inserm, "Physiologie et Physiopathologie Endocriniennes", Le Kremlin-Bicêtre 91190, France
| | - Gérald Raverot
- Inserm U1052, CNRS UMR5286, Claude Bernard Lyon 1 University, Cancer Research Center of Lyon, Lyon 69001, France
- Endocrinology Department, "Groupement Hospitalier Est" Hospices Civils de Lyon, Bron 69500, France
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8
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Soukup J, Manethova M, Faistova H, Krbal L, Vitovcova B, Hornychova H, Drugda J, Cesak T, Netuka D, Gabalec F, Ryska A. Pitx2 is a useful marker of midgut‐derived neuroendocrine tumours ‐ an immunohistochemical study of 224 cases. Histopathology 2022; 81:799-807. [DOI: 10.1111/his.14789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/03/2022] [Accepted: 08/26/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jiri Soukup
- The Fingerland Department of Pathology, Charles University Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové Czech Republic
| | - Monika Manethova
- The Fingerland Department of Pathology, Charles University Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové Czech Republic
| | - Hana Faistova
- The Fingerland Department of Pathology, Charles University Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové Czech Republic
| | - Lukas Krbal
- The Fingerland Department of Pathology, Charles University Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové Czech Republic
| | - Barbora Vitovcova
- Department of Medical Biology and Genetics Charles University Faculty of Medicine Hradec Kralove Czech Republic
| | - Helena Hornychova
- The Fingerland Department of Pathology, Charles University Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové Czech Republic
| | - Jan Drugda
- 4th Department of Internal Medicine, Charles University Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové Czech Republic
| | - Tomas Cesak
- Department of Neurosurgery, Charles University Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, 1st Medical Faculty, Charles University Military University Hospital Prague Prague Czech Republic
| | - Filip Gabalec
- 4th Department of Internal Medicine, Charles University Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové Czech Republic
| | - Ales Ryska
- The Fingerland Department of Pathology, Charles University Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové Czech Republic
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9
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Gadelha MR, Wildemberg LE, Kasuki L. The Future of Somatostatin Receptor Ligands in Acromegaly. J Clin Endocrinol Metab 2022; 107:297-308. [PMID: 34618894 PMCID: PMC8764337 DOI: 10.1210/clinem/dgab726] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Indexed: 12/13/2022]
Abstract
Currently, the first-generation somatostatin receptor ligands (fg-SRLs), octreotide LAR and lanreotide autogel, are the mainstays of acromegaly treatment and achieve biochemical control in approximately 40% of patients and tumor shrinkage in over 60% of patients. Pasireotide, a second-generation SRL, shows higher efficacy with respect to both biochemical control and tumor shrinkage but has a worse safety profile. In this review, we discuss the future perspectives of currently available SRLs, focusing on the use of biomarkers of response and precision medicine, new formulations of these SRLs and new drugs, which are under development. Precision medicine, which is based on biomarkers of response to treatment, will help guide the decision-making process by allowing physicians to choose the appropriate drug for each patient and improving response rates. New formulations of available SRLs, such as oral, subcutaneous depot, and nasal octreotide, may improve patients' adherence to treatment and quality of life since there will be more options available that better suit each patient. Finally, new drugs, such as paltusotine, somatropin, ONO-5788, and ONO-ST-468, may improve treatment adherence and present higher efficacy than currently available drugs.
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Affiliation(s)
- Monica R Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, 21941-913, Brazil
- Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, 20231-092, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, 20231-092, Brazil
- Correspondence: Mônica R. Gadelha, Rua Prof. Rodolpho Paulo Rocco, 255, 9th floor, Ilha do Fundão, Rio de Janeiro 21941-913, Brazil.
| | - Luiz Eduardo Wildemberg
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, 21941-913, Brazil
- Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, 20231-092, Brazil
| | - Leandro Kasuki
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, 21941-913, Brazil
- Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, 20231-092, Brazil
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10
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Kontogeorgos G, Markussis V, Thodou E, Kyrodimou E, Choreftaki T, Nomikos P, Lampropoulos KI, Tsagarakis S. Association of Pathology Markers with Somatostatin Analogue Responsiveness in Acromegaly. Int J Endocrinol 2022; 2022:8660470. [PMID: 36199813 PMCID: PMC9529452 DOI: 10.1155/2022/8660470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/25/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Somatotroph adenomas (SAs) exhibit a variable responsiveness to somatostatin analogue (SS-a) treatment, a process that is not well understood. We investigated established and novel histological markers as predictors of SS-a responsiveness. METHODS We retrospectively investigated pathology samples from 36 acromegalic patients that underwent transsphenoidal surgery. Clinical, hormonal, and imaging data were available in 24/36 patients, before and after SS-a treatment. Specimens were semiquantitatively analyzed with immunocytochemistry for Ki-67, KER, SSTR-2, SSTR-5, ZAC-1, E-cadherin, and AIP. RESULTS Collectively, 18 (50%) adenomas were each classified as densely/sparsely granulated somatotroph adenomas (DGSAs/SGSAs), respectively. Patients that received preoperative SS-a had lower expression of SSTR-2 compared to those that did not (2.0 (1.0, 3.0) vs. 3.0 (3.0, 3.0), p = 0.042). Compared with DGSAs, SGSAs had higher Ki-67 labeling index (LI) (1.0 (0.5, 1.0) vs. 2.0 (1.0, 3.5), p = 0.013), and a higher proportion of high MR T2 signal (1 (6%) vs. 6 (33%), p = 0.035), and tended to express less ZAC-1 (p = 0.061) and E-cadherin (p = 0.067). In linear regression corrected for baseline growth hormone (GH), ZAC-1 immunostaining was significantly associated with a decrease in GH levels after SS-a treatment (beta (95% confidence interval): -1.53 (-2.80, -0.26), p = 0.021). No markers were associated with changes in circulating insulin-like growth factor-I (IGF-I) after treatment with SS-a. CONCLUSION The novel marker ZAC-1 was associated with GH response to medical treatment with SS-a. The SGSA cases were characterized by higher Ki-67 values and MR T2 signals indicative of an inferior response to SS-a. These findings improve our understanding of the mechanisms underlying SA response to medical treatment.
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Affiliation(s)
- George Kontogeorgos
- First Propaedeutic Department of Internal Medicine, Division of Endocrinology, Laikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Pathology and Pituitary Tumor Reference Center, “G. Gennimatas” General Hospital of Athens, Athens, Greece
| | | | - Eleni Thodou
- Department of Pathology, University of Thessaly, Larissa, Greece
| | - Efi Kyrodimou
- Department of Pathology and Pituitary Tumor Reference Center, “G. Gennimatas” General Hospital of Athens, Athens, Greece
| | - Theodossia Choreftaki
- Department of Pathology and Pituitary Tumor Reference Center, “G. Gennimatas” General Hospital of Athens, Athens, Greece
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11
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Soukup J, Cesak T, Hornychova H, Manethova M, Michnova L, Netuka D, Vitovcova B, Cap J, Ryska A, Gabalec F. Cytokeratin 8/18-negative somatotroph pituitary neuroendocrine tumours (PitNETs, adenomas) show variable morphological features and do not represent a clinicopathologically distinct entity. Histopathology 2021; 79:406-415. [PMID: 33738859 DOI: 10.1111/his.14366] [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: 02/08/2021] [Revised: 03/02/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
AIMS In somatotroph pituitary neuroendocrine tumours (adenomas), a pattern of cytokeratin (CK) 18 expression is used for tumour subclassification, with possible clinical implications. Rare somatotroph tumours do not express CK 18. We aimed to characterise this subset clinically and histologically. METHODS AND RESULTS Clinical and pathological data for the study were derived from a previously published data set of a cohort of 110 patients with acromegaly. Data included serum levels of insulin-like growth factor 1 (IGF1), growth hormone (GH), prolactin and thyroid-stimulating hormone (TSH), tumour diameter, tumour invasion defined by Knosp grade and immunohistochemical data concerning the expression of Ki67, p53, E-cadherin, somatostatin receptor (SSTR)1, SSTR2A, SSTR3, SSTR5 and D2 dopamine receptor. Additional immunohistochemical analysis (AE1/3, CK 8/18, vimentin, neurofilament light chain, internexin-α) was performed. CK 18 was negative in 10 of 110 (9.1%) tumours. One of these tumours was immunoreactive with CK 8/18 antibody, while the remainder expressed only internexin-α intermediate filament in patterns similar to CK 18 (perinuclear fibrous bodies). CK-negative tumours showed no significant differences with respect to biochemical, radiological or pathological features. They showed significantly higher expression of SSTR2A compared to the sparsely granulated subtype and significantly lower expression of E-cadherin compared to the non-sparsely granulated subtypes of tumours. The tumours showed divergent morphology and hormonal expression: two corresponded to densely granulated tumours and three showed co-expression of prolactin and morphology of either mammosomatotroph or somatotroph-lactotroph tumours. Four tumours showed morphology and immunoprofile compatible with plurihormonal Pit1-positive tumours. CONCLUSIONS CK-negative somatotroph tumours do not represent a distinct subtype of somatotroph tumours, and can be further subdivided according to their morphology and immunoprofile.
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Affiliation(s)
- Jiri Soukup
- The Fingerland Department of Pathology, Faculty of Medicine Hradec Kralove, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Tomas Cesak
- Department of Neurosurgery, Faculty of Medicine Hradec Kralove, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Helena Hornychova
- The Fingerland Department of Pathology, Faculty of Medicine Hradec Kralove, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Monika Manethova
- The Fingerland Department of Pathology, Faculty of Medicine Hradec Kralove, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Ludmila Michnova
- Department of Pathology, Military University Hospital Prague, Praha, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, 1st Medical Faculty, Charles University, Military University Hospital Prague, Prague, Czech Republic
| | - Barbora Vitovcova
- Department of Medical Biology and Genetics, Faculty of Medicine Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Jan Cap
- 4th Department of Internal Medicine, Faculty of Medicine Hradec Kralove, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Ales Ryska
- The Fingerland Department of Pathology, Faculty of Medicine Hradec Kralove, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Filip Gabalec
- 4th Department of Internal Medicine, Faculty of Medicine Hradec Kralove, University Hospital, Charles University, Hradec Kralove, Czech Republic
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12
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Soukup J, Hornychova H, Manethova M, Michalova K, Michnova L, Popovska L, Skarkova V, Cesak T, Netuka D, Ryska A, Cap J, Hána V, Hána V, Kršek M, Dvořáková E, Krčma M, Lazurova I, Olšovská V, Starý K, Vaňuga P, Gabalec F. Predictive and prognostic significance of tumour subtype, SSTR1-5 and e-cadherin expression in a well-defined cohort of patients with acromegaly. J Cell Mol Med 2021; 25:2484-2492. [PMID: 33491286 PMCID: PMC7933931 DOI: 10.1111/jcmm.16173] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/29/2020] [Accepted: 11/21/2020] [Indexed: 12/11/2022] Open
Abstract
In somatotroph pituitary tumours, somatostatin analogue (SSA) therapy outcomes vary throughout the studies. We performed an analysis of cohort of patients with acromegaly from the Czech registry to identify new prognostic and predictive factors. Clinical data of patients were collected, and complex immunohistochemical assessment of tumour samples was performed (SSTR1‐5, dopamine D2 receptor, E‐cadherin, AIP). The study included 110 patients. In 31, SSA treatment outcome was evaluated. Sparsely granulated tumours (SGST) differed from the other subtypes in expression of SSTR2A, SSTR3, SSTR5 and E‐cadherin and occurred more often in young. No other clinical differences were observed. Trouillas grading system showed association with age, tumour size and SSTR2A expression. Factors significantly associated with SSA treatment outcome included age, IGF1 levels, tumour size and expression of E‐cadherin and SSTR2A. In the group of SGST, poor SSA response was observed in younger patients with larger tumours, lower levels of SSTR2A and higher Ki67. We observed no relationship with expression of other proteins including AIP. No predictive value of E‐cadherin was observed when tumour subtype was considered. Multiple additional factors apart from SSTR2A expression can predict treatment outcome in patients with acromegaly.
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Affiliation(s)
- Jiri Soukup
- The Fingerland Department of Pathology, Faculty of Medicine, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Helena Hornychova
- The Fingerland Department of Pathology, Faculty of Medicine, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Monika Manethova
- The Fingerland Department of Pathology, Faculty of Medicine, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Kvetoslava Michalova
- Department of Pathology, Faculty of Medicine, Charles University, Plzen, Czech Republic.,Bioptical Laboratory, Ltd., Plzen, Czech Republic
| | - Ludmila Michnova
- Department of Pathology, Military University Hospital Prague, Prague, Czech Republic
| | - Lenka Popovska
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Kralove, Czech Republic
| | - Veronika Skarkova
- Department of Medical Biology and Genetics, Faculty of Medicine Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Tomas Cesak
- Department of Neurosurgery, Faculty of Medicine, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, 1st Medical Faculty, Charles University, Military University Hospital Prague, Prague, Czech Republic
| | - Ales Ryska
- The Fingerland Department of Pathology, Faculty of Medicine, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Jan Cap
- 4th Department of Internal medicine, Faculty of Medicine, University Hospital, Charles University, Hradec Kralove, Czech Republic
| | - Václav Hána
- 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Václav Hána
- 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Michal Kršek
- 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Eva Dvořáková
- 1st Department of Internal Medicine, Faculty of Medicine in Pilsen, University Hospital Pilsen, Charles University, Pilsen, Czech Republic
| | - Michal Krčma
- 1st Department of Internal Medicine, Faculty of Medicine in Pilsen, University Hospital Pilsen, Charles University, Pilsen, Czech Republic
| | - Ivica Lazurova
- 1st Internal Clinic, Louis Pasteur University Hospital, Kosice, Slovakia
| | - Věra Olšovská
- 2nd Department of Internal Medicine, Faculty of Medicine, St. Ann University Hospital Brno, Masaryk University Brno, Brno, Czech Republic
| | - Karel Starý
- Department of Internal Medicine and Gastroenterology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Peter Vaňuga
- National Institute of Endocrinology and Diabetology, Lubochňa, Slovakia
| | - Filip Gabalec
- 4th Department of Internal medicine, Faculty of Medicine, University Hospital, Charles University, Hradec Kralove, Czech Republic
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