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Wei W, Xu Q, Wu L, Gong G, Tian Y, Huang H, Li Z. Drug development and potential targets for Cushing's syndrome. Eur J Med Chem 2024; 270:116333. [PMID: 38569434 DOI: 10.1016/j.ejmech.2024.116333] [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: 12/15/2023] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 04/05/2024]
Abstract
Cushing's syndrome (CS) is a complex disorder characterized by the excessive secretion of cortisol, with Cushing's disease (CD), particularly associated with pituitary tumors, exhibiting heightened morbidity and mortality. Although transsphenoidal pituitary surgery (TSS) stands as the primary treatment for CD, there is a crucial need to optimize patient prognosis. Current medical therapy serves as an adjunctive measure due to its unsatisfactory efficacy and unpredictable side effects. In this comprehensive review, we delve into recent advances in understanding the pathogenesis of CS and explore therapeutic options by conducting a critical analysis of potential drug targets and candidates. Additionally, we provide an overview of the design strategy employed in previously reported candidates, along with a summary of structure-activity relationship (SAR) analyses and their biological efficacy. This review aims to contribute valuable insights to the evolving landscape of CS research, shedding light on potential avenues for therapeutic development.
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Affiliation(s)
- Wei Wei
- Jiangsu Key Laboratory of Drug Design and Optimization, Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, PR China
| | - Qianqian Xu
- Jiangsu Key Laboratory of Drug Design and Optimization, Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, PR China
| | - Liuyi Wu
- Jiangsu Key Laboratory of Drug Design and Optimization, Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, PR China
| | - Guangyue Gong
- Jiangsu Key Laboratory of Drug Design and Optimization, Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, PR China
| | - Yucheng Tian
- Jiangsu Key Laboratory of Drug Design and Optimization, Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, PR China
| | - Huidan Huang
- Center of Drug Screening & Evaluation, Wannan Medical College, Wuhu, Anhui, 241000, PR China.
| | - Zhiyu Li
- Jiangsu Key Laboratory of Drug Design and Optimization, Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, PR China.
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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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Gentilin E, Borges De Souza P, Ambrosio MR, Bondanelli M, Gagliardi I, Zatelli MC. Protein kinase C delta mediates Pasireotide effects in an ACTH-secreting pituitary tumor cell line. J Endocrinol Invest 2023; 46:2609-2616. [PMID: 37233978 PMCID: PMC10632222 DOI: 10.1007/s40618-023-02117-0] [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: 10/12/2022] [Accepted: 05/16/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE Clinical control of corticotroph tumors is difficult to achieve since they usually persist or relapse after surgery. Pasireotide is approved to treat patients with Cushing's disease for whom surgical therapy is not an option. However, Pasireotide seems to be effective only in a sub-set of patients, highlighting the importance to find a response marker to this approach. Recent studies demonstrated that the delta isoform of protein kinase C (PRKCD) controls viability and cell cycle progression of an in vitro model of ACTH-secreting pituitary tumor, the AtT-20/D16v-F2 cells. This study aims at exploring the possible PRKCD role in mediating Pasireotide effects. METHODS It was assessed cell viability, POMC expression and ACTH secretion in AtT20/D16v-F2 cells over- or under-expressing PRKCD. RESULTS We found that Pasireotide significantly reduces AtT20/D16v-F2 cell viability, POMC expression and ACTH secretion. In addition, Pasireotide reduces miR-26a expression. PRKCD silencing decreases AtT20/D16v-F2 cell sensitivity to Pasireotide treatment; on the contrary, PRKCD overexpression increases the inhibitory effects of Pasireotide on cell viability and ACTH secretion. CONCLUSION Our results provide new insights into potential PRKCD contribution in Pasireotide mechanism of action and suggest that PRKCD might be a possible marker of therapeutic response in ACTH-secreting pituitary tumors.
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Affiliation(s)
- E Gentilin
- Bioacoustics Research Laboratory, Department of Neurosciences, University of Padua, Padua, Italy.
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept. of Medical Sciences, University of Ferrara, Ferrara, Italy.
| | - P Borges De Souza
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept. of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - M R Ambrosio
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept. of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - M Bondanelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept. of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - I Gagliardi
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept. of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - M C Zatelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept. of Medical Sciences, University of Ferrara, Ferrara, Italy.
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4
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Treppiedi D, Marra G, Di Muro G, Esposito E, Barbieri AM, Catalano R, Mangili F, Bravi F, Locatelli M, Lania AG, Ferrante E, Indirli R, Nozza E, Arlati F, Spada A, Arosio M, Mantovani G, Peverelli E. P720R USP8 Mutation Is Associated with a Better Responsiveness to Pasireotide in ACTH-Secreting PitNETs. Cancers (Basel) 2022; 14:cancers14102455. [PMID: 35626057 PMCID: PMC9139692 DOI: 10.3390/cancers14102455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 02/04/2023] Open
Abstract
Somatic mutations in the ubiquitin specific peptidase 8 (USP8) gene have been associated with higher levels of somatostatin (SS) receptor subtype 5 (SSTR5) in adrenocorticotroph hormone (ACTH)-secreting pituitary neuroendocrine tumors (PitNETs). However, a correlation between the USP8 mutational status and favourable responses to pasireotide, the somatostatin multi-receptor ligand acting especially on SSTR5, has not been investigated yet. Here, we studied the impact of USP8 mutations on pasireotide responsiveness in human and murine corticotroph tumor cells. SSTR5 upregulation was observed in USP8 wild-type primary tumor cells transfected with S718del USP8 mutant. However, cell transfection with S718del USP8 and C40-USP8 mutants in in vitro sensitive cultures from USP8 wild-type tumors abolished their ability to respond to pasireotide and did not confer pasireotide responsiveness to the in vitro resistant culture. Pasireotide failed to reduce ACTH secretion in primary cells from one S718P USP8-mutated tumor but exerted a strong antisecretory effect in primary cells from one P720R USP8-mutated tumor. In agreement, AtT-20 cells transfection with USP8 mutants led to SSTR5 expression increase but pasireotide could reduce ACTH production and cyclin E expression in P720R USP8 overexpressing cells, only. In situ Proximity Ligation Assay and immunoflurescence experiments revealed that P720R USP8 mutant is still able to bind 14-3-3 proteins in AtT-20 cells, without affecting SSTR5 localization. In conclusion, P720R USP8 mutation might be considered as a molecular predictor of favourable response to pasireotide in corticotroph tumor cells.
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Affiliation(s)
- Donatella Treppiedi
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
| | - Giusy Marra
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
| | - Genesio Di Muro
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
- PhD Program in Endocrinological Sciences, University Sapienza of Rome, 00185 Rome, Italy
| | - Emanuela Esposito
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
- PhD Program in Experimental Medicine, University of Milan, 20054 Milan, Italy
| | - Anna Maria Barbieri
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
| | - Rosa Catalano
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
| | - Federica Mangili
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
| | - Francesca Bravi
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
| | - Marco Locatelli
- Neurosurgery Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Andrea Gerardo Lania
- Endocrinology, Diabetology and Medical Andrology Unit, Humanitas Clinical and Research Center, IRCCS, 20089 Rozzano, Italy;
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Rita Indirli
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Emma Nozza
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
| | - Federico Arlati
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
| | - Anna Spada
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
| | - Maura Arosio
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Correspondence: ; Tel.: +39-02-55033512
| | - Erika Peverelli
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (D.T.); (G.M.); (G.D.M.); (E.E.); (A.M.B.); (R.C.); (F.M.); (F.B.); (R.I.); (E.N.); (F.A.); (A.S.); (M.A.); (E.P.)
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
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Tauchmanova L, Breitschaft A, Holder G, Han KT, Choudhury S, Darstein C, Paul M, Drutinus E, Gericke G, Schmid HA, Pedroncelli AM. Combination of pasireotide and octreotide: effects on GH and IGF-I secretion and glucose metabolism in healthy volunteers. Endocrine 2022; 75:537-548. [PMID: 34741720 DOI: 10.1007/s12020-021-02908-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/11/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the pharmacokinetics, pharmacodynamics and tolerability of different doses of octreotide and pasireotide (subcutaneous [sc] and long-acting release [LAR]) when co-administered in healthy volunteers. METHODS This was an exploratory, Phase I, single-centre study. Healthy adults were enrolled in a staggered approach into seven cohorts to receive octreotide and pasireotide (sc and LAR formulations), alone or in combination. Plasma drug concentrations, growth hormone (GH), insulin-like growth factor I (IGF-I), and plasma glucose were assessed at baseline, immediately after sc treatment, and 21 and 28 days after LAR treatment. RESULTS Of 88 enrolled subjects, 52 and 82 participated in sc and LAR dosing phases, respectively. There were no relevant pharmacokinetic interactions between octreotide and pasireotide. In combination, pasireotide sc (150 µg) and octreotide sc (100/300 µg) resulted in numerically greater reductions in insulin levels and a higher incidence of AEs than either single agent; the rapid (within 1 h) increase in plasma glucose after pasireotide was delayed with combination treatment. Octreotide sc and pasireotide sc, alone or in combination, reduced IGF-I levels and led to undetectable GH levels in most subjects. During the LAR phase, addition of a low dose of pasireotide (5 mg) to a standard dose of octreotide (20 mg) resulted in an ~2-fold reduction in median IGF-I versus octreotide 20 mg 21 days post-dose; this effect was numerically greater than seen for pasireotide 20 mg alone. Peak plasma glucose was substantially lower after LAR than sc dosing. Interestingly, glucose levels were also numerically lower in the pasireotide 5 mg plus octreotide 20 mg group than for 20 mg of octreotide or pasireotide alone. AEs were less frequent after LAR than sc dosing. CONCLUSIONS Combined low doses of pasireotide LAR (5 mg) and octreotide LAR (10-30 mg) provided greater suppression of IGF-I than either single agent and did not increase blood glucose or incidence of AEs versus either agent alone.
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Affiliation(s)
- Libuse Tauchmanova
- Novartis Pharma AG, Basel, Switzerland.
- Clinical Development, Debiopharm, Lausanne, Switzerland.
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Treppiedi D, Catalano R, Mangili F, Mantovani G, Peverelli E. Role of filamin A in the pathogenesis of neuroendocrine tumors and adrenal cancer. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R143-R152. [PMID: 37435454 PMCID: PMC10259351 DOI: 10.1530/eo-22-0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 07/13/2023]
Abstract
Cell cytoskeleton proteins are involved in tumor pathogenesis, progression and pharmacological resistance. Filamin A (FLNA) is a large actin-binding protein with both structural and scaffold functions implicated in a variety of cellular processes, including migration, cell adhesion, differentiation, proliferation and transcription. The role of FLNA in cancers has been studied in multiple types of tumors. FLNA plays a dual role in tumors, depending on its subcellular localization, post-translational modification (as phosphorylation at Ser2125) and interaction with binding partners. This review summarizes the experimental evidence showing the critical involvement of FLNA in the complex biology of endocrine tumors. Particularly, the role of FLNA in regulating expression and signaling of the main pharmacological targets in pituitary neuroendocrine tumors, pancreatic neuroendocrine tumors, pulmonary neuroendocrine tumors and adrenocortical carcinomas, with implications on responsiveness to currently used drugs in the treatment of these tumors, will be discussed.
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Affiliation(s)
- Donatella Treppiedi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Rosa Catalano
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Federica Mangili
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Erika Peverelli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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7
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Peverelli E, Treppiedi D, Mangili F, Catalano R, Spada A, Mantovani G. Drug resistance in pituitary tumours: from cell membrane to intracellular signalling. Nat Rev Endocrinol 2021; 17:560-571. [PMID: 34194011 DOI: 10.1038/s41574-021-00514-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 02/06/2023]
Abstract
The pharmacological treatment of pituitary tumours is based on the use of stable analogues of somatostatin and dopamine. The analogues bind to somatostatin receptor types 2 and 5 (SST2 and SST5) and dopamine receptor type 2 (DRD2), respectively, and generate signal transduction cascades in cancerous pituitary cells that culminate in the inhibition of hormone secretion, cell growth and invasion. Drug resistance occurs in a subset of patients and can involve different steps at different stages, such as following receptor activation by the agonist or during the final biological responses. Although the expression of somatostatin and dopamine receptors in cancer cells is a prerequisite for these drugs to reach a biological effect, their presence does not guarantee the success of the therapy. Successful therapy also requires the proper functioning of the machinery of signal transduction and the finely tuned regulation of receptor desensitization, internalization and intracellular trafficking. The present Review provides an updated overview of the molecular factors underlying the pharmacological resistance of pituitary tumours. The Review discusses the experimental evidence that supports a role for receptors and intracellular proteins in the function of SSTs and DRD2 and their clinical importance.
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Affiliation(s)
- Erika Peverelli
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy.
| | - Donatella Treppiedi
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy
| | - Federica Mangili
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy
| | - Rosa Catalano
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy
- PhD Program in Endocrinological Sciences, Sapienza University of Rome, Rome, Italy
| | - Anna Spada
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy
| | - Giovanna Mantovani
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
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Treppiedi D, Di Muro G, Mangili F, Catalano R, Giardino E, Barbieri AM, Locatelli M, Arosio M, Spada A, Peverelli E, Mantovani G. Filamin A is required for somatostatin receptor type 5 expression and pasireotide-mediated signaling in pituitary corticotroph tumor cells. Mol Cell Endocrinol 2021; 524:111159. [PMID: 33428965 DOI: 10.1016/j.mce.2021.111159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/16/2020] [Accepted: 01/03/2021] [Indexed: 01/08/2023]
Abstract
Somatostatin receptor type 5 (SST5) represents the main pharmacological target in the treatment of adrenocorticotroph hormone (ACTH)-secreting tumors. However, molecular predictors of responsiveness to pasireotide require further investigation. The cytoskeleton protein filamin A (FLNA) modulates the responsiveness to somatostatin analogs (SSA) treatment in other types of pituitary tumors by regulating somatostatin receptor type 2 (SST2)/dopamine receptor type 2 (DRD2) expression and activity. Here, we aimed to test the involvement of FLNA in the modulation of SST5 response to SSA in human and murine tumor corticotrophs. Western blot analysis of human corticotropinomas showed that FLNA and SST5 correlate. Both in human primary cultures and AtT-20 cells, FLNA genetic silencing caused a decrease of receptor expression level. Moreover, pasireotide-mediated SST5 downregulation observed in AtT-20 control cells was no further detected in FLNA silenced cells. In AtT-20 cells, in situ PLA experiments revealed an increased number of SST5-FLNA complexes following pasireotide incubation. Finally, FLNA knock down abolished pasireotide-induced SST5 actions on hormone secretion, cell proliferation and apoptosis. In conclusion, FLNA is implicated in SST5 expression modulation and signaling.
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Affiliation(s)
- Donatella Treppiedi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Genesio Di Muro
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Federica Mangili
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Rosa Catalano
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; PhD Program in Endocrinological Sciences, Sapienza University of Rome, Rome, Italy
| | - Elena Giardino
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Anna Maria Barbieri
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marco Locatelli
- Department of Pathophysiology and Transplantation, University of Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurosurgery Unit, Milan, Italy
| | - Maura Arosio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
| | - Anna Spada
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Erika Peverelli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
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Abstract
INTRODUCTION The treatment of Cushing's disease (CD) has been advanced well with the introduction of treatment options like transsphenoidal surgery, radiosurgery, bilateral adrenalectomy, and various classes of medication; however, many patients still fail to achieve disease remission. Osilodrostat, an orally bioavailable adrenal steroidogenesis inhibitor, was approved in the USA and EU in 2020 for the treatment of CD. AREAS COVERED This review provides an overview of Cushing's disease and the newly FDA approved 11β-hydroxylase inhibitor, osilodrostat, for CD with a focus on pharmacodynamics, pharmacokinetics, safety and efficacy data, and phase 2 and 3 clinical trials. EXPERT OPINION Osilodrostat has proven clinical efficacy and tolerability in phase 2 and 3 trials with CD patients who had an inadequate or reoccurring response to transsphenoidal surgery (TSS) and conventional first-line treatment. The phase 3 trial (LINC3) had 86% of the treatment group respond with normal urinary free cortisol (UFC) level compared to 29% in the placebo group (p < 0.001). Deemed as well-tolerated in all current pivotal trials, oral osilodrostat provides a noninvasive option for patients who cannot undergo surgery or patients who have reoccurring hypercortisolemia.
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Affiliation(s)
- Syeda Rasool
- Division of Clinical Sciences, Marian University College of Osteopathic Medicine, Indianapolis, IN, USA
| | - Brian W Skinner
- Division of Clinical Sciences, Marian University College of Osteopathic Medicine, Indianapolis, IN, USA
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10
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De Ravin E, Phan HAT, Harmsen S, Cho SS, Teng CW, Petersson EJ, White C, Galban EM, Hess R, Lee JYK. Somatostatin Receptor as a Molecular Imaging Target in Human and Canine Cushing Disease. World Neurosurg 2021; 149:94-102. [PMID: 33601082 DOI: 10.1016/j.wneu.2021.02.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Fluorescence-guided surgery may improve completeness of resection in transsphenoidal surgery for Cushing disease (CD) by enabling visualization of residual tumor tissue at the margins. In this review we discuss somatostatin receptors (SSTRs) as targets for fluorescence-guided surgery and overview existing SSTR-specific imaging agents. We also compare SSTR expression in normal pituitary and corticotrophinoma tissues from human and canine CD patients to assess canines as a translational model for CD. METHODS A PubMed literature search was conducted for publications containing the terms canine, somatostatin receptor, Cushing's disease, and corticotroph adenoma. SSTR expression data from each study was documented as the presence or absence of expression or, when possible, the number of tumors expressing a given SSTR subtype within a group of tumors being studied. Studies that used reverse transcription polymerase chain reaction to quantify SSTR expression were selected for additional comparative analysis. RESULTS SSTR5 is strongly expressed in human corticotroph adenomas and weakly expressed in surrounding pituitary parenchyma, a pattern not conclusively observed in canine patients. SSTR2 mRNA expression is similar in human normal pituitary and corticotrophinoma cells but may be significantly higher in canine normal pituitary tissue than in corticotroph tumoral tissue. Limited data were available on SSTR subtypes 1, 3, and 4. CONCLUSIONS Further studies must fill the knowledge gaps related to species-specific SSTR expression, so using canine CD as a translational model may be premature. We do conclude that the expression profile of SSTR5 (i.e., high local expression in pituitary adenomas relative to normal surrounding tissues) makes SSTR5 a promising molecular target for FGS.
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Affiliation(s)
- Emma De Ravin
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hoang Anh T Phan
- Department of Chemistry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stefan Harmsen
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steve S Cho
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clare W Teng
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - E James Petersson
- Department of Chemistry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Caitlin White
- Department of Endocrinology at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Evelyn M Galban
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecka Hess
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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11
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Pivonello R, Munster PN, Terzolo M, Ferrigno R, Simeoli C, Puglisi S, Bali U, Moraitis AG. Glucocorticoid Receptor Antagonism Upregulates Somatostatin Receptor Subtype 2 Expression in ACTH-Producing Neuroendocrine Tumors: New Insight Based on the Selective Glucocorticoid Receptor Modulator Relacorilant. Front Endocrinol (Lausanne) 2021; 12:793262. [PMID: 35058882 PMCID: PMC8764187 DOI: 10.3389/fendo.2021.793262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/22/2021] [Indexed: 12/29/2022] Open
Abstract
Somatostatin exhibits an inhibitory effect on pituitary hormone secretion, including inhibition of growth hormone and adrenocorticotropic hormone (ACTH), and it can have antisecretory and antitumor effects on neuroendocrine tumors (NETs) that express somatostatin receptors. Although the precise mechanism remains unclear, the finding that glucocorticoids downregulate somatostatin receptor subtype 2 (SSTR2) expression has been used to explain the lack of efficacy of traditional SSTR2-targeting analogs in patients with ACTH-secreting NETs. Glucocorticoid receptor (GR) antagonism with mifepristone has been shown to reverse the glucocorticoid-induced downregulation of SSTR2; however, the effects of GR modulation on SSTR2 expression in ACTH-secreting NETs, particularly corticotroph pituitary tumors, are not well known. The current study presents new insight from in vitro data using the highly selective GR modulator relacorilant, showing that GR modulation can overcome dexamethasone-induced suppression of SSTR2 in the murine At-T20 cell line. Additional data presented from clinical case observations in patients with ACTH-secreting NETs suggest that upregulation of SSTR2 via GR modulation may re-sensitize tumors to endogenous somatostatin and/or somatostatin analogs. Clinical, laboratory, and imaging findings from 4 patients [2 ACTH-secreting bronchial tumors and 2 ACTH-secreting pituitary tumors (Cushing disease)] who were treated with relacorilant as part of two clinical studies (NCT02804750 and NCT02762981) are described. In the patients with ectopic ACTH secretion, SSTR2-based imaging (Octreoscan and 68Ga-DOTATATE positron emission tomography) performed before and after treatment with relacorilant showed increased radiotracer uptake by the tumor following treatment with relacorilant without change in tumor size at computed tomography. In the patients with Cushing disease who received relacorilant prior to scheduled pituitary surgery, magnetic resonance imaging after a 3-month course of relacorilant showed a reduction in tumor size. Based on these findings, we propose that GR modulation in patients with ACTH-secreting NETs upregulates previously suppressed SSTR2s, resulting in tumor-specific antisecretory and anti-proliferative effects. The effect of relacorilant on pituitary corticotroph tumors is being investigated in an ongoing phase 3 study (NCT03697109; EudraCT 2018-003096-35).
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico Il di Napoli, Naples, Italy
| | - Pamela N. Munster
- Department of Medicine (Hematology/Oncology), University of California San Francisco, San Francisco, CA, United States
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico Il di Napoli, Naples, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico Il di Napoli, Naples, Italy
| | - Soraya Puglisi
- Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Utsav Bali
- Bioscience Department, Sygnature Discovery Ltd, Nottingham, United Kingdom
| | - Andreas G. Moraitis
- Drug Research and Development, Corcept Therapeutics, Menlo Park, CA, United States
- *Correspondence: Andreas G. Moraitis,
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12
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Gatto F, Arvigo M, Ferone D. Somatostatin receptor expression and patients' response to targeted medical treatment in pituitary tumors: evidences and controversies. J Endocrinol Invest 2020; 43:1543-1553. [PMID: 32557353 DOI: 10.1007/s40618-020-01335-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/11/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Somatostatin receptors (SSTs) are widely co-expressed in pituitary tumors. SST2 and SST5 are the most represented SST subtypes. First-generation somatostatin receptor ligands (SRLs) mainly target SST2, while pasireotide, a multi-receptor ligand, shows high binding affinity for both SST5 and SST2. Therefore, SRLs are routinely used as medical treatment for GH-, TSH-, and ACTH-secreting pituitary tumors. METHODS Critical revision of literature data correlating SST expression with patients' response to SRLs. RESULTS SST2 expression in somatroph tumors directly correlates with GH and IGF-1 decrease after first-generation SRL treatment. SST2 immunohistochemistry represents a valuable tool to predict biochemical response to first-generation SRLs in acromegalic patients. Pasireotide seems to exert its biological effects via SST2 in unselected patients. However, in those subjects resistant to first-generation SRLs, harbouring tumors with negligible SST2 expression, pasireotide can act throughout SST5. More than somatotroph tumors, TSH-omas represent the paradigm of tumors showing a satisfactory response to SRLs. This is probably due to the high SST2 expression observed in nearly 100% of cases, as well as to the balanced amount of SST5. In corticotroph tumors, pasireotide mainly act via SST5, although there is a need for translational studies correlating its efficacy with SST expression in this peculiar tumor histotype. CONCLUSIONS The assumption "more target receptor, more drug efficacy" is not straightforward for SRLs. The complex pathophysiology of SSTs, and the technical challenges faced to translate research findings into clinical practice, still need our full commitment to make receptor evaluation a worthwhile procedure for individualizing treatment decisions.
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Affiliation(s)
- F Gatto
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi, 10, 16132, Genoa, Italy.
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DIMI), Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy.
| | - M Arvigo
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DIMI), Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
| | - D Ferone
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi, 10, 16132, Genoa, Italy
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DIMI), Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
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13
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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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14
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Biological and Biochemical Basis of the Differential Efficacy of First and Second Generation Somatostatin Receptor Ligands in Neuroendocrine Neoplasms. Int J Mol Sci 2019; 20:ijms20163940. [PMID: 31412614 PMCID: PMC6720449 DOI: 10.3390/ijms20163940] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/1970] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 02/07/2023] Open
Abstract
Endogenous somatostatin shows anti-secretory effects in both physiological and pathological settings, as well as inhibitory activity on cell growth. Since somatostatin is not suitable for clinical practice, researchers developed synthetic somatostatin receptor ligands (SRLs) to overcome this limitation. Currently, SRLs represent pivotal tools in the treatment algorithm of neuroendocrine tumors (NETs). Octreotide and lanreotide are the first-generation SRLs developed and show a preferential binding affinity to somatostatin receptor (SST) subtype 2, while pasireotide, which is a second-generation SRL, has high affinity for multiple SSTs (SST5 > SST2 > SST3 > SST1). A number of studies demonstrated that first-generation and second-generation SRLs show distinct functional properties, besides the mere receptor affinity. Therefore, the aim of the present review is to critically review the current evidence on the biological effects of SRLs in pituitary adenomas and neuroendocrine tumors, by mainly focusing on the differences between first-generation and second-generation ligands.
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15
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Pivonello R, Arnaldi G, Scaroni C, Giordano C, Cannavò S, Iacuaniello D, Trementino L, Zilio M, Guarnotta V, Albani A, Cozzolino A, Michetti G, Boscaro M, Colao A. The medical treatment with pasireotide in Cushing's disease: an Italian multicentre experience based on "real-world evidence". Endocrine 2019; 64:657-672. [PMID: 30968338 PMCID: PMC6551343 DOI: 10.1007/s12020-018-1818-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/12/2018] [Indexed: 12/20/2022]
Abstract
A phase III study has demonstrated that 6-month pasireotide treatment induced disease control with good safety in 15-26% of patients with Cushing's disease (CD). The aim of the current study was to evaluate the 6-month efficacy and safety of pasireotide treatment according to the real-world evidence. Thirty-two CD patients started pasireotide at the dose of 600 µg twice a day (bid) and with the chance of up-titration to 900 µg bid, or down-titration to 450 or 300 µg bid, on the basis of urinary cortisol (UC) levels or safety. Hormonal, clinical and metabolic parameters were measured at baseline and at 3-month and 6-month follow-up, whereas tumour size was evaluated at baseline and at 6-month follow-up. At baseline, 31 patients had very mild to moderate disease and 1 patient had very severe disease. Five (15.6%) patients discontinued treatment for adverse events; the remaining 27 patients (26 with very mild to moderate disease and 1 with very severe disease), reached 6-month follow-up. Considering the group of patients with very mild to moderate disease, responsiveness, defined by the normalization (<1 the upper limit of normal range, ULN) or near normalization (>1 and ≤1.1 ULN) of UC levels, was registered in 21 patients (full control in 19 and near control in 2), corresponding to 67.7% and 80.8% according to an "intention-to-treat" or "per-protocol" methodological approach, respectively. Weight, body mass index, waist circumference, as well as total and LDL-cholesterol significantly decreased, whereas fasting plasma glucose and glycated haemoglobin significantly increased. Hyperglycaemia was documented in 81.2%, whereas gastrointestinal disturbances in 40.6% of patients. In conclusion, in the real-life clinical practice, pasireotide treatment normalizes or nearly normalizes UC in at least 68% of patients with very mild to moderate disease, with consequent improvement in weight, visceral adiposity and lipid profile, despite the occurrence or deterioration of diabetes in the majority of cases, confirming the usefulness of this treatment in patients with milder disease and without uncontrolled diabetes.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.
| | - Giorgio Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Carla Scaroni
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Carla Giordano
- Dipartimento Biomedico di Medicina Interna e Specialistica Di.Bi.MI.S, sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, A.O.U.P. "Paolo Giaccone", Palermo, Italy
| | - Salvo Cannavò
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
| | - Davide Iacuaniello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Laura Trementino
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marialuisa Zilio
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Valentina Guarnotta
- Dipartimento Biomedico di Medicina Interna e Specialistica Di.Bi.MI.S, sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, A.O.U.P. "Paolo Giaccone", Palermo, Italy
| | - Adriana Albani
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
| | - Alessia Cozzolino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Dipartimento di Medicina Sperimentale, Università "La Sapienza", Roma, Italy
| | - Grazia Michetti
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marco Boscaro
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
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Lu M, Wang Y, Zhan X. The MAPK Pathway-Based Drug Therapeutic Targets in Pituitary Adenomas. Front Endocrinol (Lausanne) 2019; 10:330. [PMID: 31231308 PMCID: PMC6558377 DOI: 10.3389/fendo.2019.00330] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/07/2019] [Indexed: 12/13/2022] Open
Abstract
Mitogen-activated protein kinases (MAPKs) include ERK, p38, and JNK MAPK subfamilies, which are crucial regulators of cellular physiology, cell pathology, and many diseases including cancers. For the MAPK signaling system in pituitary adenomas (PAs), the activation of ERK signaling is generally thought to promote cell proliferation and growth; whereas the activations of p38 and JNK signaling are generally thought to promote cell apoptosis. The role of MAPK in treatment of PAs is demonstrated through the effects of currently used medications such as somatostatin analogs such as SOM230 and OCT, dopamine agonists such as cabergoline and bromocriptine, and retinoic acid which inhibit the MAPK pathway. Further, there are potential novel therapies based on putative molecular targets of the MAPK pathway, including 18beta-glycyrrhetinic acid (GA), dopamine-somatostatin chimeric compound (BIM-23A760), ursolic acid (UA), fulvestrant, Raf kinase inhibitory protein (RKIP), epidermal growth factor pathway substrate number 8 (Eps8), transmembrane protein with EGF-like and two follistatin-like domains (TMEFF2), cold inducible RNA-binding protein (CIRP), miR-16, and mammaliansterile-20-like kinase (MST4). The combined use of ERK inhibitor (e.g., SOM230, OCT, or dopamine) plus p38 activator (e.g., cabergoline, bromocriptine, and fulvestrant) and/or JNK activator (e.g., UA), or the development of single drug (e.g., BIM-23A760) to target both ERK and p38 or JNK pathways, might produce better anti-tumor effects on PAs. This article reviews the advances in understanding the role of MAPK signaling in pituitary tumorigenesis, and the MAPK pathway-based potential therapeutic drugs for PAs.
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Affiliation(s)
- Miaolong Lu
- Key Laboratory of Cancer Proteomics of Chinese Ministry of Health, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Laboratory for Structural Biology and Drug Design, Xiangya Hospital, Central South University, Changsha, China
- State Local Joint Engineering Laboratory for Anticancer Drugs, Xiangya Hospital, Central South University, Changsha, China
| | - Ya Wang
- Key Laboratory of Cancer Proteomics of Chinese Ministry of Health, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Laboratory for Structural Biology and Drug Design, Xiangya Hospital, Central South University, Changsha, China
- State Local Joint Engineering Laboratory for Anticancer Drugs, Xiangya Hospital, Central South University, Changsha, China
| | - Xianquan Zhan
- Key Laboratory of Cancer Proteomics of Chinese Ministry of Health, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Laboratory for Structural Biology and Drug Design, Xiangya Hospital, Central South University, Changsha, China
- State Local Joint Engineering Laboratory for Anticancer Drugs, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Therapy With 177Lu-DOTATATE: Clinical Implementation and Impact on Care of Patients With Neuroendocrine Tumors. AJR Am J Roentgenol 2019; 213:309-317. [PMID: 31039017 DOI: 10.2214/ajr.19.21123] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE. The purpose of this article is to enhance knowledge of the clinical implementation of peptide receptor radionuclide therapy (PRRT) and its impact on care of patients with neuroendocrine tumors. CONCLUSION. Most well differentiated and some moderately and poorly differentiated neuroendocrine tumors express large numbers of somatostatin receptors on their cell surfaces. PRRT targets these cells with 177Lu-DOTATATE, which is a medium-energy beta emitter. Since this agent received U.S. Food and Drug Administration approval in 2018, tremendous effort has been exerted at institutions throughout the United States toward proper implementation of this promising therapy. This review summarizes clinical implementation of PRRT and its impact on patient care.
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18
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Treppiedi D, Giardino E, Catalano R, Mangili F, Vercesi P, Sala E, Locatelli M, Arosio M, Spada A, Mantovani G, Peverelli E. Somatostatin analogs regulate tumor corticotrophs growth by reducing ERK1/2 activity. Mol Cell Endocrinol 2019; 483:31-38. [PMID: 30611770 DOI: 10.1016/j.mce.2018.12.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 12/11/2018] [Accepted: 12/31/2018] [Indexed: 12/31/2022]
Abstract
Pasireotide has been associated with tumor shrinkage in patients with Cushing's disease subjected to long term treatment. However, to date the implicated molecular mechanisms are poorly elucidated. Here, we tested pasireotide-mediated cytostatic and cytotoxic effects in ACTH-secreting primary tumor cultures and murine corticotroph tumor cell line, AtT-20 cells. We found somatostatin receptor type 5 (SST5) expressed in 17 different ACTH-secreting tumors and SST2 detectable in 15 out of the 17 tissues. Pasireotide caused a slight but significant in vitro inhibition of cell growth in 3 out of 6 ACTH-secreting primary cultures (-12.1 ± 4.3%, P < 0.01 at 10 nM), remarkably reduced phospho-ERK1/2 levels in 5 out of 8 samples (-36.4 ± 20.5%, P < 0.01 at 1 μM) and triggered an increase of caspase 3/7 activity in 2 of 4 tumors (17 ± 3.6%, P < 0.05 at 1 μM). Accordingly, in AtT-20 cells, pasireotide significantly inhibited cell proliferation (-10.5 ± 7.7% at 10 nM, P < 0.05; -13.9 ± 10.9% at 100 nM, P < 0.05; -26.8 ± 8.9% at 1 μM, P < 0.01). Similar antiproliferative actions were exerted by BIM23206 and BIM23120 (SST5&2 selective ligands, respectively), whereas octreotide was effective when used at 1 μM (-13.3 ± 9.1%, P < 0.05). Moreover, a reduction of phospho-ERK1/2 was observed upon pasireotide and BIM23206 treatment (-8.4 ± 28.6%, P < 0.01 and -51.4 ± 15.9%, P < 0.001 at 10 nM, respectively) but not after octreotide and BIM23120 incubation. Finally, pasireotide was able to induce cell apoptosis in AtT-20 cells at lower concentration than octreotide. Altogether these data indicate a downstream implication of SST5-mediated phospho-ERK1/2 inhibition by pasireotide resulting in ACTH-secreting tumor cells proliferation reduction. Moreover, we describe for the first time a pro-apoptotic effect of pasireotide in corticotrophs.
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Affiliation(s)
- Donatella Treppiedi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Elena Giardino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Rosa Catalano
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; PhD Program in Endocrinological Sciences, Sapienza University of Rome, Rome, Italy
| | - Federica Mangili
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Pietro Vercesi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Elisa Sala
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marco Locatelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurosurgery Unit, Milan, Italy
| | - Maura Arosio
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Anna Spada
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Mantovani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Erika Peverelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Gatto F, Arvigo M, Amarù J, Campana C, Cocchiara F, Graziani G, Bruzzone E, Giusti M, Boschetti M, Ferone D. Cell specific interaction of pasireotide: review of preclinical studies in somatotroph and corticotroph pituitary cells. Pituitary 2019; 22:89-99. [PMID: 30483918 DOI: 10.1007/s11102-018-0926-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pasireotide is a second-generation somatostatin (SRIF) receptor ligand (SRL), approved for medical treatment of acromegaly and Cushing's disease (CD). The molecule is a stable cyclohexapeptide synthetized based on SRIF structure. Differently from first-generation SRLs (e.g. octreotide), preferentially binding somatostatin receptor (SST) subtype 2 (SST2), pasireotide has high affinity for multiple SSTs (SST5 > SST2 > SST3 > SST1). Interestingly, early preclinical studies demonstrated that pasireotide shows distinct functional properties compared to SRIF and first-generation SRLs when binding SSTs. METHODS We aimed to highlight the differential receptor-targeted action of pasireotide in the treatment of somatotroph and corticotroph adenomas, throughout the critical revision of preclinical studies carried out on acromegaly and CD models. RESULTS Different authors demonstrated that the antisecretory effect of pasireotide in somatotroph adenoma cell cultures is comparable to that of the SST2-preferential agonist octreotide. Some reports even show a direct correlation between SST2 mRNA expression and GH reduction after pasireotide treatment, thus laying for a predominant role of SST2 in driving pasireotide efficacy in somatotropinomas in vitro. On the other hand, the inhibitory effect of pasireotide on ACTH secretion in corticotropinoma cells seems to be mainly mediated by SST5. Indeed, most reports show a higher potency and efficacy of pasireotide compared to SST2 preferential agonists, while functional studies confirm the pivotal role of SST5 targeting in corticotroph cells. CONCLUSIONS The analysis of preclinical studies carried out in somatotroph and corticoph adenomas points out that pasireotide shows a cell-specific activity, exerting its biological effects via different SSTs in the different adenoma histotypes.
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Affiliation(s)
- Federico Gatto
- Endocrinology Unit, Department of Internal Medicine, Policlinico San Martino, 16132, Genoa, Italy.
| | | | | | | | | | | | | | - Massimo Giusti
- Endocrinology Unit, Department of Internal Medicine, Policlinico San Martino, 16132, Genoa, Italy
- University of Genoa, Genoa, Italy
| | - Mara Boschetti
- Endocrinology Unit, Department of Internal Medicine, Policlinico San Martino, 16132, Genoa, Italy
- University of Genoa, Genoa, Italy
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine, Policlinico San Martino, 16132, Genoa, Italy
- University of Genoa, Genoa, Italy
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Clinical usefulness of 99mTc-HYNIC-TOC, 99mTc(V)-DMSA, and 99mTc-MIBI SPECT in the evaluation of pituitary adenomas. Nucl Med Commun 2018; 40:41-51. [PMID: 30334858 PMCID: PMC6282662 DOI: 10.1097/mnm.0000000000000931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The aim of this study was to evaluate the behavioral uptake and ability to diagnose pituitary adenoma (PA) using tumor-seeking radiopharmaceuticals, and to provide a semiquantitative analysis of tracer uptake in the pituitary region. Patients and methods The study included 33 (13 hormonally active and 20 nonfunctioning) patients with PA and 45 control participants without pituitary involvement. All patients (n=78) underwent single photon emission computed tomography (SPECT) imaging with technetium-99m-labeled hydrazinonicotinyl-tyr3-octreotide (99mTc-HYNIC-TOC), dimercaptosuccinic acid (99mTc(V)-DMSA) and hexakis-2-methoxyisobutylisonitrile (99mTc-MIBI). A semiquantitative analysis of abnormal uptake was carried out by drawing identical regions of interest over the pituitary area and the normal brain on one transverse section that shows the lesion most clearly. The pituitary uptake to normal brain uptake (P/B) ratio was calculated in all cases. Results The result of this study confirms that the SPECT semiquantitative method, with all three tracers, showed statistically significant differences between the PA group and the controls. However, 99mTc-HYNIC-TOC scintigraphy could have the highest diagnostic yield because of the smallest overlap between the P/B ratios between adenoma versus nonadenoma participants (the receiver operating characteristic curve P/B ratio cut-off value was 13.08). In addition, only 99mTc-MIBI SPECT have the diagnostic potential to detect secreting PAs, with statistically significant differences between groups (P<0.001), with an receiver operating characteristic curve P/B ratio cut-off value of 16.72. Conclusion A semiquantitative analysis of increased focal tracer uptake in the sellar area showed that 99mTc-HYNIC-TOC is a highly sensitive and reliable tumor-seeking agent for detecting PA, whereas 99mTc-MIBI SPECT is a highly sensitive and specific method in differentiating hormone-secreting pituitary tumor.
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Marazuela M, Ramos-Leví AM, Borges de Souza P, Zatelli MC. Is receptor profiling useful for predicting pituitary therapy? Eur J Endocrinol 2018; 179:D15-D25. [PMID: 30139823 DOI: 10.1530/eje-18-0549] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/13/2018] [Accepted: 08/22/2018] [Indexed: 12/31/2022]
Abstract
Medical treatment of pituitary tumours may present important challenges in the presence of resistance to first line therapy. In this setting, the availability of specific markers of responsiveness/resistance could be helpful to provide tailored patients' treatment. Pituitary receptor profiling has emerged as a potentially useful tool for predicting the response to specific pituitary-directed medical therapy, mainly somatostatin analogues and dopamine agonists. However, its utility is not always straightforward. In fact, agonist-receptor coupling to the consequent biological response is complex and sometimes jeopardizes the understanding of the molecular basis of pharmacological resistance. Defective expression of pituitary receptors, genetic alterations, truncated variants, impaired signal transduction or involvement of other proteins, such as cytoskeleton proteins or the Aryl hydrocarbon receptor interacting protein amongst others, have been linked to differential tumour phenotype or treatment responsiveness with conflicting results, keeping the debate on the utility of pituitary receptor profiling open. Why does this occur? How can we overcome the difficulties? Is there a true role for pituitary receptor profiling in the near future? All authors of this debate article agree on the need of prospective studies using standardized methods in order to assess the efficacy of receptor profiling as a reliable clinical predictive factor.
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Affiliation(s)
- Monica Marazuela
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ana M Ramos-Leví
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Patricia Borges de Souza
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Maria Chiara Zatelli
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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Abstract
INTRODUCTION Cushing's disease is a rare systemic and disabling disease due to oversecretion of adrenocorticotrophic hormone (ACTH) resulting in excess cortisol levels. Diagnosis and treatment are difficult; despite the availability of various pharmaceutical treatment options, there is an ongoing, unmet need for even more effective treatment. AREAS COVERED The present review aims at providing an overview of available drugs and presenting new developments. Focusing on the pituitary as a target, the review covers compounds targeting pituitary cell signaling or cell cycle control such as heat shock protein inhibitors (e.g. silibinin), histone deacetylase inhibitors (trichostatin A, vorinostat), kinase inhibitors (gefitinib, seliciclib), and others (such as triptolide, AT-101). Levoketoconazole and osilodrostat are in clinical testing and inhibit steroidogenesis. Blockade of ACTH receptor binding at the adrenal level is explained as a theoretical drug target. Inhibition of binding of the glucocorticoid receptor in the peripheral tissue plays a minor role due to its lack of biomonitoring options. EXPERT OPINION In our opinion, further research and drug development of pituitary-directed targets are necessary. Combination therapies may exert synergistic effects and allow for smaller and better tolerated doses, but more experience and data are needed to guide such treatment schemes.
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Affiliation(s)
- Sylvère Störmann
- a Medizinische Klinik und Poliklinik IV , Klinikum der Universität München , München , Germany
| | - Jochen Schopohl
- a Medizinische Klinik und Poliklinik IV , Klinikum der Universität München , München , Germany
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Watanabe M, Nakamoto Y, Koyasu S, Ishimori T, Yasoda A, Togashi K. The influence of elevated hormone levels on physiologic accumulation of 68Ga-DOTATOC. Ann Nucl Med 2018; 32:191-196. [PMID: 29349562 DOI: 10.1007/s12149-018-1233-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 01/16/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE PET/CT imaging with 68Ga-1,4,7,10-tetraazacyclododecane-N,N',N″,N‴-tetraacetic acid-D-Phe1-Tyr3-octreotide (DOTATOC) is useful in patients with neuroendocrine tumors (NETs). Functioning NETs by definition secrete abnormal levels of hormones, causing clinical symptoms. It is known that physiologic accumulation can be seen in some organs, but it remains unknown whether elevated hormone levels can affect the physiologic accumulation pattern of 68Ga-DOTATOC. We aimed to investigate the influence of higher hormone levels on physiologic accumulation of 68Ga-DOTATOC. METHODS A total of 167 patients with known or suspected NET lesions were enrolled in this study. The numbers of patients with elevations of ACTH, gastrin, insulin, and no elevation were 10, 25, 7, and 125, respectively. We compared the maximum standardized uptake value (SUVmax) in various organs of each group. RESULTS In the group with elevated ACTH levels, SUVmax in the pituitary gland, the uncinate process of the pancreas and adrenal glands was lower than those in the group with no elevation (5.7 ± 1.9 vs. 8.4 ± 3.1, P = 0.015; 4.7 ± 3.5 vs. 6.4 ± 2.8, P = 0.037; 10.8 ± 4.8 vs. 13.9 ± 4.7, P = 0.020, respectively). There were no differences in physiologic uptake of 68Ga-DOTATOC in the thyroid gland, the pancreatic body, the liver, the spleen, the bowel, or the kidney. CONCLUSIONS In NET patients with elevated ACTH levels, physiologic uptake of 68Ga-DOTATOC in the pituitary gland, the uncinate process of the pancreas and adrenal glands was significantly decreased. Other organs were unaffected.
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Affiliation(s)
- Masao Watanabe
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoinkawahara-cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoinkawahara-cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Sho Koyasu
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoinkawahara-cho, Sakyo-Ku, Kyoto, 606-8507, Japan.,Research Center for Advanced Science and Technology, The University of Tokyo, 4-6-1 Komaba, Meguro, Tokyo, 153-0041, Japan
| | - Takayoshi Ishimori
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoinkawahara-cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Akihiro Yasoda
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, 54 Shogoinkawahara-cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Kaori Togashi
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoinkawahara-cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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Behling F, Honegger J, Skardelly M, Gepfner-Tuma I, Tabatabai G, Tatagiba M, Schittenhelm J. High Expression of Somatostatin Receptors 2A, 3, and 5 in Corticotroph Pituitary Adenoma. Int J Endocrinol 2018; 2018:1763735. [PMID: 30627156 PMCID: PMC6304820 DOI: 10.1155/2018/1763735] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 10/10/2018] [Accepted: 10/16/2018] [Indexed: 01/27/2023] Open
Abstract
The development of somatostatin analogs for the treatment of pituitary Cushing's disease has been based on somatostatin receptor expression analyses of small cohorts of pituitary adenomas. Additionally, the classification of pituitary adenomas has recently changed. To enable progress with this treatment option, we assessed somatostatin receptors in a large cohort of corticotroph and other pituitary adenomas according to the new WHO classification of endocrine tumors. Paraffin-embedded tumor samples of 88 corticotroph pituitary adenomas and 30 nonadenomatous pituitary biopsies were analyzed after processing into tissue microarrays and immunohistochemical staining for SSTR 1, SSTR2A, SSTR3, SSTR4, and SSTR5. For comparison, 159 other noncorticotroph pituitary adenomas were analyzed. SSTR3 expression was higher in corticotroph adenomas compared to PIT-1-positive, gonadotroph, and nonfunctioning pituitary adenomas (p < 0.0001, p = 0.0280, and p < 0.0001, respectively). This was also the case for the expression of SSTR5 (p = 0.0003, p < 0.0001, and p < 0.0001, respectively). SSTR2A expression was higher compared to gonadotroph and nonfunctioning pituitary adenomas (p = 0.0217 and 0.0126, respectively) while PIT-1-positive adenomas showed even higher SSTR2A expression (p < 0.0001). SSTR2A and SSTR5 were both expressed higher in nonadenomatous pituitary biopsies than in pituitary adenomas (p = 0.0126 and p = 0.0008, respectively). There are marked expression differences of SSTR1-5 as well as changes in expression in recurrent disease that need to be addressed when looking for other possible substances for the treatment of Cushing's disease. SSTR2A, SSTR3, and SSTR5 seem to be most suitable biomarkers for a targeted therapy with somatostatin analogs.
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Affiliation(s)
- Felix Behling
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
| | - Marco Skardelly
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
| | - Irina Gepfner-Tuma
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Department of Neurology, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Tuebingen, Germany
| | - Ghazaleh Tabatabai
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Department of Neurology, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Tuebingen, Germany
- Interdisciplinary Division of Neuro-Oncology, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- German Cancer Consortium (DKTK), DKFZ partner site Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
| | - Jens Schittenhelm
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Department of Neuropathology, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
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Ectopic Cushing's syndrome: Paradoxical effect of somatostatin analogs. ACTA ACUST UNITED AC 2017; 64:276-278. [PMID: 29056252 DOI: 10.1016/j.endinu.2017.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 01/14/2017] [Accepted: 01/20/2017] [Indexed: 11/22/2022]
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Abstract
Severe Cushing's syndrome presents an acute emergency and is defined by massively elevated random serum cortisol [more than 36 μg/dL (1000 nmol/L)] at any time or a 24-h urinary free cortisol more than fourfold the upper limit of normal and/or severe hypokalaemia (<3.0 mmol/L), along with the recent onset of one or more of the following: sepsis, opportunistic infection, intractable hypokalaemia, uncontrolled hypertension, heart failure, gastrointestinal haemorrhage, glucocorticoid-induced acute psychosis, progressive debilitating myopathy, thromboembolism or uncontrolled hyperglycaemia and ketocacidosis. Treatment focuses on the management of the severe metabolic disturbances followed by rapid resolution of the hypercortisolaemia, and subsequent confirmation of the cause. Emergency lowering of the elevated serum cortisol is most rapidly achieved with oral metyrapone and/or ketoconazole; if parenteral therapy is required then intravenous etomidate is rapidly effective in almost all cases, but all measures require careful supervision. The optimal order and combination of drugs to treat severe hypercortisolaemia-mostly in the context of ectopic ACTH-secreting syndrome, adrenocortical carcinoma or an ACTH-secreting pituitary adenoma (mainly macroadenomas)-is not yet established. Combination therapy may be useful not only to rapidly control cortisol excess but also to lower individual drug dosages and consequently the possibility of adverse effects. If medical treatments fail, bilateral adrenalectomy should be performed in the shortest possible time span to prevent the debilitating complications of uncontrolled hypercortisolaemia.
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Affiliation(s)
- Krystallenia I Alexandraki
- Clinic of Endocrine Oncology, Department of Pathophysology, National University of Athens, Athens, Greece
| | - Ashley B Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK.
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Ibáñez-Costa A, Rivero-Cortés E, Vázquez-Borrego MC, Gahete MD, Jiménez-Reina L, Venegas-Moreno E, de la Riva A, Arráez MÁ, González-Molero I, Schmid HA, Maraver-Selfa S, Gavilán-Villarejo I, García-Arnés JA, Japón MA, Soto-Moreno A, Gálvez MA, Luque RM, Castaño JP. Octreotide and pasireotide (dis)similarly inhibit pituitary tumor cells in vitro. J Endocrinol 2016; 231:135-145. [PMID: 27587848 DOI: 10.1530/joe-16-0332] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 09/01/2016] [Indexed: 02/01/2023]
Abstract
Somatostatin analogs (SSA) are the mainstay of pharmacological treatment for pituitary adenomas. However, some patients escape from therapy with octreotide, a somatostatin receptor 2 (sst2)-preferring SSA, and pasireotide, a novel multi-sst-preferring SSA, may help to overcome this problem. It has been proposed that correspondence between sst1-sst5 expression pattern and SSA-binding profile could predict patient's response. To explore the cellular/molecular features associated with octreotide/pasireotide response, we performed a parallel comparison of their in vitro effects, evaluating sst1-sst5 expression, intracellular Ca2+ signaling ([Ca2+]i), hormone secretion and cell viability, in a series of 85 pituitary samples. Somatotropinomas expressed sst5>sst2, yet octreotide reduced [Ca2+]i more efficiently than pasireotide, while both SSA similarly decreased growth hormone release/expression and viability. Corticotropinomas predominantly expressed sst5, but displayed limited response to pasireotide, while octreotide reduced functional endpoints. Non-functioning adenomas preferentially expressed sst3 but, surprisingly, both SSA increased cell viability. Prolactinomas mainly expressed sst1 but were virtually unresponsive to SSA. Finally, both SSA decreased [Ca2+]i in normal pituitaries. In conclusion, both SSA act in vitro on pituitary adenomas exerting both similar and distinct effects; however, no evident correspondence was found with the sst1-sst5 profile. Thus, it seems plausible that additional factors, besides the simple abundance of a given sst, critically influence the SSA response.
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Affiliation(s)
- Alejandro Ibáñez-Costa
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
| | - Esther Rivero-Cortés
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
| | - Mari C Vázquez-Borrego
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
| | - Manuel D Gahete
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
| | - Luis Jiménez-Reina
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Morphological SciencesUniversidad de Córdoba, Córdoba, Spain
| | - Eva Venegas-Moreno
- Metabolism and Nutrition UnitHospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - Andrés de la Riva
- Service of NeurosurgeryHospital Universitario Reina Sofía, Córdoba, Spain
| | | | | | - Herbert A Schmid
- Novartis Pharma AGNovartis Institutes for Biomedical Research, Oncology, CH-4057 Basel, Switzerland
| | - Silvia Maraver-Selfa
- Service of Endocrinology and NutritionHospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
| | | | | | - Miguel A Japón
- Department of PathologyHospital Universitario Virgen del Rocío, Seville, Spain
| | - Alfonso Soto-Moreno
- Metabolism and Nutrition UnitHospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - María A Gálvez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Service of Endocrinology and NutritionHospital Universitario Reina Sofía, Córdoba, Spain
| | - Raúl M Luque
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
| | - Justo P Castaño
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
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Cuevas-Ramos D, Lim DST, Fleseriu M. Update on medical treatment for Cushing's disease. Clin Diabetes Endocrinol 2016; 2:16. [PMID: 28702250 PMCID: PMC5471955 DOI: 10.1186/s40842-016-0033-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 08/25/2016] [Indexed: 12/30/2022] Open
Abstract
Cushing's disease (CD) is the most common cause of endogenous Cushing's syndrome (CS). The goal of treatment is to rapidly control cortisol excess and achieve long-term remission, to reverse the clinical features and reduce long-term complications associated with increased mortality. While pituitary surgery remains first line therapy, pituitary radiotherapy and bilateral adrenalectomy have traditionally been seen as second-line therapies for persistent hypercortisolism. Medical therapy is now recognized to play a key role in the control of cortisol excess. In this review, all currently available medical therapies are summarized, and novel medical therapies in phase 3 clinical trials, such as osilodrostat and levoketoconazole are discussed, with an emphasis on indications, efficacy and safety. Emerging data suggests increased efficacy and better tolerability with these novel therapies and combination treatment strategies, and potentially increases the therapeutic options for treatment of CD. New insights into the pathophysiology of CD are highlighted, along with potential therapeutic applications. Future treatments on the horizon such as R-roscovitine, retinoic acid, epidermal growth factor receptor inhibitors and somatostatin-dopamine chimeric compounds are also described, with a focus on potential clinical utility.
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Affiliation(s)
- Daniel Cuevas-Ramos
- Department of Endocrinology and Metabolism, Neuroendocrinology Clinic, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, Mexico City, 14030 Mexico
| | - Dawn Shao Ting Lim
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR 97239 USA
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR 97239 USA
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Ma L, Yin L, Hu Q. Therapeutic compounds for Cushing's syndrome: a patent review (2012-2016). Expert Opin Ther Pat 2016; 26:1307-1323. [PMID: 27454103 DOI: 10.1080/13543776.2016.1217331] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Endogenous Cushing's syndrome (CS) is a set of disorders caused by chronic exposure to excess glucocorticoids induced by neuroendocrine tumors in pituitary, adrenals, and infrequently other sites (ectopic ACTH syndrome). Due to various comorbidities, CS patients exhibit higher risks of cardiovascular diseases and thus increased mortality. Pharmaceutical therapy is an important constituent of treatment regimen. Areas covered: Patents published since 2012 are reviewed, which claim therapeutic compounds interfering with ACTH secretion and down-stream signal transduction, inhibiting cortisol biosynthesis and antagonizing glucocorticoid receptors. Advances focus on a) new analogues with improved efficacy and PK properties or less off-target toxicity; b) existing drugs (candidates) being repurposed to treat CS; and c) novel strategies such as selective inhibition of CYP11B1. Expert opinion: New compounds against established targets need to be developed because current drugs lack selectivity leading to off-target toxicity. Selective inhibition of CYP11B1 is a novel alternative strategy and is potentially versatile in controlling all types of hypercortisolism. Selective multi-targeting enzymes in steroidogenesis network is promising due to potential synergistic effects. However, doses toward each targets are not feasible to adjust because the corresponding intrinsic potencies are rigid. Targeting PRKACA mutations is promising in treating CS caused by adrenal adenomas.
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Affiliation(s)
- Li Ma
- a College of Pharmaceutical Sciences , Zhejiang University , Hangzhou , China PR
| | | | - Qingzhong Hu
- c Department of Chemistry , University of Cambridge , Cambridge , UK
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Mifepristone Improves Octreotide Efficacy in Resistant Ectopic Cushing's Syndrome. Case Rep Endocrinol 2016; 2016:8453801. [PMID: 26989527 PMCID: PMC4773543 DOI: 10.1155/2016/8453801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 01/26/2016] [Indexed: 12/18/2022] Open
Abstract
A 30-year-old Caucasian man presented with severe Cushing's syndrome (CS) resulting from ectopic adrenocorticotropin syndrome (EAS) from a metastatic pancreatic neuroendocrine tumor. The patient remained hypercortisolemic despite treatment with steroidogenesis inhibitors, chemotherapy, and octreotide long-acting release (LAR) and was enrolled in a 24-week, phase 3 clinical trial of mifepristone for inoperable hypercortisolemia. After mifepristone was added to ongoing octreotide LAR treatment, EAS symptoms essentially resolved. Cortisol decreased dramatically, despite mifepristone's competitive glucocorticoid receptor antagonist effects. The clinical and biochemical effects reversed upon mifepristone discontinuation despite the continued use of octreotide LAR therapy. Substantial improvement in octreotide LAR efficacy with mifepristone use was noted in this patient with ectopic CS, consistent with upregulation of somatostatin receptors previously downregulated by hypercortisolemia.
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Alexandraki KI, Grossman AB. Current strategies for the treatment of severe Cushing's syndrome. Expert Rev Endocrinol Metab 2016; 11:65-79. [PMID: 30063449 DOI: 10.1586/17446651.2016.1123615] [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: 11/08/2022]
Abstract
Severe Cushing's syndrome may present an acute emergency in patients diagnosed with Cushing's syndrome with recent onset of at least one of the following: sepsis, opportunistic infection; intractable hypokalaemia, uncontrolled hypertension; heart failure; gastrointestinal hemorrhage; acute psychosis; progressive debilitating myopathy; thromboembolism; uncontrolled hyperglycemia and ketoacidosis. The biochemical definition includes serum cortisol ≥41μg/dl (1100 nmol/l) and/or severe hypokalemia (<3.0 mmol/l) or urine free cortisol fivefold the upper limit of normal. Treatment focuses on the management of severe metabolic disturbances followed by rapid resolution of the hypercortisolemia and subsequent confirmation of the cause. We emphasize the control of the hypokalemia, hypertension, diabetes and any psychotic state, anti-coagulation, monitoring and vigorous therapy of opportunistic infections. The ideal first-line therapies include metyrapone and ketoconazole, followed by parenteral etomidate; if all else fails life-saving bilateral adrenalectomy should be considered.
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Affiliation(s)
- Krystallenia I Alexandraki
- a Clinic of Neuroendocrine Oncology, Department of Pathophysiology , National University of Athens , Athens , Greece
| | - Ashley B Grossman
- b Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital , University of Oxford , Oxford , UK
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Simeoli C, Auriemma RS, Tortora F, De Leo M, Iacuaniello D, Cozzolino A, De Martino MC, Pivonello C, Mainolfi CG, Rossi R, Cirillo S, Colao A, Pivonello R. The treatment with pasireotide in Cushing's disease: effects of long-term treatment on tumor mass in the experience of a single center. Endocrine 2015; 50:725-40. [PMID: 25743263 DOI: 10.1007/s12020-015-0557-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/17/2015] [Indexed: 01/10/2023]
Abstract
Pasireotide is the first medical therapy officially approved for the treatment of adult patients with Cushing's disease (CD) who experienced a failure of pituitary surgery or are not candidates for surgery and require medical therapeutic intervention. The current study aimed at investigating the effects of long-term treatment with pasireotide (up to 24 months) on tumor mass in a group of patients with CD, participating to a phase III study. Fourteen CD patients entered the phase III clinical trial CSOM230B2305 at Naples Center, and eight (seven women, one man, aged 38.9 ± 17.6 years), including seven with a microadenoma and one with a macroadenoma, received treatment with pasireotide at the dose of 600-1200 µg bid for at least 6 months, and were considered for the analysis of the study. These eight patients were subjected to the evaluation of pituitary tumor volume by pituitary MRI, together with the evaluation of urinary cortisol levels, at baseline and every 6 months for the entire period of treatment. Pasireotide treatment induced full disease control in 37.5 % and partial disease control in 37.5 % after 6 months, whereas full and partial disease control after 12 months was obtained in 28.6 % and in 57.1 % of patients, respectively. A significant (>25 %) reduction in tumor volume was found in 62.5 % and in 100 % of patients, after 6 and 12 months, respectively. In particular, after 6 months, a slight tumor shrinkage (between 25.1 and 50 %) was observed in 25 %, moderate (50.1-75 %) in 25 %, and marked (>75 %) in 12.5 % of patients, whereas after 12 months, a slight tumor shrinkage was observed in 43 %, moderate in 14 %, and marked in 43 % of patients. In 25 % of patients (two patients), a marked tumor shrinkage was recorded, with tumor mass disappearance in one case; this tumor shrinkage was associated to rapid and sustained biochemical remission up to 24 months of continuous pasireotide treatment. These two cases represent the first cases with a documentation of such a notable effect of pasireotide on tumor mass. Pasireotide induces significant tumor shrinkage in 62.5 % of patients after 6 months and in 100 % of patients after 12 months, and occasionally induces a radiological disappearance of the tumor. This evidence supports and strengthens the role of pasireotide as medical treatment specifically addressed to patients with CD, particularly in those who had unsuccessful pituitary surgery, or are not candidates for surgery.
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Affiliation(s)
- Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | | | - Fabio Tortora
- Department of Internal and Experimental Medicine, Division of Neurological Sciences, Second University of Naples, Naples, Italy
| | - Monica De Leo
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Davide Iacuaniello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Alessia Cozzolino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Maria Cristina De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | | | - Riccardo Rossi
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Sossio Cirillo
- Department of Internal and Experimental Medicine, Division of Neurological Sciences, Second University of Naples, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy.
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Pivonello R, De Leo M, Cozzolino A, Colao A. The Treatment of Cushing's Disease. Endocr Rev 2015; 36:385-486. [PMID: 26067718 PMCID: PMC4523083 DOI: 10.1210/er.2013-1048] [Citation(s) in RCA: 282] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Monica De Leo
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Alessia Cozzolino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
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Abstract
INTRODUCTION Considering the effects of uncontrolled hypercortisolism on morbidity and mortality, there is a clear need for effective medical therapy for patients with Cushing's disease (CD). Therefore, the search for new medical effective tools remains active, and already promising results have been obtained. AREAS COVERED The importance of the design and conduct of trials to validate old drugs or to test new compounds is discussed. The results of the ongoing clinical trials, targeting the specific properties of drugs, such as ketoconazole, LCI699, mifepristone, etomidate and pasireotide, are also reported. The authors also emphasise the advantages and drawbacks of each particular drug, and the potential combined use of agents with complementary mechanisms of action. EXPERT OPINION CD is an excellent example of a situation where effective therapy is essential, but where the balance of risk and benefit must be carefully judged. Metyrapone is the drug of choice when rapid control of the hypercortisolaemia is required, ketoconazole represents a good second-line drug, although in the future LCI699 may be a better alternative. Mifepristone can also be used in the rare situation when previous drugs are inappropriate. Etomidate is useful where immediate parenteral action is required. For drugs working directly on the pituitary, cabergoline is occasionally effective and pasireotide can be attempted in patients with mild CD.
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Affiliation(s)
- Daniela Guelho
- a 1 Department of Endocrinology, Diabetes and Metabolism of Coimbra Hospital and University Centre , Portugal
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Davi' MV, Salgarello M, Francia G. Positive (68)Ga-DOTATOC-PET/CT after cortisol level control during ketoconazole treatment in a patient with liver metastases from a pancreatic neuroendocrine tumor and ectopic Cushing syndrome. Endocrine 2015; 49:566-7. [PMID: 25168486 DOI: 10.1007/s12020-014-0391-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/08/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Maria Vittoria Davi'
- Internal Medicine, Section D, Department of Medicine, University of Verona, Piazzale Scuro Policlinico G.B. Rossi, 37134, Verona, Italy,
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Ceccato F, Scaroni C, Boscaro M. Clinical use of pasireotide for Cushing's disease in adults. Ther Clin Risk Manag 2015; 11:425-34. [PMID: 25834454 PMCID: PMC4370333 DOI: 10.2147/tcrm.s37314] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Cushing’s disease Excessive corticotroph hormone levels sustained by an adrenocorticotropic hormone-secreting pituitary adenoma lead to a severe clinical condition caused by excess cortisol secretion, called Cushing’s disease (CD). Neurosurgery and radiotherapy are used to treat the pituitary adenoma directly, but new medical treatments targeting the corticotroph cells have recently become available. Pasireotide This is a novel multireceptor ligand somatostatin (SST) analog with a high binding affinity for SST receptor 5, the predominant receptor in human corticotroph adenomas that is not downregulated by high cortisol levels (as SST receptor 2 is). Pasireotide has been recently approved by the European Medical Agency and the US Food and Drug Administration for treating adults with CD with recurrent hypercortisolism after surgery, or for whom surgery is not an option. A dose of 600–1,200 μg twice a day can normalize urinary free cortisol levels after 3 months of treatment in up to 28% of patients, reducing their blood pressure and improving their weight, lipid profile, and quality of life. Combining pasireotide with cabergoline to achieve a greater hormone response can normalize cortisol secretion in 50% of patients, and adding ketoconazole induces biochemical control in most patients with CD. Safety and hyperglycemia The adverse effects of pasireotide are similar to those of other SST analogs, including diarrhea, nausea, and biliary sludge or gallstones. Hyperglycemia is common during pasireotide treatment, which affects the secretion of pancreatic insulin and intestinal glucagon-like peptide 1. Self-monitoring is essential to achieve good metabolic control, and endocrinologists should first administer metformin if insulin resistance is evident and then add dipeptidyl peptidase 4 inhibitors/glucagon-like peptide 1 receptor agonists or insulin. Conclusion In recent years, medical treatment with pasireotide has been proposed as monotherapy for adults with CD characterized by mild to moderate hypercortisolemia, as well as in combination with other available therapies. It is generally well-tolerated, but endocrinologists need to monitor glucose levels to ensure prompt treatment.
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Affiliation(s)
- Filippo Ceccato
- Endocrinology Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine, Padova University Hospital, Padova, Italy
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Abstract
Transsphenoidal surgery remains the first line therapy in Cushing's disease, but a large number of patients will not be cured or disease will recur over time. Repeat pituitary surgery, bilateral adrenalectomy, and radiation have limitations with respect to efficacy and/or side effects. Therefore, there is a clear need for an effective medical treatment. The studies reviewed here suggest a role for pituitary-directed therapies, applying multireceptor ligand somatostatin analogs like pasireotide or second-generation dopamine agonists. Retinoic acid has been also studied in a small prospective study. These compounds target ACTH-secretion at the pituitary level and possibly inhibit corticotrope proliferation. Specific side effects of these compounds need to be considered, especially when used as long-term therapy. These novel approaches could provide options for treatment of patients in whom surgery has failed or is not possible, and while awaiting effects of radiation therapy. Preoperative use to decrease cortisol excess, potentially reducing perioperative complications, needs to be further studied.
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Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Altonaer Str. 59, 20357, Hamburg, Germany,
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Ducry J, Gomez F, Prior JO, Boubaker A, Matter M, Monti M, Pu Y, Pitteloud N, Portmann L. Mid-gut ACTH-secreting neuroendocrine tumor unmasked with (18)F-dihydroxyphenylalanine-positron emission tomography. Endocrinol Diabetes Metab Case Rep 2015; 2015:140104. [PMID: 25861450 PMCID: PMC4361871 DOI: 10.1530/edm-14-0104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 02/23/2015] [Indexed: 11/08/2022] Open
Abstract
Ectopic ACTH Cushing's syndrome (EAS) is often caused by neuroendocrine tumors (NETs) of lungs, pancreas, thymus, and other less frequent locations. Localizing the source of ACTH can be challenging. A 64-year-old man presented with rapidly progressing fatigue, muscular weakness, and dyspnea. He was in poor condition and showed facial redness, proximal amyotrophy, and bruises. Laboratory disclosed hypokalemia, metabolic alkalosis, and markedly elevated ACTH and cortisol levels. Pituitary was normal on magnetic resonance imaging (MRI), and bilateral inferior petrosal sinus blood sampling with corticotropin-releasing hormone stimulation showed no significant central-to-periphery gradient of ACTH. Head and neck, thoracic and abdominal computerized tomography (CT), MRI, somatostatin receptor scintigraphy (SSRS), and 18F-deoxyglucose-positron emission tomography (FDG-PET) failed to identify the primary tumor. 18F-dihydroxyphenylalanine (F-DOPA)-PET/CT unveiled a 20-mm nodule in the jejunum and a metastatic lymph node. Segmental jejunum resection showed two adjacent NETs, measuring 2.0 and 0.5 cm with a peritoneal metastasis. The largest tumor expressed ACTH in 30% of cells. Following surgery, after a transient adrenal insufficiency, ACTH and cortisol levels returned to normal values and remain normal over a follow-up of 26 months. Small mid-gut NETs are difficult to localize on CT or MRI, and require metabolic imaging. Owing to low mitotic activity, NETs are generally poor candidates for FDG-PET, whereas SSRS shows poor sensitivity in EAS due to intrinsically low tumor concentration of type-2 somatostatin receptors (SST2) or to receptor down regulation by excess cortisol. However, F-DOPA-PET, which is related to amine precursor uptake by NETs, has been reported to have high positive predictive value for occult EAS despite low sensitivity, and constitutes a useful alternative to more conventional methods of tumor localization.
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Affiliation(s)
- Julien Ducry
- Services of Endocrinology Diabetes and Metabolism , Lausanne University Hospital , Lausanne , Switzerland
| | - Fulgencio Gomez
- Services of Endocrinology Diabetes and Metabolism , Lausanne University Hospital , Lausanne , Switzerland
| | - John O Prior
- Nuclear Medicine , Lausanne University Hospital , Lausanne , Switzerland
| | - Ariane Boubaker
- Nuclear Medicine , Lausanne University Hospital , Lausanne , Switzerland
| | - Maurice Matter
- Visceral Surgery , Lausanne University Hospital , Lausanne , Switzerland
| | - Matteo Monti
- Internal Medicine , Lausanne University Hospital , Lausanne , Switzerland
| | - Yan Pu
- Institute of Pathology, Lausanne University Hospital , Lausanne, CH-1011 , Switzerland
| | - Nelly Pitteloud
- Services of Endocrinology Diabetes and Metabolism , Lausanne University Hospital , Lausanne , Switzerland
| | - Luc Portmann
- Services of Endocrinology Diabetes and Metabolism , Lausanne University Hospital , Lausanne , Switzerland
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Trementino L, Cardinaletti M, Concettoni C, Marcelli G, Polenta B, Spinello M, Boscaro M, Arnaldi G. Salivary cortisol is a useful tool to assess the early response to pasireotide in patients with Cushing's disease. Pituitary 2015; 18:60-7. [PMID: 24482099 DOI: 10.1007/s11102-014-0557-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE Late night salivary cortisol (LNSC) is useful for diagnosing hypercortisolism and monitoring patients with Cushing's disease (CD) following pituitary surgery. It may also be a better index of cortisol secretion than serum cortisol or urinary free cortisol (UFC). No data regarding the role of LNSC in the early monitoring of patients with CD receiving drug therapy has been published. We investigated the value of LNSC in monitoring the short-term efficacy of pasireotide. METHODS Seven patients who were enrolled in a phase II study investigating the efficacy of pasireotide in CD (CSOM230B2208) were included in this analysis. Patients self-administered subcutaneous pasireotide 600 μg bid for 15 days. LNSC and UFC levels were assessed at baseline and day 15. RESULTS At baseline, all patients had elevated LNSC which was correlated significantly with UFC levels (r = 0.97, P = .0002). At day 15, LNSC was reduced in six patients. LNSC decreases were observed from day 1 (-20%) and persisted until day 15 (overall mean reduction from baseline -51%), with the greatest decrease on day 5 (-58%). At day 15, UFC levels were decreased in all patients and normalized in one that restored also salivary cortisol rhythm. CONCLUSIONS In patients with CD, pasireotide rapidly reduced and normalized both UFC and LNSC levels. LNSC may be a simple, non-invasive biomarker to assess the early response to pasireotide, particularly in determining whether cortisol rhythm is normalized in patients with normalized UFC levels. Further studies are warranted.
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Affiliation(s)
- Laura Trementino
- Division of Endocrinology, Polytechnic University of Marche, Via Conca 71, 60020, Torrette di Ancona, AN, Italy
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An open-label dose-escalation study of once-daily and twice-daily pasireotide in healthy volunteers: safety, tolerability, and effects on glucose, insulin, and glucagon levels. Am J Ther 2014; 21:164-73. [PMID: 22713526 DOI: 10.1097/mjt.0b013e31824c3eb4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Pasireotide is a multireceptor-targeted somatostatin analogue that has high affinity for 4 of the 5 somatostatin receptor subtypes (sst1,2,3 and sst5) and has therapeutic potential in conditions with tumors of neuroendocrine origin, such as Cushing disease, acromegaly, and neuroendocrine tumors. This phase 1, open-label, dose-escalation study assessed the overall safety and tolerability of once-daily and twice-daily pasireotide and its effects on glucose, insulin, and glucagon levels in healthy volunteers. Eleven cohorts (n = 6 for each) received subcutaneous pasireotide 150, 300, 600, 900, 1200, or 1500 μg once daily, or 150, 300, 450, 600, or 750 μg twice daily, for 8 days. Pasireotide was generally well tolerated at all doses; adverse events were predominantly mild-to-moderate gastrointestinal disorders. All participants experienced fasting and postprandial plasma glucose elevations after all doses of pasireotide; increases in blood glucose level seemed to be dose dependent. Hyperglycemia was associated with a marked suppression of insulin secretion and a mild inhibition of glucagon secretion. In conclusion, pasireotide showed good overall tolerability at doses up to 1500 μg once daily and 750 μg twice daily for 8 days. Both fasting and postprandial hyperglycemia occurred after all doses of pasireotide, which was related to the suppression of insulin secretion.
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Ceccato F, Barbot M, Zilio M, Albiger N, Mantero F, Scaroni C. Therapeutic strategies for Cushing’s syndrome: an update. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2015.991714] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ferrau F, Trimarchi F, Cannavo S. Adrenocorticotropin responsiveness to acute octreotide administration is not affected by mifepristone premedication in patients with Cushing's disease. Endocrine 2014; 47:550-6. [PMID: 24408052 DOI: 10.1007/s12020-013-0163-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 12/30/2013] [Indexed: 01/27/2023]
Abstract
Octreotide (OCT) is ineffective in patients with Cushing's disease (CD) due to the cortisol-induced down-regulation of somatostatin receptor subtype 2 which was shown to be reversible in vitro by using anti-glucocorticoid mifepristone. This study aimed to verify, in vivo, if mifepristone can modulate response to acute OCT administration in patients with CD. Three men and two postmenopausal women (age 52.5 ± 2 years) with CD were enrolled in the study. OCT (100 μg, s.c.) was administered alone on the first day (OCT-only), and it was then given after mifepristone administration (2 × 200 mg, p.os, 12 and 1 h before OCT), 3 days later (OCT-mif). ACTH and cortisol levels were measured before OCT administration and every 60 min thereafter for 6 h. Baseline ACTH and cortisol values, nadir values and percentage decrements (Δn) were compared during both tests. Mean ACTH-Δn did not differ significantly during the two tests. Both tests induced a <30 % decrease in plasma ACTH in three patients (#1, 2 and 3) and a >50 % decrease in the other two cases (#4 and 5). Cortisol decreased in patients #4 and 5, during both tests. ACTH-Δn did not correlate with morning cortisol nor with urinary free cortisol values. Patients #4 and 5 with the highest ACTH-Δn had the lowest cortisol values after 1 mg of dexamethasone. Brief mifepristone pre-treatment does not modify ACTH and cortisol response to acute OCT administration in CD. However, OCT seems to be more effective in patients with partially preserved cortisol inhibitory feedback.
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Affiliation(s)
- Francesco Ferrau
- Department of Clinical and Experimental Medicine, University of Messina, AOU Policlinico "G. Martino" (Pad. H, 4th Floor), Via Consolare Valeria 1, 98125, Messina, Italy,
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Abstract
Cushing's disease (CD) is characterized by an ACTH-producing anterior corticotrope pituitary adenoma. If hypothalamus-pituitary-adrenal (HPA) axis physiology is disrupted, ACTH secretion increases, which in turn stimulates adrenocortical steroidogenesis and cortisol production. Medical treatment plays an important role for patients with persistent disease after surgery, for those in whom surgery is not feasible, or while awaiting effects of radiation. Multiple drugs, with different mechanisms of action and variable efficacy and tolerability for controlling the deleterious effects of chronic glucocorticoid excess, are available. The molecular basis and clinical data for centrally acting drugs, adrenal steroidogenesis inhibitors, and glucocorticoid receptor antagonists are reviewed, as are potential novel molecules and future possible targets for CD treatment. Although progress has been made in the understanding of specific corticotrope adenoma receptor physiology and recent clinical studies have detected improved effects with a combined medical therapy approach, there is a clear need for a more efficacious and better-tolerated medical therapy for patients with CD. A better understanding of the molecular mechanisms in CD and of HPA axis physiology should advance the development of new drugs in the future.
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Affiliation(s)
- Daniel Cuevas-Ramos
- Department of MedicinePituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USANeuroendocrinology ClinicDepartment of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, MexicoDepartments of Medicine and Neurological Surgeryand Northwest Pituitary Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Road (BTE 472), Portland, Oregon 97239, USA Department of MedicinePituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USANeuroendocrinology ClinicDepartment of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, MexicoDepartments of Medicine and Neurological Surgeryand Northwest Pituitary Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Road (BTE 472), Portland, Oregon 97239, USA
| | - Maria Fleseriu
- Department of MedicinePituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USANeuroendocrinology ClinicDepartment of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, MexicoDepartments of Medicine and Neurological Surgeryand Northwest Pituitary Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Road (BTE 472), Portland, Oregon 97239, USA
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Pivonello R, Petersenn S, Newell-Price J, Findling JW, Gu F, Maldonado M, Trovato A, Hughes G, Salgado LR, Lacroix A, Schopohl J, Biller BMK. Pasireotide treatment significantly improves clinical signs and symptoms in patients with Cushing's disease: results from a Phase III study. Clin Endocrinol (Oxf) 2014; 81:408-17. [PMID: 24533697 DOI: 10.1111/cen.12431] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 01/28/2014] [Accepted: 02/11/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Signs and symptoms of Cushing's disease are associated with high burden of illness. In this analysis, we evaluated the effect of pasireotide treatment on signs and symptoms in patients with Cushing's disease. DESIGN Phase III study with double-blind randomization of two pasireotide doses. METHODS Patients (n = 162) with persistent/recurrent or de novo Cushing's disease and urinary free cortisol (UFC) levels ≥1·5× upper limit of normal (ULN) were randomized to receive subcutaneous pasireotide (600/900 μg bid). At month 3, patients with UFC ≤2 × ULN and not exceeding the baseline value continued their randomized dose; all others received 300 μg bid uptitration. At month 6, patients could enter an open-label phase until month 12 with a maximal dose of 1200 μg bid. Changes in signs and symptoms of hypercortisolism over 12 months' treatment in patients still enroled in the study and with evaluable measurements were assessed in relation to degree of UFC control. RESULTS Reductions in blood pressure were observed even without full UFC control and were greatest in patients who did not receive antihypertensive medications during the study. Significant reductions in total cholesterol and low-density lipoprotein (LDL)-cholesterol were observed in patients who achieved UFC control. Reductions in BMI, weight and waist circumference occurred during the study even without full UFC control. Adverse effects were typical of somatostatin analogues except for hyperglycaemia-related events, which were experienced by 72·8% of patients. CONCLUSIONS In the largest Phase III study of medical therapy in Cushing's disease, significant improvements in signs and symptoms were seen during 12 months of pasireotide treatment, as UFC levels decreased.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
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Murasawa S, Kageyama K, Sugiyama A, Ishigame N, Niioka K, Suda T, Daimon M. Inhibitory effects of SOM230 on adrenocorticotropic hormone production and corticotroph tumor cell proliferation in vitro and in vivo. Mol Cell Endocrinol 2014; 394:37-46. [PMID: 25011056 DOI: 10.1016/j.mce.2014.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 06/22/2014] [Accepted: 07/01/2014] [Indexed: 11/30/2022]
Abstract
Adrenocorticotropic hormone (ACTH) production by pituitary corticotroph adenomas is the main cause of Cushing's disease. A drug that targets pituitary ACTH-secreting adenomas would aid treatment of Cushing's disease. Octreotide, a somatostatin receptor type 2 (SSTR2)-preferring somatostatin analogue, has no effect on ACTH secretion in patients with Cushing's disease. The multiligand SOM230 (pasireotide) displays a much higher affinity for SSTR1 and SSTR5 than octreotide and suppresses ACTH secretion in cultures of human corticotroph tumors to a greater extent than octreotide. In the present in vitro and in vivo study, we determined the effect of SOM230 on ACTH production and cell proliferation of AtT-20 corticotroph tumor cells. SOM230 decreased proopiomelanocortin (POMC) mRNA levels in AtT-20 cells and ACTH levels in the culture medium of these cells, suggesting that SOM230 suppresses ACTH synthesis and secretion in corticotroph tumor cells. SOM230 also decreased cell proliferation and both cyclic adenosine monophosphate response element-binding protein and Akt phosphorylation in AtT-20 cells. SSTR5 knockdown inhibited the SOM230-induced decreases in cell proliferation. Fluorescence-activated cell sorting analyses revealed that SOM230 did not attenuate cell cycle progression. Tumor weight in mice xenografted with AtT-20 cells and treated with SOM230 was significantly lower than in AtT-20-xenografted control mice. SOM230 also significantly decreased plasma ACTH levels, and POMC and pituitary tumor transforming gene mRNA levels in the tumor cells. Thus, SOM230 inhibits ACTH production and corticotroph tumor cell proliferation in vitro and in vivo.
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Affiliation(s)
- Shingo Murasawa
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Kazunori Kageyama
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan; Department of Endocrinology, Metabolism, and Infectious Diseases, Hirosaki University School of Medicine & Hospital, 53 Hon-cho, Hirosaki, Aomori 036-8563, Japan.
| | - Aya Sugiyama
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Noriko Ishigame
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Kanako Niioka
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Toshihiro Suda
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Makoto Daimon
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
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Abstract
The somatostatin (SRIF) system, which includes the SRIF ligand and receptors, regulates anterior pituitary gland function, mainly inhibiting hormone secretion and to some extent pituitary tumor cell growth. SRIF-14 via its cognate G-protein-coupled receptors (subtypes 1-5) activates multiple cellular signaling pathways including adenylate cyclase/cAMP, MAPK, ion channel-dependent pathways, and others. In addition, recent data have suggested SRIF-independent constitutive SRIF receptor activity responsible for GH and ACTH inhibition in vitro. This review summarizes current knowledge on ligand-dependent and independent SRIF receptor molecular and functional effects on hormone-secreting cells in the anterior pituitary gland.
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Affiliation(s)
- Tamar Eigler
- Division of EndocrinologyDiabetes and Metabolism, Department of Medicine, Pituitary Center, Cedars Sinai Medical Center, Davis Building, Room 3066, 8700 Beverly Boulevard, Los Angeles, California 90048, USA
| | - Anat Ben-Shlomo
- Division of EndocrinologyDiabetes and Metabolism, Department of Medicine, Pituitary Center, Cedars Sinai Medical Center, Davis Building, Room 3066, 8700 Beverly Boulevard, Los Angeles, California 90048, USA
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Ferone D, Pivonello C, Vitale G, Zatelli MC, Colao A, Pivonello R. Molecular basis of pharmacological therapy in Cushing's disease. Endocrine 2014; 46:181-98. [PMID: 24272603 DOI: 10.1007/s12020-013-0098-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/19/2013] [Indexed: 01/16/2023]
Abstract
Cushing's disease (CD) is a severe endocrine condition caused by an adrenocorticotropin (ACTH)-producing pituitary adenoma that chronically stimulates adrenocortical cortisol production and with potentially serious complications if not or inadequately treated. Active CD may produce a fourfold increase in mortality and is associated with significant morbidities. Moreover, excess mortality risk may persist even after CD treatment. Although predictors of risk in treated CD are not fully understood, the importance of early recognition and adequate treatment is well established. Surgery with resection of a pituitary adenoma is still the first line therapy, being successful in about 60-70 % of patients; however, recurrence within 2-4 years may often occur. When surgery fails, medical treatment can reduce cortisol production and ameliorate clinical manifestations while more definitive therapy becomes effective. Compounds that target hypothalamic-pituitary axis, glucocorticoid synthesis or adrenocortical function are currently used to control the deleterious effects of chronic glucocorticoid excess. In this review we describe and analyze the molecular basis of the drugs targeting the disease at central level, suppressing ACTH secretion, as well as at peripheral level, acting as adrenal inhibitors, or glucocorticoid receptor antagonists. Understanding of the underlying molecular mechanisms in CD and of glucocorticoid biology should promote the development of new targeted and more successful therapies in the future. Indeed, most of the drugs discussed have been tested in limited clinical trials, but there is potential therapeutic benefit in compounds with better specificity for the class of receptors expressed by ACTH-secreting tumors. However, long-term follow-up with management of persistent comorbidities is needed even after successful treatment of CD.
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Affiliation(s)
- Diego Ferone
- Endocrinology, Department of Internal Medicine and Medical Specialties & Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Viale Benedetto XV, 6, 16132, Genoa, Italy,
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Rajendran R, Naik S, Sandeman DD, Nasruddin AB. Pasireotide therapy in a rare and unusual case of plurihormonal pituitary macroadenoma. Endocrinol Diabetes Metab Case Rep 2013; 2013:130026. [PMID: 24616766 PMCID: PMC3922038 DOI: 10.1530/edm-13-0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 08/19/2013] [Indexed: 11/26/2022] Open
Abstract
We report the use of pasireotide in a rare and unusual case of pituitary macroadenoma co-secreting GH, prolactin and ACTH. A 62-year-old Caucasian man presented with impotence. Clinically, he appeared acromegalic and subsequent investigations confirmed GH excess and hyperprolactinaemia. Magnetic resonance imaging (MRI) of pituitary revealed a large pituitary macroadenoma. He underwent trans-sphenoidal surgery and histology confirmed an adenoma with immunohistochemistry positive for ACTH, GH and prolactin. Acromegaly was not cured following surgery and inadequately controlled despite subsequent octreotide therapy. He underwent further debulking pituitary surgery, following which IGF1 levels improved but still high. This time adenoma cells showed immunohistochemistry positivity for ACTH only, following which subsequent investigations confirmed intermittent hypercortisolaemia compatible with pituitary Cushing's disease. We recommended radiotherapy, but in view of the pluripotential nature of the tumour, we proceeded with a trial of s.c. pasireotide therapy on the basis that it may control both his acromegaly and Cushing's disease. After 3 months of pasireotide therapy, his mean GH and IGF1 levels improved significantly, with improvement in his symptoms but intermittent hypercortisolaemia persists. His glycaemic control deteriorated requiring addition of new anti-diabetic medication. MRI imaging showed loss of contrast uptake within the tumour following pasireotide therapy but no change in size. We conclude that our patient has had a partial response to pasireotide therapy. Long-term follow-up studies are needed to establish its safety and efficacy in patients with acromegaly and/or Cushing's disease.
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Affiliation(s)
- Rajesh Rajendran
- Department of Diabetes and Endocrinology The Ipswich Hospital NHS Trust Ipswich, IP4 5PD UK
| | - Sarita Naik
- Department of Diabetes and Endocrinology Royal United Hospital Bath NHS Trust Bath, BA1 3NG UK
| | - Derek D Sandeman
- Department of Diabetes and Endocrinology University Hospital of Southampton NHS Foundation Trust Southampton, SO16 6YD UK
| | - Azraai B Nasruddin
- Department of Diabetes and Endocrinology University Hospital of Southampton NHS Foundation Trust Southampton, SO16 6YD UK
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Fleseriu M, Petersenn S. New avenues in the medical treatment of Cushing's disease: corticotroph tumor targeted therapy. J Neurooncol 2013; 114:1-11. [PMID: 23673515 PMCID: PMC3724972 DOI: 10.1007/s11060-013-1151-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/06/2013] [Indexed: 01/23/2023]
Abstract
Cushing's disease (CD) is a condition of chronic hypercortisolism caused by an adrenocorticotropic hormone-secreting pituitary adenoma. First-line transsphenoidal surgery is not always curative and disease sometimes recurs. Radiotherapy often requires months or years to be effective, and is also not curative in many cases. Consequently, effective medical therapies for patients with CD are needed. Corticotroph adenomas frequently express both dopamine (D2) and somatostatin receptors (predominantly sstr5). Pasireotide, a somatostatin analog with high sstr5 binding affinity, has shown urinary free cortisol (UFC) reductions in most patients with CD in a large phase 3 trial, with UFC normalization and tumor shrinkage in a subset of patients. Adverse events were similar to other somatostatin analogs, with the exception of the degree and severity of hyperglycemia. Two small trials (one prospective and one retrospective) have suggested that cabergoline, a D2 receptor agonist, could be effective in normalizing UFC, but current long-term data results are conflicting. Combination treatment with pasireotide plus cabergoline and the adrenal steroidogenesis inhibitor ketoconazole has been successful, but further investigation in larger trials is necessary. Retinoic acid also showed interesting results in a recent very small prospective study. Glucocorticoid receptor blockade with mifepristone has recently demonstrated improvement in signs and symptoms of Cushing's and glycemic control; however, this modality does not address the etiology of the disease and has inherent adverse events related to its mechanism of action. Pituitary-targeted medical therapies will soon play a more prominent role in treating CD, and may potentially become first-line medical therapy when surgery fails or is contraindicated.
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Affiliation(s)
- Maria Fleseriu
- Departments of Medicine and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University, Portland, OR 97239, USA.
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Theodoropoulou M, Stalla GK. Somatostatin receptors: from signaling to clinical practice. Front Neuroendocrinol 2013; 34:228-52. [PMID: 23872332 DOI: 10.1016/j.yfrne.2013.07.005] [Citation(s) in RCA: 237] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 06/13/2013] [Accepted: 07/12/2013] [Indexed: 02/08/2023]
Abstract
Somatostatin is a peptide with a potent and broad antisecretory action, which makes it an invaluable drug target for the pharmacological management of pituitary adenomas and neuroendocrine tumors. Somatostatin receptors (SSTR1, 2A and B, 3, 4 and 5) belong to the G protein coupled receptor family and have a wide expression pattern in both normal tissues and solid tumors. Investigating the function of each SSTR in several tumor types has provided a wealth of information about the common but also distinct signaling cascades that suppress tumor cell proliferation, survival and angiogenesis. This provided the rationale for developing multireceptor-targeted somatostatin analogs and combination therapies with signaling-targeted agents such as inhibitors of the mammalian (or mechanistic) target of rapamycin (mTOR). The ability of SSTR to internalize and the development of rabiolabeled somatostatin analogs have improved the diagnosis and treatment of neuroendocrine tumors.
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Affiliation(s)
- Marily Theodoropoulou
- Department of Endocrinology, Max Planck Institute of Psychiatry, Kraepelinstrasse 10, 80804 Munich, Germany.
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