1
|
Riedmeier M, Antonini SRR, Brandalise S, Costa TEJB, Daiggi CM, de Figueiredo BC, de Krijger RR, De Sá Rodrigues KE, Deal C, Del Rivero J, Engstler G, Fassnacht M, Fernandes Luiz Canali GC, Molina CAF, Gonc EN, Gültekin M, Haak HR, Guran T, Hendriks Allaird EJ, Idkowiak J, Kuhlen M, Malkin D, Meena JP, Pamporaki C, Pinto E, Puglisi S, Ribeiro RC, Thompson LDR, Yalcin B, Van Noesel M, Wiegering V. International consensus on mitotane treatment in pediatric patients with adrenal cortical tumors: indications, therapy, and management of adverse effects. Eur J Endocrinol 2024; 190:G15-G24. [PMID: 38552173 DOI: 10.1093/ejendo/lvae038] [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: 11/21/2023] [Revised: 01/17/2024] [Accepted: 02/19/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE Mitotane is an important cornerstone in the treatment of pediatric adrenal cortical tumors (pACC), but experience with the drug in the pediatric age group is still limited and current practice is not guided by robust evidence. Therefore, we have compiled international consensus statements from pACC experts on mitotane indications, therapy, and management of adverse effects. METHODS A Delphi method with 3 rounds of questionnaires within the pACC expert consortium of the international network groups European Network for the Study of Adrenal Tumors pediatric working group (ENSAT-PACT) and International Consortium of pediatric adrenocortical tumors (ICPACT) was used to create 21 final consensus statements. RESULTS We divided the statements into 4 groups: environment, indications, therapy, and adverse effects. We reached a clear consensus for mitotane treatment for advanced pACC with stages III and IV and with incomplete resection/tumor spillage. For stage II patients, mitotane is not generally indicated. The timing of initiating mitotane therapy depends on the clinical condition of the patient and the setting of the planned therapy. We recommend a starting dose of 50 mg/kg/d (1500 mg/m²/d) which can be increased up to 4000 mg/m2/d. Blood levels should range between 14 and 20 mg/L. Duration of mitotane treatment depends on the clinical risk profile and tolerability. Mitotane treatment causes adrenal insufficiency in virtually all patients requiring glucocorticoid replacement shortly after beginning. As the spectrum of adverse effects of mitotane is wide-ranging and can be life-threatening, frequent clinical and neurological examinations (every 2-4 weeks), along with evaluation and assessment of laboratory values, are required. CONCLUSIONS The Delphi method enabled us to propose an expert consensus statement, which may guide clinicians, further adapted by local norms and the individual patient setting. In order to generate evidence, well-constructed studies should be the focus of future efforts.
Collapse
Affiliation(s)
- Maria Riedmeier
- University Hospital Würzburg, Department of Pediatrics, Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Wuerzburg, Wuerzburg 97080, Germany
| | - Sonir R R Antonini
- Department of Pediatrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo 14051-200, Brazil
| | - Silvia Brandalise
- Boldrini Children's Hospital, Department of Pediatrics, São Paulo 13083-210, Brazil
| | - Tatiana El Jaick B Costa
- Service of Pediatric Oncology, Hospital Infantil Joana de Gusmão, Florianópolis, SC 88025-301, Brazil
| | - Camila M Daiggi
- Boldrini Children's Hospital, Department of Pediatrics, São Paulo 13083-210, Brazil
| | | | - Ronald R de Krijger
- Department of Pathology, University Medical Center Utrecht, Utrecht 3584 CS, The Netherlands
| | | | - Cheri Deal
- Research Center, CHU Sainte-Justine and University of Montreal, Montreal, Québec H3T 1C5, Canada
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, United States
| | - Gernot Engstler
- St. Anna Kinderspital, Department of Pediatrics, Medical University Vienna, Vienna 1090, Austria
| | - Martin Fassnacht
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg 97080, Germany
| | | | - Carlos A Fernandes Molina
- Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao 15 Paulo, Ribeirao Preto, Sao Paulo 14049-900, Brazil
| | - Elmas Nazli Gonc
- Department of Pediatric Endocrinology, Faculty of Medicine, Hacettepe University, Ankara 06230, Turkey
| | - Melis Gültekin
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
| | - Harm R Haak
- Department of Internal Medicine, Máxima MC, Eindhoven 5631 BM/Veldhoven 5504 DB, The Netherlands
- CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht University, Maastricht 616 6200 MD, The Netherlands
| | - Tulay Guran
- Department of Paediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul 34722, Turkey
| | - Emile J Hendriks Allaird
- Department of Paediatrics, University of Cambridge, Cambridge CB20QQ, United Kingdom
- Department of Paediatric Endocrinology and Diabetes, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB20QQ, United Kingdom
| | - Jan Idkowiak
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B152TT, United Kingdom
- Department of Endocrinology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B46NH, United Kingdom
| | - Michaela Kuhlen
- Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Augsburg 86135, Germany
| | - David Malkin
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario M5G1X8, Canada
| | - Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, Mother & Child Block, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, TU Dresden, Dresden 01307, Germany
| | - Emilia Pinto
- St. Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Soraya Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano 10043, Italy
| | - Raul C Ribeiro
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Lester D R Thompson
- Pathology, Head and Neck Pathology Consultations, Woodland Hills, CA 91364, United States
| | - Bilgehan Yalcin
- Department of Pediatric Oncology, Faculty of Medicine, Hacettepe University, Ankara 06230, Turkey
| | - Max Van Noesel
- Pediatric Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht 3584 CS, The Netherlands
- Division Imaging & Cancer, University Medical Center Utrecht, Utrecht 3584 CS, The Netherlands
| | - Verena Wiegering
- University Hospital Würzburg, Department of Pediatrics, Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Wuerzburg, Wuerzburg 97080, Germany
| |
Collapse
|
2
|
Savage MO, Ferrigno R. Paediatric Cushing's disease: long-term outcome and predictors of recurrence. Front Endocrinol (Lausanne) 2024; 15:1345174. [PMID: 38318299 PMCID: PMC10838966 DOI: 10.3389/fendo.2024.1345174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024] Open
Abstract
Paediatric Cushing's disease (CD) is characterized by excess ACTH secretion from a pituitary adenoma, leading to hypercortisolism. It has approximately 5% of the incidence of adult CD and is a rare disorder in the paediatric age range. The four most specific presenting features of hypercortisolism are: change in facial appearance, weight gain, decreased linear growth and virilisation shown by advanced pubic hair for the stage of breast development or testicular volume. The main diagnostic priority is the demonstration of hypercortisolism followed by distinction between its ACTH-dependent and ACTH-independent origin, thus leading to identification of aetiology. All treatment options aim to resolve or control hypercortisolism. Consensus favours transsphenoidal (TSS) pituitary surgery with selective removal of the corticotroph adenoma. TSS in children with CD is now well established and induces remission in 70-100% of cases. External pituitary radiotherapy and bilateral adrenalectomy are second-line therapeutic approaches in subjects not responding to TSS. Long-term medical treatment is less frequently adopted. Recurrence in paediatric CD cases is low with factors predicting relapse being higher post-TSS cortisol and ACTH levels and rapid recovery of the hypothalamic-pituitary-adrenal axis after TSS. In summary, complete excision of the microadenoma with histological and biochemical evidence for this, predicts a low rate of recurrence of CD. Due to the need for rapid diagnosis and management to avoid the burden of prolonged exposure to hypercortisolism, tertiary university centres comprising both paediatric and adult endocrinology specialists together with experienced pituitary surgery and, eventually, radiotherapy units are recommended for referral of these patients.
Collapse
Affiliation(s)
- Martin O. Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School for Medicine & Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Rosario Ferrigno
- UOSD di Auxologia e Endocrinologia, AORN Santobono-Pausilipon, Napoli, Italy
| |
Collapse
|
3
|
Martino M, Aboud N, Lucchetti B, Salvio G, Arnaldi G. An evaluation of pharmacological options for Cushing's disease: what are the state-of-the-art options? Expert Opin Pharmacother 2023; 24:557-576. [PMID: 36927238 DOI: 10.1080/14656566.2023.2192349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Untreated Cushing's syndrome (CS) is associated with significant morbidity and mortality. Cortisol normalization is a key goal to treatment. Pituitary surgery remains the first-line approach for Cushing's disease, but sometimes it is impracticable, unsuccessful, or complicated by recurrence. Medical therapy has been historically considered a palliative. However, in the latest years, interest on this topic has grown due to both the availability of new drugs and the reevaluation of the old, commonly used drugs in clinical practice. AREAS COVERED In this article, we will discuss the current options and future directions of medical therapy for CS, aiming at fitting best patients' features. An extensive literature search regarding already approved and investigational principles was conducted (PubMed, ClinicalTrials.gov. Available drugs include inhibitors of ACTH secretion, steroidogenesis inhibitors, and glucocorticoid receptor antagonists; drugs acting at different levels can be also combined in uncontrolled patients. EXPERT OPINION Since there is still no standardized pharmacological approach and the superiority of one drug over another has not been established yet in the absence of comparative studies, each time clinicians' choices should be patient-tailored. Age, gender, tumor features, severity of hypercortisolism, comorbidities/complications, rapidity of action, side effects, drug-drug interactions, contraindications, availability, patients' preferences, and costs should be all considered.
Collapse
Affiliation(s)
- Marianna Martino
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Nairus Aboud
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Beatrice Lucchetti
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Gianmaria Salvio
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| | - Giorgio Arnaldi
- Division of Endocrinology and Metabolic Diseases, Department of Clinical and Molecular Sciences (DISCLIMO). Polytechnic University of Marche Ancona, Italy
| |
Collapse
|
4
|
Steenaard RV, Rutjens M, Ettaieb MHT, van Noesel MM, Haak HR. EDP-mitotane in children: reassuring evidence of reversible side-effects and neurotoxicity. Discov Oncol 2022; 13:25. [PMID: 35435506 PMCID: PMC9016089 DOI: 10.1007/s12672-022-00486-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/16/2022] [Indexed: 12/14/2022] Open
Abstract
Adrenocortical carcinoma affects one in 5 million children each year. Since prognosis for children older than 4 years is limited, clinicians often choose aggressive treatment with etoposide, doxorubicin, cisplatin (EDP) and mitotane after resection. However, little is known about the impact of EDP-mitotane in children. We provide an overview of case-reports and case series listing side-effects and neurotoxicity of EDP-mitotane in children. Fourteen studies were identified describing a range of gastro-intestinal, endocrine, developmental and neuropsychological side-effects. Neurotoxicity included motor- and speech delay, decreased concentration and lower school performance. These side-effects appear to be reversible after mitotane discontinuation. We have added our own experience with a 10 year old girl with advanced adrenocortical carcinoma treated with EDP and 2 years of mitotane after irradical resection. She developed an impactful, but reversible, decrease in cognitive development measured by a standardized neuropsychological assessment before, during and after mitotane therapy. This decrease was mostly measurable in terms of decreased processing speed and concentration and a significant drop in school performance. Combined with fatigue and insecurity, this caused problems in short-term memory and the need to change her school type. In conclusion, EDP-mitotane is associated with several side-effects including neurotoxicity in pediatric cases, all reversible after mitotane discontinuation.
Collapse
Affiliation(s)
- Rebecca V Steenaard
- Department of Internal Medicine, Máxima MC, Ds. Th. Fliedernerstraat 1, Eindhoven/Veldhoven, 5631 BM , The Netherlands.
- CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht University, Maastricht, The Netherlands.
| | - Marieke Rutjens
- Department of Internal Medicine, Máxima MC, Ds. Th. Fliedernerstraat 1, Eindhoven/Veldhoven, 5631 BM , The Netherlands
| | | | - Max M van Noesel
- Princes Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Division of Cancer and Imaging, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Harm R Haak
- Department of Internal Medicine, Máxima MC, Ds. Th. Fliedernerstraat 1, Eindhoven/Veldhoven, 5631 BM , The Netherlands
- CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| |
Collapse
|
5
|
Ferrigno R, Hasenmajer V, Caiulo S, Minnetti M, Mazzotta P, Storr HL, Isidori AM, Grossman AB, De Martino MC, Savage MO. Paediatric Cushing's disease: Epidemiology, pathogenesis, clinical management and outcome. Rev Endocr Metab Disord 2021; 22:817-835. [PMID: 33515368 PMCID: PMC8724222 DOI: 10.1007/s11154-021-09626-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 12/12/2022]
Abstract
Cushing's disease (CD) is rare in paediatric practice but requires prompt investigation, diagnosis and therapy to prevent long-term complications. Key presenting features are a change in facial appearance, weight gain, growth failure, virilization, disturbed puberty and psychological disturbance. Close consultation with an adult endocrinology department is recommended regarding diagnosis and therapy. The incidence of CD, a form of ACTH-dependent Cushing's syndrome (CS), is equal to approximately 5% of that seen in adults. The majority of ACTH-secreting adenomas are monoclonal and sporadic, although recent studies of pituitary tumours have shown links to several deubiquitination gene defects. Diagnosis requires confirmation of hypercortisolism followed by demonstration of ACTH-dependence. Identification of the corticotroph adenoma by pituitary MRI and/or bilateral inferior petrosal sampling for ACTH may contribute to localisation before pituitary surgery. Transsphenoidal surgery (TSS) with selective microadenomectomy is first-line therapy, followed by external pituitary irradiation if surgery is not curative. Medical therapy to suppress adrenal steroid synthesis is effective in the short-term and bilateral adrenalectomy should be considered in cases unfit for TSS or radiotherapy or when urgent remission is needed after unsuccessful surgery. TSS induces remission of hypercortisolism and improvement of symptoms in 70-100% of cases, particularly when performed by a surgeon with experience in children. Post-TSS complications include pituitary hormone deficiencies, sub-optimal catch-up growth, and persisting excess of BMI. Recurrence of hypercortisolism following remission is recognised but infrequent, being less common than in adult CD patients. With experienced specialist medical and surgical care, the overall prognosis is good. Early referral to an experienced endocrine centre is advised.
Collapse
Affiliation(s)
- Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Federico II University, Naples, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvana Caiulo
- Primary care Paediatrician, Local Health Unit of Brindisi, Brindisi, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Paola Mazzotta
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, London, UK
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Ashley B Grossman
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, London, UK
- Royal Free Hospital ENETs Centre of Excellence, London, UK
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | | | - Martin O Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, London, UK.
- Centre for Endocrinology, William Harvey Research Institute, Charterhouse Square, London, EC1M 6BQ, UK.
| |
Collapse
|
6
|
Zhao N, Yang X, Li C, Ma J, Yin X. Efficacy and safety of pasireotide for Cushing's disease: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23824. [PMID: 33371162 PMCID: PMC7748338 DOI: 10.1097/md.0000000000023824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cushing's disease (CD) is associated with increased risk of mortality, myocardial infarction, stroke, peptic ulcers, fractures and infections. The prevalence of CD is nearly 40 per million and higher in women than in men. When surgery has failed, is not feasible, or has been refused, pharmacotherapy can be considered a valuable option. Pasireotide is the first medical therapy officially approved for adult patients with CD. We will conduct a comprehensive systematic review and meta-analysis to systematically evaluate the efficacy and safety of pasireotide for CD. METHODS Five English databases (PubMed, Web of Science, Embase, Cochrane Library, and OVID) and 3 Chinese databases (China National Knowledge Infrastructure, China Science and Technology Journal Database, and Chinese Biomedical Literature Database) will be searched from their respective inception of databases to December 2020. Two reviewers will select articles, extract data and assess the risk of bias independently. Any disagreement will be resolved by discussion with the third reviewer. Review Manager 5.3 software will be used for data synthesis. The Cochrane risk of bias assessment tool will be used to evaluate the bias risk. RESULTS This systematic review and meta-analysis will conduct a comprehensive literature search and provide a systematic synthesis of current published data to explore the efficacy and safety of pasireotide for CD. CONCLUSIONS This systematic review and meta-analysis will provide clinical evidence for the efficacy and safety of pasireotide for CD, and inform our understanding of the value of pasireotide in improving CD clinical signs and symptoms. The conclusions drawn from this study may be beneficial to patients, clinicians, and health-related policy makers. STUDY REGISTRATION NUMBER INPLASY2020110070.
Collapse
|
7
|
Abstract
Endogenous Cushing's syndrome is a chronic disease associated with increased morbidity and mortality if not appropriately treated. Recurrence and/or persistence of hypercortisolemia after surgical treatment, especially for Cushing's disease, are high, and long-term medical treatment is used to decrease cortisol levels and risk of metabolic comorbidities. Medical treatment is also often required while waiting for radiation effects to take place. In some cases, severe or life-threatening hypercortisolism must be urgently and medically treated, via intravenous medications or with combination therapy, before patients can undergo surgery. In the last decade, medical treatment has progressed from a few steroidogenesis inhibitors to three novel drug groups: new inhibitors for steroidogenic enzymes with possibly fewer side effects, pituitary-directed drugs that aim to inhibit the pathophysiological pathways of Cushing's disease, and glucocorticoid receptor antagonists that block cortisol's action. Understanding the pathophysiology of Cushing's syndrome has also led to the identification of potential targets that may decrease adrenocorticotrophic hormone and/or cortisol excess, and/or decrease tumor cell proliferation, and induce senescence or apoptosis. We provide here a review of current and near-future medical options to treat Cushing's syndrome, and discuss updates on clinical trials and the efficacy and safety of novel or in-development drugs, as well as future potential targets.
Collapse
|