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Aksoy YA, Xu B, Viswanathan K, Ahadi MS, Al Ghuzlan A, Alzumaili B, Bani MA, Barletta JA, Chau N, Chou A, Clarkson A, Clifton-Bligh RJ, De Leo A, Dogan S, Ganly I, Ghossein R, Gild ML, Glover AR, Hadoux J, Lamartina L, Lubin DJ, Magliocca K, Najdawi F, Nigam A, Papachristos A, Repaci A, Robinson BG, Sheen A, Shi Q, Sidhu SB, Sioson L, Solaroli E, Sywak MS, Tallini G, Tsang V, Turchini J, Untch BR, Gill AJ, Fuchs TL. Novel prognostic nomogram for predicting recurrence-free survival in medullary thyroid carcinoma. Histopathology 2024; 84:947-959. [PMID: 38253940 DOI: 10.1111/his.15141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/18/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024]
Abstract
AIMS Recently, there have been attempts to improve prognostication and therefore better guide treatment for patients with medullary thyroid carcinoma (MTC). In 2022, the International MTC Grading System (IMTCGS) was developed and validated using a multi-institutional cohort of 327 patients. The aim of the current study was to build upon the findings of the IMTCGS to develop and validate a prognostic nomogram to predict recurrence-free survival (RFS) in MTC. METHODS AND RESULTS Data from 300 patients with MTC from five centres across the USA, Europe, and Australia were used to develop a prognostic nomogram that included the following variables: age, sex, AJCC stage, tumour size, mitotic count, necrosis, Ki67 index, lymphovascular invasion, microscopic extrathyroidal extension, and margin status. A process of 10-fold cross-validation was used to optimize the model's performance. To assess discrimination and calibration, the area-under-the-curve (AUC) of a receiver operating characteristic (ROC) curve, concordance-index (C-index), and dissimilarity index (D-index) were calculated. Finally, the model was externally validated using a separate cohort of 87 MTC patients. The model demonstrated very strong performance, with an AUC of 0.94, a C-index of 0.876, and a D-index of 19.06. When applied to the external validation cohort, the model had an AUC of 0.9. CONCLUSIONS Using well-established clinicopathological prognostic variables, we developed and externally validated a robust multivariate prediction model for RFS in patients with resected MTC. The model demonstrates excellent predictive capability and may help guide decisions on patient management. The nomogram is freely available online at https://nomograms.shinyapps.io/MTC_ML_DFS/.
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Affiliation(s)
- Yagiz A Aksoy
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Bin Xu
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kartik Viswanathan
- Department of Pathology, Emory University Hospital Midtown, Atlanta, GA, USA
| | - Mahsa S Ahadi
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Abir Al Ghuzlan
- Medical Pathology and Biology Department, Gustave Roussy Campus Cancer, Villejuif, France
| | - Bayan Alzumaili
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Mohamed-Amine Bani
- Medical Pathology and Biology Department, Gustave Roussy Campus Cancer, Villejuif, France
| | - Justine A Barletta
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Chau
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Angela Chou
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Adele Clarkson
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Roderick J Clifton-Bligh
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Antonio De Leo
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna Medical Center, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Snjezana Dogan
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ian Ganly
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald Ghossein
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matti L Gild
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Anthony R Glover
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Julien Hadoux
- Endocrine Oncology, Gustave Roussy Campus Cancer, Villejuif, France
| | - Livia Lamartina
- Endocrine Oncology, Gustave Roussy Campus Cancer, Villejuif, France
| | - Daniel J Lubin
- Department of Pathology, Emory University Hospital Midtown, Atlanta, GA, USA
| | - Kelly Magliocca
- Department of Pathology, Emory University Hospital Midtown, Atlanta, GA, USA
| | - Fedaa Najdawi
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aradhya Nigam
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alex Papachristos
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, St Leonards, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Andrea Repaci
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Bruce G Robinson
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, St Leonards, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Amy Sheen
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Qiuying Shi
- Department of Pathology, Emory University Hospital Midtown, Atlanta, GA, USA
| | - Stan B Sidhu
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, St Leonards, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Loretta Sioson
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Erica Solaroli
- Endocrinology Unit, Azienda USL di Bologna, Bologna, Italy
| | - Mark S Sywak
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Giovanni Tallini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna Medical Center, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Venessa Tsang
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - John Turchini
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Douglass Hanly Moir Pathology, Macquarie Park, New South Wales, Australia
| | - Brian R Untch
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anthony J Gill
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Talia L Fuchs
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Douglass Hanly Moir Pathology, Macquarie Park, New South Wales, Australia
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Deschler-Baier B, Konda B, Massarelli E, Hu MI, Wirth LJ, Xu X, Wright J, Clifton-Bligh RJ. Clinical Activity of Selpercatinib in RET-mutant Pheochromocytoma. J Clin Endocrinol Metab 2024:dgae283. [PMID: 38661071 DOI: 10.1210/clinem/dgae283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/15/2024] [Accepted: 04/22/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Activating RET alterations have been reported in a variety of solid tumors, including pheochromocytoma where they occur both sporadically and as part of familial multiple endocrine neoplasia type 2 (MEN2) syndromes. Selpercatinib is a first-in-class, highly selective, and potent small molecule RET kinase inhibitor that has demonstrated marked and durable anti-tumor activity in diverse RET-activated solid tumors in the LIBRETTO-001 study (NCT03157128). METHODS We describe the first six pheochromocytoma cases treated with selpercatinib in the LIBRETTO-001 study. RESULTS Of the six patients (one sporadic and five reported as part of MEN2 syndromes) in this case report, four had a partial response/complete response and two had stable disease per independent review committee. Treatment duration ranged from 9.2 months to more than 56.4 months. The safety profile of treatment was consistent with selpercatinib in other indications. CONCLUSION These data support selpercatinib as an effective therapy against RET-mutant pheochromocytoma, adding to the diversity of RET-activated tumor types that may benefit from targeted RET inhibition.
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Affiliation(s)
| | - Bhavana Konda
- The Ohio State University, Comprehensive Cancer Center, Columbus, OH, USA
| | | | - Mimi I Hu
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Xiaojian Xu
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Roderick J Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
- Kolling Institute of Medical Research, University of Sydney, NSW, Australia
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Davidoff DF, De Abreu Lourenco R, Tsang VHM, Benn DE, Clifton-Bligh RJ. Outcomes of SDHB pathogenic variant carriers: A systematic review and meta-analysis. J Clin Endocrinol Metab 2024:dgae233. [PMID: 38605204 DOI: 10.1210/clinem/dgae233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/29/2024] [Accepted: 04/08/2024] [Indexed: 04/13/2024]
Abstract
CONTEXT Carriers of germline pathogenic variants (PV) in succinate dehydrogenase type B (SDHB) are at increased risk of developing pheochromocytomas and paragangliomas (PPGL). Understanding their outcomes can guide recommendations for risk assessment and early detection. OBJECTIVE We performed a systematic review and meta-analysis of the following outcomes in SDHB PV carriers: age-specific risk of developing tumors, metastatic progression, second primary tumor development, and mortality. MATERIALS AND METHODS Pubmed, MEDLINE and EMBASE were searched. Sixteen studies met the inclusion criteria and were sorted into four outcome categories: age-specific penetrance, metastatic disease, risk of second tumour and mortality. We assessed heterogeneity and performed a meta-analysis across studies using a random effects model with the DerSimonian and Laird method. RESULTS Penetrance of PPGL for non-proband/non-index SDHB PV carriers by age 20 was 4% (95% CI, 3%-6%), 11% (95% CI, 8%-15%) by age 40, 24% (95% CI, 19%-31%) by age 60 and 35% (95% CI, 25%-47%) by age 80. The overall risk of metastatic disease for non-proband/non-index carriers with PPGL was 9% (95% CI, 5-16%) per lifetime. In all affected cases (combining both proband/index and non-proband/non-index carriers with tumors), the risk of a second tumor was 24% (95% CI, 18-31%) and all cause 5-year mortality was 18% (95% CI 6-40%). CONCLUSION Penetrance for PPGL in SDHB PV carriers increases linearly with age. Affected carriers are at risk of developing and dying from metastatic disease, or of developing second tumors. Lifelong surveillance is appropriate.
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Affiliation(s)
- Dahlia F Davidoff
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
- University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Haymarket, Sydney, Australia
| | - Venessa H M Tsang
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
- University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Diana E Benn
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
- University of Sydney, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
- University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
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4
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Gild ML, Kumar S, Fuchs TL, Glover A, Sidhu S, Sywak M, Tsang V, Gill AJ, Robinson BG, Schembri G, Clifton-Bligh RJ, Hoang J. The Clinical Utility of Gallium-68-DOTATATE Positron Emission Tomography Scanning in Medullary Thyroid Cancer. Endocr Pract 2024; 30:218-224. [PMID: 38103829 DOI: 10.1016/j.eprac.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE Somatostatin receptor (SST) functional imaging with positron emission tomography (PET)/computed tomography (CT) has broadened the diagnostic and staging capabilities for medullary thyroid cancer (MTC). Gallium-68 (68Ga)-DOTA-conjugated peptide (Tyr3)-octreotate (DOTATATE) is a radiotracer with a high affinity for type 2 SSTs expressed in several, but not all, MTCs. The utility of 68Ga-DOTATATE PET/CT and 18fluorine-labeled fluoro-2-deoxy-D-glucose (18F-FDG)-PET/CT imaging in predicting MTC prognosis is also unknown. METHODS In this single-center retrospective study, 103 of patients with MTC underwent assessment of SST2 and SST5 immunohistochemistry (IHC). A subgroup of 37 patients received 68Ga-DOTATATE PET/CT imaging, and 13 received contemporaneous 18F-FDG-PET/CT imaging. The maximum standardized uptake value (SUV), mean SUV, metabolic tumor volume, and total lesion activity (TLA) were assessed. RESULTS Forty-two patients (41%) demonstrated positive expression of SST2, and 45 (44%) had a positive SST5 IHC result. Seventeen patients (17%) expressed both SST2 and SST5. No survival advantage was identified with SST2 or SST5 IHC positivity. No correlation was noted between the maximum SUV, mean SUV, metabolic tumor volume, or TLA and SST2 and/or SST5 expression by IHC. Shorter survival was associated with a TLA of >20 (P = .04). A RET-negative status also appeared to have shorter survival, although this may be because the small numbers did not reach statistical significance (P = .12). CONCLUSION Assessment of TLA from 68Ga-DOTATATE PET/CT may predict survival. SST2 IHC was not correlated with 68Ga-DOTATATE avidity. Metastatic disease may be optimally assessed by concurrent 18F-FDG and 68Ga-DOTATATE imaging.
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Affiliation(s)
- Matti L Gild
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
| | - Shejil Kumar
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia
| | - Talia L Fuchs
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Anthony Glover
- Department of Endocrine Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Stan Sidhu
- Department of Endocrine Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Mark Sywak
- Department of Endocrine Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Venessa Tsang
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Anthony J Gill
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Bruce G Robinson
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Geoffrey Schembri
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jeremy Hoang
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, Australia
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5
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Chou A, Qiu MR, Crayton H, Wang B, Ahadi MS, Turchini J, Clarkson A, Sioson L, Sheen A, Singh N, Clifton-Bligh RJ, Robinson BG, Gild ML, Tsang V, Leong D, Sidhu SB, Sywak M, Delbridge L, Aniss A, Wright D, Graf N, Kumar A, Rathi V, Benitez-Aguirre P, Glover AR, Gill AJ. A Detailed Histologic and Molecular Assessment of the Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma. Mod Pathol 2023; 36:100329. [PMID: 37716505 DOI: 10.1016/j.modpat.2023.100329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/20/2023] [Accepted: 09/07/2023] [Indexed: 09/18/2023]
Abstract
Diffuse sclerosing variant papillary thyroid carcinoma (DS-PTC) is characterized clinically by a predilection for children and young adults, bulky neck nodes, and pulmonary metastases. Previous studies have suggested infrequent BRAFV600E mutation but common RET gene rearrangements. Using strict criteria, we studied 43 DS-PTCs (1.9% of unselected PTCs in our unit). Seventy-nine percent harbored pathogenic gene rearrangements involving RET, NTRK3, NTRK1, ALK, or BRAF; with the remainder driven by BRAFV600E mutations. All 10 pediatric cases were all gene rearranged (P = .02). Compared with BRAFV600E-mutated tumors, gene rearrangement was characterized by psammoma bodies involving the entire lobe (P = .038), follicular predominant or mixed follicular architecture (P = .003), pulmonary metastases (24% vs none, P = .04), and absent classical, so-called "BRAF-like" atypia (P = .014). There was no correlation between the presence of gene rearrangement and recurrence-free survival. Features associated with persistent/recurrent disease included pediatric population (P = .030), gene-rearranged tumors (P = .020), microscopic extrathyroidal extension (P = .009), metastases at presentation (P = .007), and stage II disease (P = .015). We conclude that DS-PTC represents 1.9% of papillary thyroid carcinomas and that actionable gene rearrangements are extremely common in DS-PTC. DS-PTC can be divided into 2 distinct molecular subtypes and all BRAFV600E-negative tumors (1.5% of papillary thyroid carcinomas) are driven by potentially actionable oncogenic fusions.
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Affiliation(s)
- Angela Chou
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Cancer Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia.
| | - Min Ru Qiu
- Department of Anatomical Pathology, SydPATH, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; University of NSW, Randwick, New South Wales, Australia
| | - Henry Crayton
- Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Bin Wang
- Department of Anatomical Pathology, SydPATH, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Mahsa S Ahadi
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Cancer Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - John Turchini
- Department of Anatomical Pathology, Douglass Hanly Moir Pathology (A Sonic Healthcare Practice), Macquarie Park, New South Wales, Australia; Discipline of Pathology, Macquarie Medical School, Macquarie University, New South Wales, Australia
| | - Adele Clarkson
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Cancer Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Loretta Sioson
- Cancer Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Amy Sheen
- Cancer Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Nisha Singh
- NSW Health Pathology, Cytogenetics Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Roderick J Clifton-Bligh
- Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Bruce G Robinson
- Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Matti L Gild
- Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Venessa Tsang
- Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - David Leong
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, University of Sydney, New South Wales, Australia
| | - Stanley B Sidhu
- Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, University of Sydney, New South Wales, Australia
| | - Mark Sywak
- Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, University of Sydney, New South Wales, Australia
| | - Leigh Delbridge
- Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, University of Sydney, New South Wales, Australia
| | - Ahmad Aniss
- Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, University of Sydney, New South Wales, Australia
| | - Dale Wright
- Cytogenetics Department, Sydney Genome Diagnostics, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Specialty of Genome Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Nicole Graf
- Histopathology Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Amit Kumar
- Diagnostic Genomics, Monash Health Pathology, Monash Health, Clayton, Victoria, Australia
| | - Vivek Rathi
- LifeStrands Genomics, Mount Waverley, Victoria, Australia
| | - Paul Benitez-Aguirre
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Anthony R Glover
- Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, University of Sydney, New South Wales, Australia; The Kinghorn Cancer Centre, Garvan Institute of Medical Research, St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Darlinghurst, New South Wales, Australia.
| | - Anthony J Gill
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Faculty of Medicine and Health Sciences and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia; Cancer Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia.
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Abstract
A personalized approach to the management of medullary thyroid cancer (MTC) presents several challenges; however, in the past decade significant progress has been made in both diagnostic and treatment modalities. Germline rearranged in transfection (RET) testing in multiple endocrine neoplasia 2 and 3, and somatic RET testing in sporadic MTC have revolutionized the treatment options available to patients. Positron emission tomography imaging with novel radioligands has improved characterization of disease and a new international grading system can predict prognosis. Systemic therapy for persistent and metastatic disease has evolved significantly with targeted kinase therapy especially for those harboring germline or somatic RET variants. Selpercatinib and pralsetinib are highly selective RET kinase inhibitors that have shown improved progression-free survival with better tolerability than outcomes seen in earlier multikinase inhibitor studies. Here we discuss changes in paradigms for MTC patients: from determining RET alteration status upfront to novel techniques for the evaluation of this heterogenous disease. Successes and challenges with kinase inhibitor use will illustrate how managing this rare malignancy continues to evolve.
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Affiliation(s)
- Matti L Gild
- Faculty of Health and Medicine, University of Sydney, Sydney 2006, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney 2065, Australia
| | - Roderick J Clifton-Bligh
- Faculty of Health and Medicine, University of Sydney, Sydney 2006, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney 2065, Australia
| | - Lori J Wirth
- Department of Medicine, Massachusetts General Hospital, & Harvard Medical School, Boston 02114, USA
| | - Bruce G Robinson
- Faculty of Health and Medicine, University of Sydney, Sydney 2006, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney 2065, Australia
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Davidoff DF, Lim ES, Benn DE, Subramaniam Y, Dorman E, Burgess JR, Akker SA, Clifton-Bligh RJ. Distortion in transmission of pathogenic SDHB- and SDHD-mutated alleles from parent to offspring. Endocr Relat Cancer 2023; 30:e220233. [PMID: 36786389 DOI: 10.1530/erc-22-0233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/14/2023] [Indexed: 02/15/2023]
Abstract
Phaeochromocytoma and paraganglioma are highly heritable tumours; half of those associated with a germline mutation are caused by mutations in genes for Krebs's cycle enzymes, including succinate dehydrogenase (SDH). Inheritance of SDH alleles is assumed to be Mendelian (probability of 50% from each parent). The departure from transmission of parental alleles in a ratio of 1:1 is termed transmission ratio distortion (TRD). We sought to assess whether TRD occurs in the transmission of SDHB pathogenic variants (PVs). This study was conducted with 41 families of a discovery cohort from Royal North Shore Hospital, Australia, and 41 families from a validation cohort from St. Bartholomew's Hospital, United Kingdom (UK). Inclusion criteria were a clinically diagnosed SDHB PV and a pedigree available for at least two generations. TRD was assessed in 575 participants with the exact binomial test. The transmission ratio for SDHB PV was 0.59 (P = 0.005) in the discovery cohort, 0.67 (P < 0.001) in the validation cohort, and 0.63 (P < 0.001) in the combined cohort. No parent-of-origin effect was observed. TRD remained significant after adjusting for potential confounders: 0.67 (P < 0.001) excluding families with incomplete family size data; 0.58 (P < 0.001) when probands were excluded. TRD was also evident for SDHD PVs in a cohort of 81 patients from 13 families from the UK. The reason for TRD of SDHB and SDHD PVs is unknown, but we hypothesize a survival advantage selected during early embryogenesis. The existence of TRD for SDHB and SDHD has implications for reproductive counselling, and further research into the heterozygote state.
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Affiliation(s)
- Dahlia F Davidoff
- Cancer Genetics, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- University of Sydney, Camperdown, New South Wales, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Eugénie S Lim
- Department of Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Endocrinology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Diana E Benn
- Cancer Genetics, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- University of Sydney, Camperdown, New South Wales, Australia
| | - Yuvanaa Subramaniam
- Department of Endocrinology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Eleanor Dorman
- Department of Endocrinology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - John R Burgess
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Tasmania, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Scott A Akker
- Department of Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Endocrinology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Roderick J Clifton-Bligh
- Cancer Genetics, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- University of Sydney, Camperdown, New South Wales, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Richter S, Garrett TJ, Bechmann N, Clifton-Bligh RJ, Ghayee HK. Metabolomics in paraganglioma: applications and perspectives from genetics to therapy. Endocr Relat Cancer 2023; 30:ERC-22-0376. [PMID: 36897220 DOI: 10.1530/erc-22-0376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/10/2023] [Indexed: 03/11/2023]
Abstract
Metabolites represent the highest layer of biological information. Their diverse chemical nature enables networks of chemical reactions that are critical for maintaining life by providing energy and building blocks. Quantification by targeted and untargeted analytical methods using either mass spectrometry or nuclear magnetic resonance spectroscopy has been applied to pheochromocytoma/paraganglioma (PPGL) with the long-term goal to improve diagnosis and therapy. PPGLs have unique features that provide useful biomarkers and clues for targeted treatments. Firstly, high production rates of catecholamines and metanephrines allow for specific and sensitive detection of the disease in plasma or urine. Secondly, PPGLs are associated with heritable pathogenic variants (PV) in around 40% of cases, many of which occur in genes encoding enzymes, such as succinate dehydrogenase (SDH) and fumarate hydratase (FH). These genetic aberrations lead to overproduction of oncometabolites succinate or fumarate, respectively, and are detectable in tumors and blood. Such metabolic dysregulation can be exploited diagnostically, with the aim to ensure appropriate interpretation of gene variants, especially those with unknown significance, and facilitate early tumor detection through regular patient follow-up. Furthermore, SDHx and FH PV alter cellular pathways, including DNA hypermethylation, hypoxia signaling, redox homeostasis, DNA repair, calcium signaling, kinase cascades, and central carbon metabolism. Pharmacological interventions targeted towards such features have the potential to uncover treatments against metastatic PPGL, around 50% of which are associated with germline PV in SDHx. With the availability of omics technologies for all layers of biological information personalized diagnostics and treatment is in close reach.
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Affiliation(s)
- Susan Richter
- S Richter, Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Timothy J Garrett
- T Garrett, Medicine, University of Florida, Gainesville, United States
| | - Nicole Bechmann
- N Bechmann, Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Hans K Ghayee
- H Ghayee, Medicine, University of Florida College of Medicine, Gainesville, United States
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9
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Pacak K, Clifton-Bligh RJ. International Symposium on Pheochromocytoma: an event of dedicated healthcare professionals and researchers striving for better patient outcomes. Endocr Relat Cancer 2023; 30:ERC-23-0030. [PMID: 36883571 DOI: 10.1530/erc-23-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/27/2023] [Indexed: 03/09/2023]
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are defined as neuroendocrine tumors that produce catecholamines. Many recent advances in their management, localization, treatment, as well as surveillance have significantly improved outcomes for patients with PPGLs or carriers of pathogenic genetic variants linked to the development of these tumors. At present those advances mainly include: the molecular stratification of PPGLs into 7 clusters, the 2017 WHO revised definition of these tumors, the presence of specific clinical features pointing towards PPGL, the use of plasma metanephrines and 3-methoxytyramine with specific reference limits to assess the likelihood of having a PPGL (e.g. patients at high and low risk) including age-specific reference limits, nuclear medicine guidelines outlining cluster- and metastatic disease-specific functional (here mainly positron emission tomography and metaiodobenzylguanidine scintigraphy) imaging in the precise diagnostic localization of PPGLs, the guidelines for using radio- vs chemotherapy for patients with metastatic disease, and the international consensus on initial screening and follow-up of asymptomatic germline SDHx pathogenic variant carriers. Furthermore, new collaborative efforts particularly based on multi-institutional and worldwide initiatives are now considered key forces in improving our understanding and knowledge about these tumors and future successful treatments or even preventative interventions.
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Affiliation(s)
- Karel Pacak
- K Pacak, Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, United States
| | - Roderick J Clifton-Bligh
- R Clifton-Bligh, Department of Endocrinology , Royal North Shore Hospital, St Leonards, Australia
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10
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Clifton-Bligh RJ. The diagnosis and management of pheochromocytoma and paraganglioma during pregnancy. Rev Endocr Metab Disord 2023; 24:49-56. [PMID: 36637675 PMCID: PMC9884650 DOI: 10.1007/s11154-022-09773-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 01/14/2023]
Abstract
Diagnosis of pheochromocytoma or paraganglioma (PPGL) in pregnancy has been associated historically with high rates of materno-fetal morbidity and mortality. Recent evidence suggests outcomes are improved by recognition of PPGL before or during pregnancy and appropriate medical management with alpha-blockade. Whether antepartum surgery (before the third trimester) is required remains controversial and open to case-based merits. Women with PPGL in pregnancy are more commonly delivered by Caesarean section, although vaginal delivery appears to be safe in selected cases. At least some PPGLs express the luteinizing hormone/chorionic gonadotropin receptor (LHCGR) which may explain their dramatic manifestation in pregnancy. PPGLs in pregnancy are often associated with heritable syndromes, and genetic counselling and testing should be offered routinely in this setting. Since optimal outcomes are only achieved by early recognition of PPGL in (or ideally before) pregnancy, it is incumbent for clinicians to be aware of this diagnosis in a pregnant woman with hypertension occurring before 20 weeks' gestation, and acute and/or refractory hypertension particularly if paroxysmal and accompanied by sweating, palpitations and/or headaches. All women with a past history of PPGL and/or heritable PPGL syndrome should be carefully assessed for the presence of residual or recurrent disease before considering pregnancy.
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Affiliation(s)
- Roderick J Clifton-Bligh
- University of Sydney, Sydney, NSW, Australia.
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
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11
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Grassi ES, Rurale G, de Filippis T, Gentilini D, Carbone E, Coscia F, Uraghi S, Bullock M, Clifton-Bligh RJ, Gupta AK, Persani L. The length of FOXE1 polyalanine tract in congenital hypothyroidism: Evidence for a pathogenic role from familial, molecular and cohort studies. Front Endocrinol (Lausanne) 2023; 14:1127312. [PMID: 37008944 PMCID: PMC10060985 DOI: 10.3389/fendo.2023.1127312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/28/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION FOXE1 is required for thyroid function and its homozygous mutations cause a rare syndromic form of congenital hypothyroidism (CH). FOXE1 has a polymorphic polyalanine tract whose involvement in thyroid pathology is controversial. Starting from genetic studies in a CH family, we explored the functional role and involvement of FOXE1 variations in a large CH population. METHODS We applied NGS screening to a large CH family and a cohort of 1752 individuals and validated these results by in silico modeling and in vitro experiments. RESULTS A new heterozygous FOXE1 variant segregated with 14-Alanine tract homozygosity in 5 CH siblings with athyreosis. The p.L107V variant demonstrated to significantly reduce the FOXE1 transcriptional activity. The 14-Alanine-FOXE1 displayed altered subcellular localization and significantly impaired synergy with other transcription factors, when compared with the more common 16-Alanine-FOXE1. The CH group with thyroid dysgenesis was largely and significantly enriched with the 14-Alanine-FOXE1 homozygosity. DISCUSSION We provide new evidence that disentangle the pathophysiological role of FOXE1 polyalanine tract, thereby significantly broadening the perspective on the role of FOXE1 in the complex pathogenesis of CH. FOXE1 should be therefore added to the group of polyalanine disease-associated transcription factors.
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Affiliation(s)
- Elisa Stellaria Grassi
- Department of Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Giuditta Rurale
- Laboratory of Endocrine and Metabolic Research, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano, Milan, Italy
| | - Tiziana de Filippis
- Laboratory of Endocrine and Metabolic Research, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano, Milan, Italy
| | - Davide Gentilini
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Bioinformatics and Statistical Genomics Unit, Milano, Italy
| | - Erika Carbone
- Laboratory of Endocrine and Metabolic Research, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano, Milan, Italy
| | | | - Sarah Uraghi
- Department of Health Science, University of Milan, Milan, Italy
| | - Martyn Bullock
- Cancer Genetics Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Roderick J. Clifton-Bligh
- Cancer Genetics Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Abhinav K. Gupta
- Department of Diabetes and Endocrine Sciences, CK Birla Hospitals, Jaipur, Rajasthan, India
| | - Luca Persani
- Department of Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Laboratory of Endocrine and Metabolic Research, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano, Milan, Italy
- *Correspondence: Luca Persani,
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12
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Worrall BJ, Papachristos A, Aniss A, Glover A, Sidhu SB, Clifton-Bligh RJ, Learoyd D, Tsang VHM, Gild M, Robinson BG, Sywak MS. Lobectomy and completion thyroidectomy rates increase after the 2015 American Thyroid Association Differentiated Thyroid Cancer Guidelines update. Endocr Oncol 2023; 3:e220095. [PMID: 37434647 PMCID: PMC10305631 DOI: 10.1530/eo-22-0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 03/13/2023] [Indexed: 07/13/2023]
Abstract
Background The 2015 American Thyroid Association (ATA) Guidelines permit thyroid lobectomy (TL) or total thyroidectomy in the management of low-risk papillary thyroid cancer (PTC). As definitive risk-stratification is only possible post-operatively, some patients may require completion thyroidectomy (CT) after final histopathological analysis. Methods A retrospective cohort study of patients undergoing surgery for low-risk PTC in a tertiary referral centre was undertaken. Consecutive adult patients treated from January 2013 to March 2021 were divided into two groups (pre- and post-publication of ATA Guidelines on 01/01/2016). Only those eligible for lobectomy under rule 35(B) of the ATA Guidelines were included: Bethesda V/VI cytology, 1-4 cm post-operative size and without pre-operative evidence of extrathyroidal extension or nodal metastases. We examined rates of TL, CT, local recurrence and surgical complications. Results There were 1488 primary surgical procedures performed for PTC on consecutive adult patients during the study period, of which 461 were eligible for TL. Mean tumour size (P = 0.20) and mean age (P = 0.78) were similar between time periods. The TL rate increased significantly from 4.5 to 18% in the post-publication period (P < 0.001). The proportion of TL patients requiring CT (43 vs 38%) was similar between groups (P = 1.0). There was no significant change in complications (P = 0.55) or local recurrence rates (P = 0.24). Conclusion The introduction of the 2015 ATA Guidelines resulted in a modest but significant increase in the rate of lobectomy for eligible PTC patients. In the post-publication period, 38% of patients who underwent TL ultimately required CT after complete pathological analysis.
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Affiliation(s)
- Benjamin J Worrall
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexander Papachristos
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ahmad Aniss
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia
| | - Anthony Glover
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- The Kinghorn Cancer Centre, Garvan Institute of Medical Research, St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Stan B Sidhu
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Roderick J Clifton-Bligh
- Department of Endocrinology and metabolism, Royal North Shore Hospital, Sydney, Australia Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Diana Learoyd
- GenesisCare North Shore Health Hub Tower A, St Leonards, New South Wales, Australia
| | - Venessa H M Tsang
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and metabolism, Royal North Shore Hospital, Sydney, Australia Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Matti Gild
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia
- Department of Endocrinology and metabolism, Royal North Shore Hospital, Sydney, Australia Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Bruce G Robinson
- Department of Endocrinology and metabolism, Royal North Shore Hospital, Sydney, Australia Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Mark S Sywak
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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13
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Lim G, Widiapradja A, Levick SP, McKelvey KJ, Liao XH, Refetoff S, Bullock M, Clifton-Bligh RJ. Foxe1 Deletion in the Adult Mouse Is Associated With Increased Thyroidal Mast Cells and Hypothyroidism. Endocrinology 2022; 163:bqac158. [PMID: 36156081 PMCID: PMC9618408 DOI: 10.1210/endocr/bqac158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Indexed: 11/29/2022]
Abstract
CONTEXT Foxe1 is a key thyroid developmental transcription factor. Germline deletion results in athyreosis and congenital hypothyroidism. Some data suggest an ongoing role for maintaining thyroid differentiation. OBJECTIVE We created a mouse model to directly examine the role of Foxe1 in the adult thyroid. METHODS A model of tamoxifen-inducible Cre-mediated ubiquitous deletion of Foxe1 was generated in mice of C57BL/6J background (Foxe1flox/flox/Cre-TAM). Tamoxifen or vehicle was administered to Foxe1flox/flox/Cre mice aged 6-8 weeks. Blood was collected at 4, 12, and 20 weeks, and tissues after 12 or 20 weeks for molecular and histological analyses. Plasma total thyroxine (T4), triiodothyronine, and thyrotropin (TSH) were measured. Transcriptomics was performed using microarray or RNA-seq and validated by reverse transcription quantitative polymerase chain reaction. RESULTS Foxe1 was decreased by approximately 80% in Foxe1flox/flox/Cre-TAM mice and confirmed by immunohistochemistry. Foxe1 deletion was associated with abnormal follicular architecture and smaller follicle size at 12 and 20 weeks. Plasma TSH was elevated in Foxe1flox/flox/Cre-TAM mice as early as 4 weeks and T4 was lower in pooled samples from 12 and 20 weeks. Foxe1 deletion was also associated with an increase in thyroidal mast cells. Transcriptomic analyses found decreased Tpo and Tg and upregulated mast cell markers Mcpt4 and Ctsg in Foxe1flox/flox/Cre-TAM mice. CONCLUSION Foxe1 deletion in adult mice was associated with disruption in thyroid follicular architecture accompanied by biochemical hypothyroidism, confirming its role in maintenance of thyroid differentiation. An unanticipated finding was an increase in thyroidal mast cells. These data suggest a possible explanation for previous human genetic studies associating alleles in/near FOXE1 with hypothyroidism and/or autoimmune thyroiditis.
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Affiliation(s)
- Grace Lim
- Cancer Genetics Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW 2065, Australia
| | - Alexander Widiapradja
- Cardiac Biology and Heart Failure Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW 2065, Australia
| | - Scott P Levick
- Cardiac Biology and Heart Failure Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW 2065, Australia
| | - Kelly J McKelvey
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW 2065, Australia
| | - Xiao-Hui Liao
- Department of Medicine, The University of Chicago, Chicago, Illinois 60637, USA
| | - Samuel Refetoff
- Department of Medicine, Pediatrics and Committee on Genetics, The University of Chicago, Chicago, Illinois 60637, USA
| | - Martyn Bullock
- Cancer Genetics Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW 2065, Australia
| | - Roderick J Clifton-Bligh
- Cancer Genetics Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW 2065, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
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14
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Papachristos A, Do K, Tsang VH, Sywak M, Gill AJ, Sidhu S, Clifton-Bligh RJ, Glover A, Gild ML. Outcomes of Papillary Thyroid Microcarcinoma Presenting with Palpable Lateral Lymphadenopathy. Thyroid 2022; 32:1086-1093. [PMID: 35703333 DOI: 10.1089/thy.2022.0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Purpose: Papillary thyroid microcarcinoma (PTMC) is typically indolent in nature, allowing management with active surveillance protocols. Occasionally, a more aggressive phenotype can present and may lead to poor outcomes such as patients presenting with clinically significant lateral lymphadenopathy (cN1b). Prior analysis of the outcomes of this cohort is largely from papillary thyroid cancer (PTC) (>1 cm) or from institutions where use of radioactive iodine (RAI) is limited. Hence, we aim to describe the outcomes of patients with PTMC who presented with palpable cN1b disease, treated with total thyroidectomy and RAI. Methodology: We performed a retrospective cohort study. Outcomes of patients with PTMC who presented with palpable lateral lymph node (LN) metastases (microPTC cN1b) treated between 1997 and 2020 at Royal North Shore Hospital were compared with two control groups' outcomes: patients with clinically detected PTMC without evidence of involved LNs (microPTC cN0) and with larger PTC (>10 mm) who presented with palpable lateral lymphadenopathy (larger PTC cN1b). We assessed clinicopathological variables, postoperative risk stratification, rates of disease recurrence, reoperative surgery, and structural disease-free survival (DFS). Results: In total, 1534 PTMCs were diagnosed following thyroid surgery in the study period; of these, 157 (10%) were clinically detected microPTC cN0 and 26 microPTC cN1b (1.7%). There were 138 patients in the larger PTC cN1b control group. All cN1b patients were treated with total thyroidectomy and adjuvant RAI. Mean size of the largest LN deposit was similar between the microPTC cN1b and larger PTC cN1b groups (23 vs. 27 mm, p = 0.11). Patients with microPTC cN1b were more likely to have biochemical or structural persistence or recurrence compared with microPTC cN0 (19%, 5/26 vs. 3.8%, 6/157, p = 0.002) but less likely than larger PTC cN1b patients (19%, 5/26 vs. 42%, 58/138, p = 0.04). All patients in the microPTC cN1b group who had an excellent response to initial therapy (85%, 22/26) were disease free at last follow-up. The rate of reoperation was similar for the microPTC cN1b and microPTC cN0 groups (4%, 1/26 vs. 2%, 3/157, p = 0.461) and significantly lower than the larger PTC cN1b group (4%, 1/26 vs. 26%, 36/138, p = 0.002). Five-year DFS estimates were significantly better for microPTC cN1b patients than for larger PTC cN1b patients (94% vs. 59%, p = 0.001). Conclusions: MicroPTC cN1b patients treated with thyroidectomy and adjuvant RAI have inferior clinical outcomes compared with microPTC cN0 patients but have better outcomes than their larger PTC cN1b counterparts with respect to disease persistence and recurrence. Response to initial therapy provides valuable prognostication in microPTC cN1b patients: if these patients had an excellent response to initial treatment, they achieved long-term DFS in this series.
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Affiliation(s)
- Alexander Papachristos
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kimchi Do
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Venessa H Tsang
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Mark Sywak
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony J Gill
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Stan Sidhu
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Roderick J Clifton-Bligh
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anthony Glover
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Matti L Gild
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
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15
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Abstract
Abuse of androgens and erythropoietin has led to hormones being the most effective and frequent class of ergogenic substances prohibited in elite sports by the World Anti-Doping Agency (WADA). At present, thyroid hormone (TH) abuse is not prohibited, but its prevalence among elite athletes and nonprohibited status remains controversial. A corollary of prohibiting hormones for elite sports is that endocrinologists must be aware of a professional athlete's risk of disqualification for using prohibited hormones and/or to certify Therapeutic Use Exemptions, which allow individual athletes to use prohibited substances for valid medical indications. This narrative review considers the status of TH within the framework of the WADA Code criteria for prohibiting substances, which requires meeting 2 of 3 equally important criteria of potential performance enhancement, harmfulness to health, and violation of the spirit of sport. In considering the valid clinical uses of TH, the prevalence of TH use among young adults, the reason why some athletes seek to use TH, and the pathophysiology of sought-after and adverse effects of TH abuse, together with the challenges of detecting TH abuse, it can be concluded that, on the basis of present data, prohibition of TH in elite sport is neither justified nor feasible.
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Affiliation(s)
- Matti L Gild
- Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, St Leonards 2065, Australia
| | - Mark Stuart
- Division of Medicine, Centre for Metabolism and Inflammation, University College London, WC1E 6BT, UK
- International Testing Agency Lausanne, Lausanne 1007, Switzerland
| | - Roderick J Clifton-Bligh
- Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, St Leonards 2065, Australia
| | | | - David J Handelsman
- Correspondence: Professor David Handelsman, ANZAC Research Institute, Department of Andrology, Concord Hospital, Sydney, New South Wales, Australia.
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16
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Kaplan AI, Luxford C, Clifton-Bligh RJ. Novel TSHB variant (c.217A>C) causing severe central hypothyroidism and pituitary hyperplasia. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0230. [PMID: 36001021 PMCID: PMC9422232 DOI: 10.1530/edm-22-0230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/27/2022] [Indexed: 11/08/2022] Open
Abstract
Summary Biallelic pathological variants in the thyroid stimulating hormone (TSH) subunit β gene (TSHB) result in isolated TSH deficiency and secondary hypothyroidism, a rare form of central congenital hypothyroidism (CCH), with an estimated incidence of 1 in 65 000 births. It is characterised by low levels of free thyroxine and inappropriately low serum TSH and may therefore be missed on routine neonatal screening for hypothyroidism, which relies on elevated TSH. We describe a patient with CCH who developed recurrence of pituitary hyperplasia and symptomatic hypothyroidism due to poor compliance with thyroxine replacement. She was diagnosed with CCH as a neonate and had previously required trans-sphenoidal hypophysectomy surgery for pituitary hyperplasia associated with threatened chiasmal compression at 17 years of age due to variable adherence to thyroxine replacement. Genetic testing of TSHB identified compound heterozygosity with novel variant c.217A>C, p.(Thr73Pro), and a previously reported variant c.373delT, p.(Cys125Valfs*10). Continued variable adherence to treatment as an adult resulted in recurrence of significant pituitary hyperplasia, which subsequently resolved with improved compliance without the need for additional medications or repeat surgery. This case describes a novel TSHB variant associated with CCH and demonstrates the importance of consistent compliance with thyroxine replacement to treat hypothyroidism and prevent pituitary hyperplasia in central hypothyroidism. Learning points Pathogenic variants in the TSH subunit β gene (TSHB) are rare causes of central congenital hypothyroidism (CCH). c.217A>C, p.(Thr73Pro), is a novel TSHB variant, presented in association with CCH in this case report. Thyroxine replacement is critical to prevent clinical hypothyroidism and pituitary hyperplasia. Pituitary hyperplasia can recur post-surgery if adherence to thyroxine replacement is not maintained. Pituitary hyperplasia can dramatically reverse if compliance with thyroxine replacement is improved to maintain free thyroxine (FT4) levels in the middle-to-upper normal range, without the need for additional medications or surgeries.
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Affiliation(s)
- Adam I Kaplan
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, Australia
| | - Catherine Luxford
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, Australia
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, Sydney, Australia
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17
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Muir CA, Wood CCG, Clifton-Bligh RJ, Long GV, Scolyer RA, Carlino MS, Menzies AM, Tsang VHM. Association of Antithyroid Antibodies in Checkpoint Inhibitor-Associated Thyroid Immune-Related Adverse Events. J Clin Endocrinol Metab 2022; 107:e1843-e1849. [PMID: 35104870 DOI: 10.1210/clinem/dgac059] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The significance of thyroid peroxidase (TPOAb) and thyroglobulin antibody (TgAb) in the pathogenesis of thyroid immune-related adverse events (irAEs) is unknown. OBJECTIVE To characterize the association of anti-thyroid antibodies with the development of thyroid immune related adverse events. METHODS A retrospective cohort study was conducted of patients with melanoma receiving immune checkpoint inhibitor (ICI) treatment. TPOAb, TgAb, and interleukin-6 (IL-6) were measured retrospectively using tumor-banked samples at baseline and at time of diagnosis of a thyroid irAE. In euthyroid patients (without thyroid irAEs) measures were repeated 30 to 60 days after ICI commencement, which was similar to the median time to onset of thyroid irAEs in other patients. RESULTS A total of 122 patients were included-31 remained euthyroid, 47 developed subclinical thyrotoxicosis, 37 developed overt thyrotoxicosis, and 7 developed overt hypothyroidism without preceding thyrotoxicosis. Baseline elevation of TPOAb or TgAb was present in 19 (16%) and 28 (23%) patients, respectively. Positive TPOAb or TgAb at baseline was 97% and 100% specific for eventual development of a thyroid irAE, respectively. During ICI treatment, overt thyrotoxicosis, but not other subtypes of thyroid irAE, was associated with statistically significant increases in the titer of TgAb and TPOAb. Baseline IL-6 levels were not associated with thyroid irAE onset but statistically significantly increased during treatment in patients who developed overt hypothyroidism. CONCLUSIONS TPOAb and TgAb positivity at baseline was more prevalent in patients who developed thyroid irAEs. Statistically significant increases or new antibody positivity was observed in association with overt thyrotoxicosis. TPOAb and TgAb positivity or increases during ICI treatment may be a useful biomarker to identify patients at increased risk of thyroid irAEs, particularly overt thyrotoxicosis.
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Affiliation(s)
- Christopher A Muir
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW 2065, Australia
| | - Cameron C G Wood
- NSW Health Pathology, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Roderick J Clifton-Bligh
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW 2065, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Georgina V Long
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2065, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW 2065, Australia
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW 2065, Australia
- Department of Medical Oncology, Mater Hospital, Sydney, NSW 2065, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW 2050, Australia
| | - Richard A Scolyer
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2065, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW 2065, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW 2050, Australia
- Department of Tissue Pathology & Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW 2050, Australia
| | - Matteo S Carlino
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2065, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW 2065, Australia
- Crown Princess Mary Cancer Centre, Westmead and Blacktown Hospitals, Sydney, NSW 2145, Australia
| | - Alexander M Menzies
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2065, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW 2065, Australia
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW 2065, Australia
- Department of Medical Oncology, Mater Hospital, Sydney, NSW 2065, Australia
| | - Venessa H M Tsang
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW 2065, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW 2065, Australia
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18
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Davidoff DF, Benn DE, Field M, Crook A, Robinson BG, Tucker K, De Abreu Lourenco R, Burgess JR, Clifton-Bligh RJ. Surveillance Improves Outcomes for Carriers of SDHB Pathogenic Variants: A Multicenter Study. J Clin Endocrinol Metab 2022; 107:e1907-e1916. [PMID: 35037935 PMCID: PMC9016424 DOI: 10.1210/clinem/dgac019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Indexed: 11/22/2022]
Abstract
CONTEXT Carriers of succinate dehydrogenase type B (SDHB) pathogenic variants (PVs) are at risk of pheochromocytoma and paraganglioma (PPGL) from a young age. It is widely recommended carriers enter a surveillance program to detect tumors, but there are limited studies addressing outcomes of surveillance protocols for SDHB PV carriers. OBJECTIVE The purpose of this study was to describe surveillance-detected (s-d) tumors in SDHB PV carriers enrolled in a surveillance program and to compare their outcomes to probands. METHODS This was a multicenter study of SDHB PV carriers with at least 1 surveillance episode (clinical, biochemical, imaging) in Australian genetics clinics. Data were collected by both retrospective and ongoing prospective follow-up. Median duration of follow-up was 6.0 years. RESULTS 181 SDHB PV carriers (33 probands and 148 nonprobands) were assessed. Tumors were detected in 20% of nonprobands undergoing surveillance (age range 9-76 years). Estimated 10-year metastasis-free survival was 66% for probands and 84% for nonprobands with s-d tumors (P = .027). S-d tumors were smaller than those in probands (median 27 mm vs 45 mm respectively, P = .001). Tumor size ≥40 mm was associated with progression to metastatic disease (OR 16.9, 95% CI 2.3-187.9, P = .001). Patients with s-d tumors had lower mortality compared to probands: 10-year overall survival was 79% for probands and 100% for nonprobands (P = .029). CONCLUSION SDHB carriers with s-d tumors had smaller tumors, reduced risk of metastatic disease, and lower mortality than probands. Our results suggest that SDHB PV carriers should undertake surveillance to improve clinical outcomes.
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Affiliation(s)
- Dahlia F Davidoff
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Diana E Benn
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Michael Field
- NSLHD Familial Cancer Service, Department of Cancer Services, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Ashley Crook
- NSLHD Familial Cancer Service, Department of Cancer Services, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Bruce G Robinson
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Katherine Tucker
- Hereditary Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia
- Prince of Wales Clinical School, UNSW Medicine, Kensington, NSW, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Haymarket, Sydney, Australia
| | - John R Burgess
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, TAS, Australia
- School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Roderick J Clifton-Bligh
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
- Correspondence: Roderick J. Clifton-Bligh, BSc (med), MBBS, PhD, FRACP, FFSc (RCPA), Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW 2065, Australia.
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19
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Gild ML, Chan M, Gajera J, Lurie B, Gandomkar Z, Clifton-Bligh RJ. Risk stratification of indeterminate thyroid nodules using ultrasound and machine learning algorithms. Clin Endocrinol (Oxf) 2022; 96:646-652. [PMID: 34642976 DOI: 10.1111/cen.14612] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/02/2021] [Accepted: 09/21/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Indeterminate thyroid nodules (Bethesda III) are challenging to characterize without diagnostic surgery. Auxiliary strategies including molecular analysis, machine learning models, and ultrasound grading with Thyroid Imaging, Reporting and Data System (TI-RADS) can help to triage accordingly, but further refinement is needed to prevent unnecessary surgeries and increase positive predictive values. DESIGN Retrospective review of 88 patients with Bethesda III nodules who had diagnostic surgery with final pathological diagnosis. MEASUREMENTS Each nodule was retrospectively scored through TI-RADS. Two deep learning models were tested, one previously developed and trained on another data set, mainly containing determinate cases and then validated on our data set while the other one trained and tested on our data set (indeterminate cases). RESULTS The mean TI-RADS score was 3 for benign and 4 for malignant nodules (p = .0022). Radiological high risk (TI-RADS 4,5) and low risk (TI-RADS 2,3) categories were established. The PPV for the high radiological risk category in those with >10 mm nodules was 85% (CI: 70%-93%). The NPV for low radiological risk in patients >60 years (mean age was 100% (CI: 83%-100%). The area under the curve (AUC) value of our novel classifier was 0.75 (CI: 0.62-0.84) and differed significantly from the chance-level (p < .00001). CONCLUSIONS Novel radiomic and radiologic strategies can be employed to assist with preoperative diagnosis of indeterminate thyroid nodules.
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Affiliation(s)
- Matti Lauren Gild
- Northern Clinical School, Faculty of Health and Medicine, University of Sydney, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia
| | - Mico Chan
- Department of Radiology, Royal North Shore Hospital, Sydney, Australia
| | - Jay Gajera
- Department of Radiology, Royal North Shore Hospital, Sydney, Australia
| | - Brett Lurie
- Department of Radiology, Royal North Shore Hospital, Sydney, Australia
| | - Ziba Gandomkar
- Discipline of Clinical Imaging, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Northern Clinical School, Faculty of Health and Medicine, University of Sydney, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia
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20
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De Sousa SMC, Carroll RW, Henderson A, Burgess J, Clifton-Bligh RJ. A contemporary clinical approach to genetic testing for heritable hyperparathyroidism syndromes. Endocrine 2022; 75:23-32. [PMID: 34773560 DOI: 10.1007/s12020-021-02927-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The improved access and affordability of next generation sequencing has facilitated the clinical use of gene panel testing to test concurrently patients for multiple heritable hyperparathyroidism syndromes. However, there is little guidance as to which patients should be selected for gene panel testing and which genes should be included in such panels. In this review, we provide a practical approach to considering, interpreting and managing genetic testing for familial primary hyperparathyroidism (PHPT) syndromes and familial hypocalciuric hypercalcaemia (FHH) in patients with PTH-dependent hypercalcaemia. We discuss known genes implicated in PHPT and FHH, testing criteria and yields, pre-test counselling, laboratory considerations, and post-test management. METHODS In addition to reviewing the literature, we conducted audits of local genetic testing data to examine the real-world yield of genetic testing in patients with PTH-dependent hypercalcaemia. RESULTS Our local audits revealed a positive genetic testing rate of 15-26% in patients with suspected hyperparathyroidism syndromes. CONCLUSION Based on the particular testing criteria met, affected patients should be tested for variants in the genes currently implicated in PHPT (MEN1, CDC73, RET, CDKN1B, GCM2, CASR) and/or FHH (CASR, GNA11, AP2S1). Patients should be provided with pre- and post-test counselling, including consideration of potential implications for family members.
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Affiliation(s)
- Sunita M C De Sousa
- Endocrine & Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.
- South Australian Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.
| | - Richard W Carroll
- Endocrine, Diabetes, and Research Centre, Wellington Regional Hospital, Wellington, New Zealand
| | - Alex Henderson
- Wellington Hospital, Genetic Health Service New Zealand, Wellington, New Zealand
| | - John Burgess
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, TAS, Australia
- School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Roderick J Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
- Cancer Genetics Laboratory, Kolling Institute, University of Sydney, Sydney, NSW, Australia
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21
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Abstract
Immune checkpoints are small molecules present on the cell surface of T-lymphocytes. They maintain self-tolerance and regulate the amplitude and duration of T-cell responses. Antagonism of immune checkpoints with monoclonal antibodies (immune checkpoint inhibitors) is a rapidly evolving field of anti-cancer immunotherapy and has become standard of care in management of many cancer subtypes. Immune checkpoint inhibition is an effective cancer treatment but can precipitate immune related adverse events (irAEs). Thyroid dysfunction is the most common endocrine irAE and can occur in up to 40% of treated patients. Both thyrotoxicosis and hypothyroidism occur. The clinical presentation and demographic associations of thyrotoxicosis compared to hypothyroidism suggest unique entities with different etiologies. Thyroid irAEs, particularly overt thyrotoxicosis, are associated with increased immune toxicity in other organ systems, but also with longer progression-free and overall survival. Polygenic risk scores using susceptibility loci associated with autoimmune thyroiditis predict development of checkpoint inhibitor associated irAEs, suggesting potentially shared mechanisms underpinning their development. Our review will provide an up-to-date summary of knowledge in the field of thyroid irAEs. Major focus will be directed toward pathogenesis (including genetic factors shared with autoimmune thyroid disease), demographic associations, clinical presentation and course, treatment, and the relationship with cancer outcomes.
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Affiliation(s)
- Christopher A. Muir
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- *Correspondence: Christopher A. Muir,
| | - Venessa H. M. Tsang
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Alexander M. Menzies
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
- Department of Medical Oncology, Mater Hospital, Sydney, NSW, Australia
| | - Roderick J. Clifton-Bligh
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
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22
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Sutherland R, Tsang V, Clifton-Bligh RJ, Gild ML. Papillary thyroid microcarcinoma: Is active surveillance always enough? Clin Endocrinol (Oxf) 2021; 95:811-817. [PMID: 34021503 DOI: 10.1111/cen.14529] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/07/2021] [Accepted: 05/09/2021] [Indexed: 11/29/2022]
Abstract
The incidence of papillary thyroid carcinoma (PTC) has increased over recent decades. This apparent epidemic has been attributed to the overdiagnosis of small PTC ≤10 mm in diameter (papillary thyroid microcarcinoma [PTMC]) incidentally detected on imaging for unrelated presentations. Although most PTMCs follow an indolent disease course, there is a small but significant proportion of cases that display more biologically aggressive features such as early metastasis and lymph node involvement. Management of PTMC diagnosed preoperatively should be distinguished from managing those PTMCs incidentally discovered after thyroidectomy. Here, we will focus on the challenge of managing the preoperative patient. Current guidelines recommend against routine biopsy of nodules ≤10 mm, even if they display highly suspicious features on ultrasound; however, it is not known how to identify those PTMCs at higher risk of disease progression. In view of their good prognosis even without surgical resection, active surveillance has emerged as an alternative to operative management for low-risk PTMC without lymph node involvement or distant metastasis. This review aims to summarise active surveillance data for PTMC and identify clinical features that may differentiate the indolent majority from those PTMCs that exhibit early disease progression and metastasis.
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Affiliation(s)
- Rosie Sutherland
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia
| | - Venessa Tsang
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Cancer Genetics Unit, Kolling Institute of Medical Research, Sydney, Australia
| | - Matti L Gild
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Cancer Genetics Unit, Kolling Institute of Medical Research, Sydney, Australia
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23
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Ben Aim L, Maher ER, Cascon A, Barlier A, Giraud S, Ercolino T, Pigny P, Clifton-Bligh RJ, Mirebeau-Prunier D, Mohamed A, Favier J, Gimenez-Roqueplo AP, Schiavi F, Toledo RA, Dahia PL, Robledo M, Bayley JP, Burnichon N. International initiative for a curated SDHB variant database improving the diagnosis of hereditary paraganglioma and pheochromocytoma. J Med Genet 2021; 59:785-792. [PMID: 34452955 PMCID: PMC8882202 DOI: 10.1136/jmedgenet-2020-107652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 07/18/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND SDHB is one of the major genes predisposing to paraganglioma/pheochromocytoma (PPGL). Identifying pathogenic SDHB variants in patients with PPGL is essential to the management of patients and relatives due to the increased risk of recurrences, metastases and the emergence of non-PPGL tumours. In this context, the 'NGS and PPGL (NGSnPPGL) Study Group' initiated an international effort to collect, annotate and classify SDHB variants and to provide an accurate, expert-curated and freely available SDHB variant database. METHODS A total of 223 distinct SDHB variants from 737 patients were collected worldwide. Using multiple criteria, each variant was first classified according to a 5-tier grouping based on American College of Medical Genetics and NGSnPPGL standardised recommendations and was then manually reviewed by a panel of experts in the field. RESULTS This multistep process resulted in 23 benign/likely benign, 149 pathogenic/likely pathogenic variants and 51 variants of unknown significance (VUS). Expert curation reduced by half the number of variants initially classified as VUS. Variant classifications are publicly accessible via the Leiden Open Variation Database system (https://databases.lovd.nl/shared/genes/SDHB). CONCLUSION This international initiative by a panel of experts allowed us to establish a consensus classification for 223 SDHB variants that should be used as a routine tool by geneticists in charge of PPGL laboratory diagnosis. This accurate classification of SDHB genetic variants will help to clarify the diagnosis of hereditary PPGL and to improve the clinical care of patients and relatives with PPGL.
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Affiliation(s)
- Laurene Ben Aim
- Genetics Department, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
| | - Eamonn R Maher
- Department of Medical Genetics, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - Anne Barlier
- Laboratory of Molecular Biology, La Conception Hospital, Marseille, France
| | - Sophie Giraud
- Department of Genetics, Hospices Civils de Lyon, Bron, France
| | - Tonino Ercolino
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Pascal Pigny
- Institut de Biochimie & Biologie Moléculaire, Lille University Hospital Center, Lille, France
| | - Roderick J Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | | | - Amira Mohamed
- Laboratory of Molecular Biology, La Conception Hospital, Marseille, France
| | - Judith Favier
- Université de Paris, PARCC, INSERM, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
| | - Anne-Paule Gimenez-Roqueplo
- Genetics Department, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France.,Université de Paris, PARCC, INSERM, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
| | - Francesca Schiavi
- Familial Cancer Clinic and Oncoendocrinology, IOV IRCCS, Padova, Italy
| | - Rodrigo A Toledo
- CIBERONC, Gastrointestinal and Endocrine Tumors, VHIO, Barcelona, Spain
| | - Patricia L Dahia
- Department of Medicine, Division of Hematology and Medical Oncology, Mays Cancer Center, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | | | | | - Nelly Burnichon
- Genetics Department, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France .,Université de Paris, PARCC, INSERM, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
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24
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Muir CA, Clifton-Bligh RJ, Long GV, Scolyer RA, Lo SN, Carlino MS, Tsang VHM, Menzies AM. Thyroid Immune-related Adverse Events Following Immune Checkpoint Inhibitor Treatment. J Clin Endocrinol Metab 2021; 106:e3704-e3713. [PMID: 33878162 DOI: 10.1210/clinem/dgab263] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Indexed: 01/03/2023]
Abstract
CONTEXT Thyroid dysfunction occurs commonly following immune checkpoint inhibition. The etiology of thyroid immune-related adverse events (irAEs) remains unclear and clinical presentation can be variable. OBJECTIVE This study sought to define thyroid irAEs following immune checkpoint inhibitor (ICI) treatment and describe their clinical and biochemical associations. METHODS We performed a retrospective cohort study of thyroid dysfunction in patients with melanoma undergoing cytotoxic T-lymphocyte antigen-4 (CTLA-4) and/or programmed cell death protein-1 (PD-1) based ICI treatment from November 1, 2009, to December 31, 2019. Thyroid function was measured at baseline and at regular intervals following the start of ICI treatment. Clinical and biochemical features were evaluated for associations with ICI-associated thyroid irAEs. The prevalence of thyroid autoantibodies and the effect of thyroid irAEs on survival were analyzed. RESULTS A total of 1246 patients were included with a median follow-up of 11.3 months. Five hundred and eighteen (42%) patients developed an ICI-associated thyroid irAE. Subclinical thyrotoxicosis (n = 234) was the most common thyroid irAE, followed by overt thyrotoxicosis (n = 154), subclinical hypothyroidism (n = 61), and overt hypothyroidism (n = 39). Onset of overt thyrotoxicosis occurred a median of 5 weeks (interquartile range [IQR] 2-8) after receipt of a first dose of ICI. Combination immunotherapy was strongly associated with development of overt thyrotoxicosis (odds ratio [OR] 10.8, 95% CI 4.51-25.6 vs CTLA-4 monotherapy; P < .001), as was female sex (OR 2.02, 95% CI 1.37-2.95; P < .001) and younger age (OR 0.83 per 10 years, 95% CI 0.72-0.95; P = .007). By comparison, median onset of overt hypothyroidism was 14 weeks (IQR 8-25). The frequency of overt hypothyroidism did not differ between different ICI types. The strongest associations for hypothyroidism were higher baseline thyroid-stimulating hormone (OR 2.33 per mIU/L, 95% CI 1.61-3.33; P < .001) and female sex (OR 3.31, 95% CI 1.67-6.56; P = .01). Overt thyrotoxicosis was associated with longer progression free survival (hazard ratio [HR] 0.68, 95% CI 0.49-0.94; P = .02) and overall survival (HR 0.57, 95% CI 0.39-0.84; P = .005). There was no association between hypothyroidism and cancer outcomes. CONCLUSION Thyroid irAEs are common and there are multiple distinct phenotypes. Different thyroid irAE subtypes have unique clinical and biochemical associations, suggesting potentially distinct etiologies for thyrotoxicosis and hypothyroidism arising in this context.
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Affiliation(s)
- Christopher A Muir
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, Australia
| | - Georgina V Long
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
- Department of Medical Oncology, Mater Hospital, Sydney, Australia
| | - Richard A Scolyer
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
- Department of Tissue Pathology & Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, Australia
| | - Serigne N Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - Matteo S Carlino
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
- Crown Princess Mary Cancer Centre, Westmead and Blacktown Hospitals, Sydney, Australia
| | - Venessa H M Tsang
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, Australia
| | - Alexander M Menzies
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
- Department of Medical Oncology, Mater Hospital, Sydney, Australia
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25
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Amar L, Pacak K, Steichen O, Akker SA, Aylwin SJB, Baudin E, Buffet A, Burnichon N, Clifton-Bligh RJ, Dahia PLM, Fassnacht M, Grossman AB, Herman P, Hicks RJ, Januszewicz A, Jimenez C, Kunst HPM, Lewis D, Mannelli M, Naruse M, Robledo M, Taïeb D, Taylor DR, Timmers HJLM, Treglia G, Tufton N, Young WF, Lenders JWM, Gimenez-Roqueplo AP, Lussey-Lepoutre C. International consensus on initial screening and follow-up of asymptomatic SDHx mutation carriers. Nat Rev Endocrinol 2021; 17:435-444. [PMID: 34021277 PMCID: PMC8205850 DOI: 10.1038/s41574-021-00492-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 12/11/2022]
Abstract
Approximately 20% of patients diagnosed with a phaeochromocytoma or paraganglioma carry a germline mutation in one of the succinate dehydrogenase (SDHx) genes (SDHA, SDHB, SDHC and SDHD), which encode the four subunits of the SDH enzyme. When a pathogenic SDHx mutation is identified in an affected patient, genetic counselling is proposed for first-degree relatives. Optimal initial evaluation and follow-up of people who are asymptomatic but might carry SDHx mutations have not yet been agreed. Thus, we established an international consensus algorithm of clinical, biochemical and imaging screening at diagnosis and during surveillance for both adults and children. An international panel of 29 experts from 12 countries was assembled, and the Delphi method was used to reach a consensus on 41 statements. This Consensus Statement covers a range of topics, including age of first genetic testing, appropriate biochemical and imaging tests for initial tumour screening and follow-up, screening for rare SDHx-related tumours and management of elderly people who have an SDHx mutation. This Consensus Statement focuses on the management of asymptomatic SDHx mutation carriers and provides clinicians with much-needed guidance. The standardization of practice will enable prospective studies in the near future.
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Affiliation(s)
- Laurence Amar
- Paris University, Hypertension unit, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.
- INSERM, PARCC, Equipe Labellisée par la Ligue contre le Cancer, Paris, France.
| | - Karel Pacak
- Eunice Kennedy Shriver NICHD, NIH, Bethesda, MD, USA
| | - Olivier Steichen
- Sorbonne University, Department of Internal Medicine, Hôpital Tenon, AP-HP, Paris, France
| | - Scott A Akker
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | | | - Eric Baudin
- Gustave Roussy Institute and Paris Saclay University, Villejuif, France
| | - Alexandre Buffet
- INSERM, PARCC, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
- Genetics Department, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Nelly Burnichon
- INSERM, PARCC, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
- Genetics Department, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Roderick J Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Patricia L M Dahia
- Department of Medicine, Mays Cancer Center, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Martin Fassnacht
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Ashley B Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
- NET Unit, Royal Free Hospital, London, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
| | - Philippe Herman
- ENT unit, Lariboisière Hospital, AP-HP, University of Paris, Paris, France
| | - Rodney J Hicks
- Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henricus P M Kunst
- Department of ENT, Radboud University Medical Center, Nijmegen, Netherlands
- Maastricht University Medical Center, Maastricht, Netherlands
| | - Dylan Lewis
- King's College Hospital NHS Foundation Trust, London, UK
| | - Massimo Mannelli
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Mitsuhide Naruse
- Endocrine Center, Ijinkai Takeda General Hospital and Clinical Research Institute, NHO Kyoto Medical Center, Kyoto, Japan
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group. Spanish National Cancer Research Center (CNIO), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras, Madrid, Spain
| | - David Taïeb
- Aix-Marseille University, La Timone university hospital, European Center for Research in Medical Imaging, Marseille, France
| | - David R Taylor
- King's College Hospital NHS Foundation Trust, London, UK
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Giorgio Treglia
- Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Nicola Tufton
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Anne-Paule Gimenez-Roqueplo
- INSERM, PARCC, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
- Genetics Department, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Charlotte Lussey-Lepoutre
- INSERM, PARCC, Equipe Labellisée par la Ligue contre le Cancer, Paris, France.
- Sorbonne University, Nuclear medicine department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.
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26
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Crouch G, Dhanekula ND, Byth K, Burn E, Lau SL, Nairn L, Nery L, Doyle J, Graham E, Ellis A, Clifton-Bligh RJ, Girgis CM. The Sydney AFF Score: A Simple Tool to Distinguish Females Presenting With Atypical Femur Fractures Versus Typical Femur Fractures. J Bone Miner Res 2021; 36:910-920. [PMID: 33528853 DOI: 10.1002/jbmr.4255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 01/05/2021] [Accepted: 01/12/2021] [Indexed: 01/21/2023]
Abstract
Atypical femur fractures (AFF) are a rare but serious complication of long-term bisphosphonate use. Although clearly defined by ASBMR criteria, a proportion of patients with AFFs may go unrecognized and the use of qualitative fracture criteria may lead to uncertainty in AFF diagnosis, with significant therapeutic implications. A score that rapidly and accurately identifies AFFs among subtrochanteric femur fractures using quantitative, measurable parameters is needed. In a retrospective cohort of 110 female patients presenting with AFFs or typical femur fractures (TFFs), multiple logistic regression and decision tree analysis were used to develop the Sydney AFF score. This score, based on demographic and femoral geometry variables, uses three dichotomized independent predictors and adds one point for each: (age ≤80 years) + (femoral neck width <37 mm) + (lateral cortical width at lesser trochanter ≥5 mm), (score, 0 to 3). In an independent validation set of 53 female patients at a different centre in Sydney, a score ≥2 demonstrated 73.3% sensitivity and 69.6% specificity for AFF (area under the receiver-operating characteristic curve [AUC] 0.775, SE 0.063) and remained independently associated with AFF after adjustment for bisphosphonate use. The Sydney AFF score provides a quantitative means of flagging female patients with atraumatic femur fractures who have sustained an AFF as opposed to a TFF. This distinction has clear management implications and may augment current ASBMR diagnostic criteria. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Gareth Crouch
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nitesh D Dhanekula
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Department of Orthopaedic Surgery, Westmead Hospital, Westmead, NSW, Australia
| | - Karen Byth
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Western Sydney Local Health District (WSLHD) Research and Education Network, Westmead Hospital, Westmead, NSW, Australia
| | - Emma Burn
- Department of Medicine, West Suffolk Hospital, Bury St Edmonds, UK
| | - Sue Lynn Lau
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Department of Endocrinology and Diabetes, Westmead Hospital, Westmead, NSW, Australia
| | - Lillias Nairn
- Department of Physiotherapy, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Liza Nery
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Jean Doyle
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Edward Graham
- Department of Orthopaedic Surgery, Westmead Hospital, Westmead, NSW, Australia
| | - Andrew Ellis
- Department of Orthopaedic Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Roderick J Clifton-Bligh
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, Australia.,Kolling Institute of Medical Research, Sydney, NSW, Australia
| | - Christian M Girgis
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Department of Endocrinology and Diabetes, Westmead Hospital, Westmead, NSW, Australia.,Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, Australia.,The Westmead Institute for Medical Research, Westmead, NSW, Australia
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27
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Abstract
In the 9 years since the publication of our 2011 review of targeted treatment of thyroid cancer with multikinase inhibitors, much has changed in the landscape of this heterogeneous disease. New multikinase and selective inhibitor treatments for medullary thyroid cancer, radioiodine-refractory thyroid cancer and anaplastic thyroid cancer have completed trials and improved progression-free survival. Many physicians are concerned by dose-limiting adverse effects of these drugs and are wary to begin treatment in patients who are systemically well but have marked disease burden, which makes the timing of treatment initiation challenging. Published mechanistic data on tyrosine kinase inhibitors (TKIs) have helped guide our understanding of how to dose effectively with these drugs. A major goal in TKI therapy is to optimize inhibition of oncogenic kinase drivers while maintaining patient quality of life. Real-world data have now been published on how TKIs have fared outside the clinical trial environment. In this Review, we provide a summary of published data on the efficacy of TKIs in clinical practice, to provide clinicians with a more realistic view of how their patients will manage and respond to TKI therapy. Furthermore, we review the data on mechanisms of inhibition, outcomes and adverse effects of TKIs and provide an update on targeted treatment of thyroid cancer, focusing on optimizing the timing of treatment initiation.
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Affiliation(s)
- Matti L Gild
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, NSW, Australia.
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW, Australia.
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - Venessa H M Tsang
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, NSW, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Roderick J Clifton-Bligh
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, NSW, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Bruce G Robinson
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, NSW, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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28
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Girgis CM, Clifton-Bligh RJ. Reply to Comment on "Osteoporosis in the Age of COVID-19". Osteoporos Int 2021; 32:795. [PMID: 33661310 PMCID: PMC7931499 DOI: 10.1007/s00198-021-05901-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/19/2021] [Indexed: 10/29/2022]
Affiliation(s)
- C M Girgis
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
- Department of Endocrinology and Diabetes, Westmead Hospital, Sydney, Australia.
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, Australia.
| | - R J Clifton-Bligh
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, Australia
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29
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Davidoff DF, Luxford C, Kim E, Novos T, Horvath AR, Gill AJ, Dwight T, Clifton-Bligh RJ, Burgess JR. Measuring Tumor Succinate and Fumarate to Resolve Pathogenicity of an SDHA Variant. Clin Chem 2021; 67:696-699. [PMID: 36869672 DOI: 10.1093/clinchem/hvab004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/23/2020] [Indexed: 11/14/2022]
Affiliation(s)
- Dahlia F Davidoff
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,University of Sydney, Sydney, Australia.,Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Catherine Luxford
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,University of Sydney, Sydney, Australia
| | - Edward Kim
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,University of Sydney, Sydney, Australia
| | - Talia Novos
- Department of Chemical Pathology, NSW Health Pathology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Andrea R Horvath
- Department of Chemical Pathology, NSW Health Pathology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Anthony J Gill
- University of Sydney, Sydney, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Trisha Dwight
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,University of Sydney, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,University of Sydney, Sydney, Australia.,Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - John R Burgess
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, TAS, Australia.,School of Medicine, University of Tasmania, Hobart, TAS, Australia
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30
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Seabrook AJ, Harris JE, Velosa SB, Kim E, McInerney-Leo AM, Dwight T, Hockings JI, Hockings NG, Kirk J, Leo PJ, Love AJ, Luxford C, Marshall M, Mete O, Pennisi DJ, Brown MA, Gill AJ, Hockings GI, Clifton-Bligh RJ, Duncan EL. Multiple Endocrine Tumors Associated with Germline MAX Mutations: Multiple Endocrine Neoplasia Type 5? J Clin Endocrinol Metab 2021; 106:1163-1182. [PMID: 33367756 DOI: 10.1210/clinem/dgaa957] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Pathogenic germline MAX variants are associated with pheochromocytoma and paraganglioma (PPGL), pituitary neuroendocrine tumors and, possibly, other endocrine and nonendocrine tumors. OBJECTIVE To report 2 families with germline MAX variants, pheochromocytomas (PCs) and multiple other tumors. METHODS Clinical, genetic, immunohistochemical, and functional studies at University hospitals in Australia on 2 families with germline MAX variants undergoing usual clinical care. The main outcome measures were phenotyping; germline and tumor sequencing; immunohistochemistry of PC and other tumors; functional studies of MAX variants. RESULTS Family A has multiple individuals with PC (including bilateral and metastatic disease) and 2 children (to date, without PC) with neuroendocrine tumors (paravertebral ganglioneuroma and abdominal neuroblastoma, respectively). One individual has acromegaly; immunohistochemistry of PC tissue showed positive growth hormone-releasing hormone staining. Another individual with previously resected PCs has pituitary enlargement and elevated insulin-like growth factor (IGF-1). A germline MAX variant (c.200C>A, p.Ala67Asp) was identified in all individuals with PC and both children, with loss of heterozygosity in PC tissue. Immunohistochemistry showed loss of MAX staining in PCs and other neural crest tumors. In vitro studies confirmed the variant as loss of function. In Family B, the proband has bilateral and metastatic PC, prolactin-producing pituitary tumor, multigland parathyroid adenomas, chondrosarcoma, and multifocal pulmonary adenocarcinomas. A truncating germline MAX variant (c.22G>T, p.Glu8*) was identified. CONCLUSION Germline MAX mutations are associated with PCs, ganglioneuromas, neuroblastomas, pituitary neuroendocrine tumors, and, possibly, parathyroid adenomas, as well as nonendocrine tumors of chondrosarcoma and lung adenocarcinoma, suggesting MAX is a novel multiple endocrine neoplasia gene.
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Affiliation(s)
- Amanda J Seabrook
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jessica E Harris
- The University of Queensland Diamantina Institute, The University of Queensland, Translational Research Institute, Woolloongabba, Australia
| | | | - Edward Kim
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Aideen M McInerney-Leo
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Australia
| | - Trisha Dwight
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | | | | | - Judy Kirk
- Familial Cancer Service, Westmead Hospital, Sydney, Australia
| | - Paul J Leo
- Australian Translational Genomics Centre, Institute of Health and Biomedical Innovation, School of Biomedical Sciences, Queensland University of Technology (QUT), Translational Research Institute, Woolloongabba, Australia
| | - Amanda J Love
- Department of Endocrinology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Catherine Luxford
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Mhairi Marshall
- Australian Translational Genomics Centre, Institute of Health and Biomedical Innovation, School of Biomedical Sciences, Queensland University of Technology (QUT), Translational Research Institute, Woolloongabba, Australia
| | - Ozgur Mete
- Department of Pathology, University Health Network, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - David J Pennisi
- Australian Translational Genomics Centre, Institute of Health and Biomedical Innovation, School of Biomedical Sciences, Queensland University of Technology (QUT), Translational Research Institute, Woolloongabba, Australia
| | - Matthew A Brown
- Guy's and St Thomas' NHS Foundation Trust and King's College London NIHR Biomedical Research Centre, King's College London, London, UK
| | - Anthony J Gill
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Gregory I Hockings
- Endocrinology Unit, Greenslopes Private Hospital, Brisbane, Australia
- University of Queensland Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Roderick J Clifton-Bligh
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, Australia
| | - Emma L Duncan
- Australian Translational Genomics Centre, Institute of Health and Biomedical Innovation, School of Biomedical Sciences, Queensland University of Technology (QUT), Translational Research Institute, Woolloongabba, Australia
- University of Queensland Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Twin Research & Genetic Epidemiology, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London; St Thomas' Campus, London, UK
- Department of Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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31
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Nylén C, Eriksson FB, Yang A, Aniss A, Turchini J, Learoyd D, Robinson BG, Gill AJ, Clifton-Bligh RJ, Sywak MS, Glover AR, Sidhu SB. Prophylactic central lymph node dissection informs the decision of radioactive iodine ablation in papillary thyroid cancer. Am J Surg 2020; 221:886-892. [PMID: 32878695 DOI: 10.1016/j.amjsurg.2020.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/02/2020] [Accepted: 08/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prophylactic central lymph node dissection (CLND) in papillary thyroid cancer (PTC) is controversial. We aimed to investigate if prophylactic CLND aids risk stratification and contributes to the decision for postoperative RAI ablation. METHODS Patients undergoing thyroidectomy for PTC and prophylactic CLND were identified from an endocrine surgical unit database. Pathology reports where reviewed for number and size of lymph nodes and patients stratified by risk according to the ATA guidelines. RESULTS 426 patients were identified with PTC ≤4 cm and prophylactic CLND. 96 patients (23%) had central lymph node metastasis (CLNM) that qualified them for the intermediate risk group. In 17 patients (4%), the CLNM data led to upgrading independently of other histopathological characteristics. Correcting for multiple variables, CLNM was an independent factor contributing to RAI treatment. CONCLUSION Prophylactic CLND provides information to aid the selection of RAI ablation independent of primary cancer histology for risk stratification in 4% of patients. This benefit should be carefully balanced with the risk of CLND and patient treatment choice when deciding on management of PTC ≤4 cm.
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Affiliation(s)
- Carolina Nylén
- Department of Endocrine Surgery, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; Endocrine Surgery Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden.
| | - Frida Bragvad Eriksson
- Department of Endocrine Surgery, Uppsala University, Akademiska Hospital, 751 85 Uppsala, Sweden
| | - Anna Yang
- Department of Endocrine Surgery, Uppsala University, Akademiska Hospital, 751 85 Uppsala, Sweden
| | - Ahmad Aniss
- Department of Endocrine Surgery, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - John Turchini
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia; Department of Histopathology, Douglass Hanly Moir Pathology, Macquarie Park, NSW, 2113, Australia; Discipline of Pathology, MQ Health, Macquarie University, NSW, 2109, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Diana Learoyd
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia; Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Bruce G Robinson
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia; Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; Cancer Genetics Unit, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Anthony J Gill
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Roderick J Clifton-Bligh
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia; Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; Cancer Genetics Unit, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Mark S Sywak
- Department of Endocrine Surgery, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia
| | - Anthony R Glover
- Department of Endocrine Surgery, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia; Endocrine Cancer Program, Cancer Theme, The Kinghorn Cancer Centre, Garvan Institute of Medical Research, St. Vincent's Clinical School. Faculty of Medicine, University of New South Wales Sydney, NSW, 2010, Australia
| | - Stan B Sidhu
- Department of Endocrine Surgery, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia; Cancer Genetics Unit, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
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Nylén C, Mechera R, Maréchal-Ross I, Tsang V, Chou A, Gill AJ, Clifton-Bligh RJ, Robinson BG, Sywak MS, Sidhu SB, Glover AR. Molecular Markers Guiding Thyroid Cancer Management. Cancers (Basel) 2020; 12:cancers12082164. [PMID: 32759760 PMCID: PMC7466065 DOI: 10.3390/cancers12082164] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 12/12/2022] Open
Abstract
The incidence of thyroid cancer is rapidly increasing, mostly due to the overdiagnosis and overtreatment of differentiated thyroid cancer (TC). The increasing use of potent preclinical models, high throughput molecular technologies, and gene expression microarrays have provided a deeper understanding of molecular characteristics in cancer. Hence, molecular markers have become a potent tool also in TC management to distinguish benign from malignant lesions, predict aggressive biology, prognosis, recurrence, as well as for identification of novel therapeutic targets. In differentiated TC, molecular markers are mainly used as an adjunct to guide management of indeterminate nodules on fine needle aspiration biopsies. In contrast, in advanced thyroid cancer, molecular markers enable targeted treatments of affected signalling pathways. Identification of the driver mutation of targetable kinases in advanced TC can select treatment with mutation targeted tyrosine kinase inhibitors (TKI) to slow growth and reverse adverse effects of the mutations, when traditional treatments fail. This review will outline the molecular landscape and discuss the impact of molecular markers on diagnosis, surveillance and treatment of differentiated, poorly differentiated and anaplastic follicular TC.
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Affiliation(s)
- Carolina Nylén
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, NSW 2065, Australia; (C.N.); (R.M.); (M.S.S.); (S.B.S.)
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Solna L1:00, 171 76 Stockholm, Sweden
| | - Robert Mechera
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, NSW 2065, Australia; (C.N.); (R.M.); (M.S.S.); (S.B.S.)
- Department of Visceral Surgery, Clarunis University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Isabella Maréchal-Ross
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
| | - Venessa Tsang
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- Department of Endocrinology, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW 2065, Australia
| | - Angela Chou
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW 2065, Australia
| | - Anthony J. Gill
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW 2065, Australia
| | - Roderick J. Clifton-Bligh
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- Department of Endocrinology, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW 2065, Australia
- Cancer Genetics Unit, Kolling Institute, Sydney, NSW 2010, Australia
| | - Bruce G. Robinson
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- Department of Endocrinology, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW 2065, Australia
- Cancer Genetics Unit, Kolling Institute, Sydney, NSW 2010, Australia
| | - Mark S. Sywak
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, NSW 2065, Australia; (C.N.); (R.M.); (M.S.S.); (S.B.S.)
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
| | - Stan B. Sidhu
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, NSW 2065, Australia; (C.N.); (R.M.); (M.S.S.); (S.B.S.)
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- Cancer Genetics Unit, Kolling Institute, Sydney, NSW 2010, Australia
| | - Anthony R. Glover
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, NSW 2065, Australia; (C.N.); (R.M.); (M.S.S.); (S.B.S.)
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- The Kinghorn Cancer Centre, Garvan Institute of Medical Research, Faculty of Medicine, St. Vincent’s Clinical School, University of New South Wales Sydney, Sydney, NSW 2010, Australia
- Correspondence: ; Tel.: +61-2-9463-1477
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Abstract
As the world grapples with the crisis of COVID-19, established economies and healthcare systems have been brought to their knees. Tough decisions regarding redirection of resources away from the management of conditions deemed "nonessential" are being made. How can we balance urgent resourcing of our acute crisis while not abandoning the real need of patients with osteoporosis? This article offers a few practical solutions.
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Affiliation(s)
- C M Girgis
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, Sydney, Australia.
- Department of Endocrinology and Diabetes, Westmead Hospital, Westmead, Sydney, Australia.
| | - R J Clifton-Bligh
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, Sydney, Australia
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Gild ML, Bullock M, Luxford C, Field M, Clifton-Bligh RJ. Congenital Hypoparathyroidism Associated With Elevated Circulating Nonfunctional Parathyroid Hormone Due to Novel PTH Mutation. J Clin Endocrinol Metab 2020; 105:5839775. [PMID: 32421798 DOI: 10.1210/clinem/dgaa279] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/13/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Familial hypoparathyroidism has a heterogeneous presentation where patients usually have low parathyroid hormone (PTH) levels due to impaired production or secretion. This contrasts with pseudohypoparathyroidism, in which PTH resistance is usually associated with an elevated serum PTH. High levels of circulating PTH can also be due to bioinactive PTH, which is difficult to distinguish from pseudohypoparathyroidism on biochemical grounds. CASE DESCRIPTION We report on 2 sisters from consanguineous parents who presented with tetany at birth and were diagnosed with congenital hypocalcemia. Serum PTH levels were normal for many years, but progressively increased in midadulthood to greater than 100x the upper limit of normal on multiple assays. Homozygosity mapping was performed on 1 sister that demonstrated loss of heterozygosity (LOH) around PTH. Sequencing revealed a previously unreported variant, c.94T>C, predicting a codon change of p.Ser32Pro that is biologically inactive. CONCLUSIONS This case report shows a previously unreported unusual biochemical phenotype of a rising PTH in the context of a novel PTH mutation. This expands the evolving genotypes associated with hypoparathyroidism without established gene mutations.
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Affiliation(s)
- Matti L Gild
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, North South Wales, Australia
- Department of Genetics, Royal North Shore Hospital, Sydney, Australia
| | - Martyn Bullock
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, North South Wales, Australia
| | - Catherine Luxford
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, North South Wales, Australia
| | - Michael Field
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, North South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, North South Wales, Australia
- Department of Genetics, Royal North Shore Hospital, Sydney, Australia
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De Sousa SMC, Toubia J, Hardy TSE, Feng J, Wang P, Schreiber AW, Geoghegan J, Hall R, Rawlings L, Buckland M, Luxford C, Novos T, Clifton-Bligh RJ, Poplawski NK, Scott HS, Torpy DJ. Aberrant Splicing of SDHC in Families With Unexplained Succinate Dehydrogenase-Deficient Paragangliomas. J Endocr Soc 2020; 4:bvaa071. [PMID: 33195952 PMCID: PMC7646550 DOI: 10.1210/jendso/bvaa071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Indexed: 12/12/2022] Open
Abstract
Context Germline mutations in the succinate dehydrogenase genes (SDHA/B/C/D, SDHAF2-collectively, "SDHx") have been implicated in paraganglioma (PGL), renal cell carcinoma (RCC), gastrointestinal stromal tumor (GIST), and pituitary adenoma (PA). Negative SDHB tumor staining is indicative of SDH-deficient tumors, usually reflecting an underlying germline SDHx mutation. However, approximately 20% of individuals with SDH-deficient tumors lack an identifiable germline SDHx mutation. Methods We performed whole-exome sequencing (WES) of germline and tumor DNA followed by Sanger sequencing validation, transcriptome analysis, metabolomic studies, and haplotype analysis in 2 Italian-Australian families with SDH-deficient PGLs and various neoplasms, including RCC, GIST, and PA. Results Germline WES revealed a novel SDHC intronic variant, which had been missed during previous routine testing, in 4 affected siblings of the index family. Transcriptome analysis demonstrated aberrant SDHC splicing, with the retained intronic segment introducing a premature stop codon. WES of available tumors in this family showed chromosome 1 deletion with loss of wild-type SDHC in a PGL and a somatic gain-of-function KIT mutation in a GIST. The SDHC intronic variant identified was subsequently detected in the second family, with haplotype analysis indicating a founder effect. Conclusions This is the deepest intronic variant to be reported among the SDHx genes. Intronic variants beyond the limits of standard gene sequencing analysis should be considered in patients with SDH-deficient tumors but negative genetic test results.
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Affiliation(s)
- Sunita M C De Sousa
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia.,Department of Genetics and Molecular Pathology, Centre for Cancer Biology, an SA Pathology and University of South Australia alliance, Adelaide, Australia.,Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia
| | - John Toubia
- ACRF Cancer Genomics Facility, Centre for Cancer Biology, SA Pathology, Adelaide, Australia
| | | | - Jinghua Feng
- ACRF Cancer Genomics Facility, Centre for Cancer Biology, SA Pathology, Adelaide, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Paul Wang
- ACRF Cancer Genomics Facility, Centre for Cancer Biology, SA Pathology, Adelaide, Australia
| | - Andreas W Schreiber
- ACRF Cancer Genomics Facility, Centre for Cancer Biology, SA Pathology, Adelaide, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,School of Biological Sciences, University of Adelaide, Adelaide, Australia
| | - Joel Geoghegan
- ACRF Cancer Genomics Facility, Centre for Cancer Biology, SA Pathology, Adelaide, Australia
| | - Rachel Hall
- SA Pathology, Flinders Medical Centre, Bedford Park, Australia
| | | | - Michael Buckland
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, Australia.,School of Medical Sciences, University of Sydney, Sydney, Australia
| | - Catherine Luxford
- Cancer Genetics, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Talia Novos
- Cancer Genetics, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Cancer Genetics, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Nicola K Poplawski
- Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia
| | - Hamish S Scott
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, an SA Pathology and University of South Australia alliance, Adelaide, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia.,ACRF Cancer Genomics Facility, Centre for Cancer Biology, SA Pathology, Adelaide, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,School of Biological Sciences, University of Adelaide, Adelaide, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia
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Tsang VHM, McGrath RT, Clifton-Bligh RJ, Scolyer RA, Jakrot V, Guminski AD, Long GV, Menzies AM. Response to Letter to the Editor: "Checkpoint Inhibitor-Associated Autoimmune Diabetes is Distinct From Type 1 Diabetes". J Clin Endocrinol Metab 2020; 105:5809738. [PMID: 32188993 PMCID: PMC7170215 DOI: 10.1210/clinem/dgaa144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/15/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Venessa H M Tsang
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, St Leonards Sydney, Australia
- Sydney Medical School, Northern, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cancer Genetics Laboratory, Hormones and Cancer Group, Kolling Institute of Medical Research, Sydney, NSW, Australia
- Correspondence and Reprint Requests: Venessa H. M. Tsang, MBBS, BSc(Med), PhD, FRACP, Department of Endocrinology, Royal North Shore Hospital, St. Leonards, NSW, 2065, Australia. E-mail:
| | - Rachel T McGrath
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, St Leonards Sydney, Australia
- Sydney Medical School, Northern, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, St Leonards Sydney, Australia
- Sydney Medical School, Northern, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cancer Genetics Laboratory, Hormones and Cancer Group, Kolling Institute of Medical Research, Sydney, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Valerie Jakrot
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia
| | - Alexander D Guminski
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia
- Departments of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Georgina V Long
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia
- Departments of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Alexander M Menzies
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia
- Departments of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, Australia
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Thompson LDR, Gill AJ, Asa SL, Clifton-Bligh RJ, de Krijger RR, Kimura N, Komminoth P, Lack EE, Lenders JWM, Lloyd RV, Papathomas TG, Sadow PM, Tischler AS. Data set for the reporting of pheochromocytoma and paraganglioma: explanations and recommendations of the guidelines from the International Collaboration on Cancer Reporting. Hum Pathol 2020; 110:83-97. [PMID: 32407815 DOI: 10.1016/j.humpath.2020.04.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES The International Collaboration on Cancer Reporting (ICCR) is a not-for-profit to develop evidence-based, internationally agreed-upon standardized data sets for each anatomic site, to be used throughout the world. Providing global standardization of pathology tumor classification, staging, and other reporting elements will lead to improved patient management and enhanced epidemiological research. METHODS Pheochromocytoma and paraganglioma are uncommon and are frequently overlooked in registry data sets. Malignant criteria have previously been defined only when there was metastatic disease. RESULTS With recent recognition of a significant inheritance association and the development of risk stratification tools, this data set was created in order to obtain more meaningful outcomes and management data, using similar criteria across the global pathology community. Issues related to key core and non-core elements, especially clinical hormonal status, familial history, tumor focality, proliferative fraction, adverse or risk stratification features, and ancillary techniques, are discussed in the context of daily application to these types of specimens. CONCLUSIONS The ICCR data set, developed by an international panel of endocrine organ specialists, establishes a pathology-standardized reporting guide for pheochromocytoma and paraganglioma.
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Affiliation(s)
- Lester D R Thompson
- Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, CA, USA.
| | - Anthony J Gill
- University of Sydney, Sydney, New South Wales, Australia; Cancer Diagnosis and Pathology Group Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Pathology, Case Western Reserve University, Cleveland, OH, USA; University Health Network, Toronto, Canada.
| | - Roderick J Clifton-Bligh
- University of Sydney, Sydney, New South Wales, Australia; Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
| | - Ronald R de Krijger
- Department of Pathology, University Medical Centre and Princess Maxima Centre, Utrecht, the Netherlands.
| | - Noriko Kimura
- Department of Diagnostic Pathology, Department of Clinical Research, Pathology Division, National Hospital Organization Hakodate Hospital, Japan.
| | - Paul Komminoth
- University of Zürich, Institute of Pathology, City Hospital Triemli, Zürich, Switzerland.
| | - Ernest E Lack
- Department of Endocrine Pathology, The Joint Pathology Center, Silver Spring, MD, USA.
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Medicine III, University Hospital Carl Gustav Carus and Medical Faculty, Technical University Dresden, Dresden, Germany.
| | - Ricardo V Lloyd
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Wisconsin, USA.
| | - Thomas G Papathomas
- Institute of Metabolism and Systems Research, University of Birmingham, United Kingdom.
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - Arthur S Tischler
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, USA.
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McDonnell JE, Gild ML, Clifton-Bligh RJ, Robinson BG. Multiple endocrine neoplasia: an update. Intern Med J 2020; 49:954-961. [PMID: 31387156 DOI: 10.1111/imj.14394] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/22/2019] [Accepted: 05/29/2019] [Indexed: 12/17/2022]
Abstract
The multiple endocrine neoplasia (MEN) syndromes include MEN1, MEN2 (formerly MEN2A), MEN3 (formerly MEN2B) and the recently identified MEN4. Clinical presentations are varied and often relate to the overproduction of specific hormones. Understanding the genetics of each syndrome assists in determining screening timelines. Treatments for each manifestation are dependent on location, risk of recurrence or malignancy, hormone excess and surgical morbidity. Multidisciplinary management should include geneticists, genetic counsellors, endocrinologists and endocrine surgeons.
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Affiliation(s)
- Jane E McDonnell
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Matti L Gild
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Cancer Genetics Unit, Kolling Institute, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Roderick J Clifton-Bligh
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Cancer Genetics Unit, Kolling Institute, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Bruce G Robinson
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Cancer Genetics Unit, Kolling Institute, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Gild ML, Heath L, Paik JY, Clifton-Bligh RJ, Robinson BG. Malignant struma ovarii with a robust response to radioactive iodine. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM190130. [PMID: 32061155 PMCID: PMC7040530 DOI: 10.1530/edm-19-0130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/21/2020] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Struma ovarii is a rare, usually benign ovarian tumour with malignancy occurring in <5% of cases. Metastases, particularly seeding to bone, are extremely rare. Presentation is variable but often features local pain and/or ascites and hyperthyroidism may occur. It is not established how to best treat and follow patients with extensive disease. Case reports of radioiodine (I131) ablative therapy following thyroidectomy have shown reduced recurrence. We describe the case of a 33-year-old woman who presented with bone pain and was diagnosed with skeletal metastases with features of follicular thyroid carcinoma. However, thyroid pathology was benign. She recalled that 5 years prior, an ovarian teratoma was excised, classified at that time as a dermoid cyst. Retrospective review of this pathology confirmed struma ovarii without obvious malignant features. The patient was found to have widespread metastases to bone and viscera and her thyroglobulin was >3000 µg/L following recombinant TSH administration prior to her first dose of I131. At 25 months following radioiodine treatment, she is in remission with an undetectable thyroglobulin and clear I131 surveillance scans. This case demonstrates an unusual presentation of malignant struma ovarii together with challenges of predicting metastatic disease, and demonstrates a successful radioiodine regimen inducing remission. LEARNING POINTS Malignant transformation of struma ovarii (MSO) is extremely rare and even rarer are metastatic deposits in bone and viscera. MSO can be difficult to predict by initial ovarian pathology, analogous to the difficulty in some cases of differentiating between follicular thyroid adenoma and carcinoma. No consensus exists on the management for post operative treatment of MSO; however, in this case, three doses of 6Gbq radioiodine therapy over a short time period eliminated metastases to viscera and bone. Patients should continue to have TSH suppression for ~5 years. Monitoring thyroglobulin levels can predict recurrence.
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Affiliation(s)
- M L Gild
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - L Heath
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - J Y Paik
- Department of Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - R J Clifton-Bligh
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - B G Robinson
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Tsang VHM, McGrath RT, Clifton-Bligh RJ, Scolyer RA, Jakrot V, Guminski AD, Long GV, Menzies AM. Checkpoint Inhibitor-Associated Autoimmune Diabetes Is Distinct From Type 1 Diabetes. J Clin Endocrinol Metab 2019; 104:5499-5506. [PMID: 31265074 DOI: 10.1210/jc.2019-00423] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/26/2019] [Indexed: 01/03/2023]
Abstract
CONTEXT Checkpoint inhibitor-associated autoimmune diabetes mellitus (CIADM) is a rare illness, and little is known about its incidence, clinical features, or pathogenesis. CASE SERIES DESCRIPTION Consecutive patients from a single quaternary melanoma center who developed new-onset insulin-requiring diabetes after commencing anti-programmed cell death-1 (PD-1) immunotherapy were studied to describe CIADM characteristics. Ten (1.9%) of 538 patients with metastatic melanoma treated with anti-PD-1-based immunotherapy from March 2015 to March 2018 developed CIADM. Nine patients had no history of diabetes, and one had pre-existing type 2 diabetes mellitus. Median time from immunotherapy start to CIADM diagnosis was 25 weeks [interquartile range (IQR), 17.5 to 34.5 weeks]. All patients had normal serum C-peptide shortly before CIADM onset and an inappropriately low level when measured soon after. At CIADM diagnosis, median hemoglobin A1c was 7.6% (IQR, 7.15% to 9.75%), median glucose level was 32.5 mmol/L (IQR, 21.6 to 36.7 mmol/L), and median C-peptide concentration was 0.35 nmol/L (IQR, 0.10 to 0.49 mmol/L). Type 1 diabetes (T1D)-associated autoantibodies (DAAs) were present in two patients (both of whom had anti-glutamic acid decarboxylase antibody); all were negative for insulin-associated protein 2, insulin, and ZnT8. Three patients were heterozygous for an HLA class II T1D-risk haplotype; two additional patients also carried protective haplotypes for T1D. All patients continued immunotherapy; eight (80%) had complete or partial oncological response, and all patients required ongoing insulin therapy. CONCLUSION CIADM is characterized by sudden permanent β-cell failure occurring after immunotherapy. It is distinct from T1D, usually lacks DAA or T1D-associated HLA-risk haplotypes, and is associated with difficult glycemic control from the onset. As such, CIADM represents a new model of auto-inflammatory β-cell failure.
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Affiliation(s)
- Venessa H M Tsang
- Department of Diabetes, Endocrinology & Metabolism and Northern Clinical School, the University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Cancer Genetics Laboratory, Hormones and Cancer Group, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
| | - Rachel T McGrath
- Department of Diabetes, Endocrinology & Metabolism and Northern Clinical School, the University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Roderick J Clifton-Bligh
- Department of Diabetes, Endocrinology & Metabolism and Northern Clinical School, the University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Cancer Genetics Laboratory, Hormones and Cancer Group, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia and the University of Sydney, Sydney, New South Wales, Australia
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Valerie Jakrot
- Melanoma Institute Australia and the University of Sydney, Sydney, New South Wales, Australia
| | - Alexander D Guminski
- Melanoma Institute Australia and the University of Sydney, Sydney, New South Wales, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Department of Medical Oncology, Mater Hospital, Sydney, New South Wales, Australia
| | - Georgina V Long
- Melanoma Institute Australia and the University of Sydney, Sydney, New South Wales, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Department of Medical Oncology, Mater Hospital, Sydney, New South Wales, Australia
| | - Alexander M Menzies
- Melanoma Institute Australia and the University of Sydney, Sydney, New South Wales, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Department of Medical Oncology, Mater Hospital, Sydney, New South Wales, Australia
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Abstract
Metabolomics refers to the detection and measurement of small molecules (metabolites) within biological systems, and is therefore a powerful tool for identifying dysfunctional cellular physiologies. For pheochromocytomas and paragangliomas (PPGLs), metabolomics has the potential to become a routine addition to histology and genomics for precise diagnostic evaluation. Initial metabolomic studies of ex vivo tumors confirmed, as expected, succinate accumulation in PPGLs associated with pathogenic variants in genes encoding succinate dehydrogenase subunits or their assembly factors (SDHx). Metabolomics has now shown utility in clarifying SDHx variants of uncertain significance, as well as the accurate diagnosis of PPGLs associated with fumarate hydratase (FH), isocitrate dehydrogenase (IDH), malate dehydrogenase (MDH2) and aspartate transaminase (GOT2). The emergence of metabolomics resembles the advent of genetic testing in this field, which began with single-gene discoveries in research laboratories but is now done by standardized massively parallel sequencing (targeted panel/exome/genome testing) in pathology laboratories governed by strict credentialing and governance requirements. In this setting, metabolomics is poised for rapid translation as it can utilize existing infrastructure, namely liquid chromatography-tandem mass spectrometry (LC-MS/MS), for the measurement of catecholamine metabolites. Metabolomics has also proven tractable to in vivo diagnosis of SDH-deficient PPGLs using magnetic resonance spectroscopy (MRS). The future of metabolomics - embedded as a diagnostic tool - will require adoption by pathologists to shepherd development of standardized assays and sample preparation, reference ranges, gold standards, and credentialing.
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Affiliation(s)
- Trisha Dwight
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, Australia
- University of Sydney, Sydney, Australia
| | - Edward Kim
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, Australia
- University of Sydney, Sydney, Australia
| | - Talia Novos
- Clinical Chemistry, South Eastern Area Laboratory Services Pathology, Prince of Wales Private Hospital, Randwick, Australia
| | - Roderick J Clifton-Bligh
- Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, Australia
- University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, Australia
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Gill P, Kim E, Chua TC, Clifton-Bligh RJ, Nahm CB, Mittal A, Gill AJ, Samra JS. MiRNA-3653 Is a Potential Tissue Biomarker for Increased Metastatic Risk in Pancreatic Neuroendocrine Tumours. Endocr Pathol 2019; 30:128-133. [PMID: 30767148 DOI: 10.1007/s12022-019-9570-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatic neuroendocrine tumours (PNETs) are relatively uncommon, accounting for 1-2% of all pancreatic neoplasms. Tumour grade (based on the Ki67 proliferative index and mitotic rate) is associated with metastatic risk across large cohorts; however, predicting the behaviour of individual tumours can be difficult. Therefore, any tool which could further stratify metastatic risk may be clinically beneficial. We sought to investigate microRNA (miRNA) expression as a marker of metastatic disease in PNETs. Tumours from 37 patients, comprising 23 with locoregional disease (L) and 14 with distant metastases (DM), underwent miRNA profiling. In total 506 miRNAs were differentially expressed between the L and DM groups, with four miRNAs (miR-3653 upregulated, and miR-4417, miR-574-3p and miR-664b-3p downregulated) showing statistical significance. A database search demonstrated that miRNA-3653 was associated with ATRX abnormalities. Mean survival between the two groups was correlated with mean expression of miRNA-3653; however, this did not reach statistical significance (p = 0.204). Although this is a small study, we conclude that miRNA-3653 upregulation may be associated with an increased risk of metastatic disease in PNETS, perhaps through interaction with ATRX and the alternate lengthening of telomeres pathway.
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Affiliation(s)
- Preetjote Gill
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia
| | - Edward Kim
- Sydney Medical School, University of Sydney, Sydney, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Terence C Chua
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Sydney Medical School, University of Sydney, Sydney, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, 2065, Australia
| | - Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Australian Pancreatic Centre, St Leonards, Sydney, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Australian Pancreatic Centre, St Leonards, Sydney, Australia
| | - Anthony J Gill
- Sydney Medical School, University of Sydney, Sydney, Australia.
- Australian Pancreatic Centre, St Leonards, Sydney, Australia.
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia.
- Cancer Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW, Australia.
| | - Jaswinder S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.
- Sydney Medical School, University of Sydney, Sydney, Australia.
- Australian Pancreatic Centre, St Leonards, Sydney, Australia.
- Faculty of Medical and Health Sciences, Macquarie University, Sydney, Australia.
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Benn DE, Zhu Y, Andrews KA, Wilding M, Duncan EL, Dwight T, Tothill RW, Burgess J, Crook A, Gill AJ, Hicks RJ, Kim E, Luxford C, Marfan H, Richardson AL, Robinson B, Schlosberg A, Susman R, Tacon L, Trainer A, Tucker K, Maher ER, Field M, Clifton-Bligh RJ. Bayesian approach to determining penetrance of pathogenic SDH variants. J Med Genet 2018; 55:729-734. [PMID: 30201732 PMCID: PMC6252366 DOI: 10.1136/jmedgenet-2018-105427] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 08/15/2018] [Accepted: 08/20/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Until recently, determining penetrance required large observational cohort studies. Data from the Exome Aggregate Consortium (ExAC) allows a Bayesian approach to calculate penetrance, in that population frequencies of pathogenic germline variants should be inversely proportional to their penetrance for disease. We tested this hypothesis using data from two cohorts for succinate dehydrogenase subunits A, B and C (SDHA-C) genetic variants associated with hereditary pheochromocytoma/paraganglioma (PC/PGL). METHODS Two cohorts were 575 unrelated Australian subjects and 1240 unrelated UK subjects, respectively, with PC/PGL in whom genetic testing had been performed. Penetrance of pathogenic SDHA-C variants was calculated by comparing allelic frequencies in cases versus controls from ExAC (removing those variants contributed by The Cancer Genome Atlas). RESULTS Pathogenic SDHA-C variants were identified in 106 subjects (18.4%) in cohort 1 and 317 subjects (25.6%) in cohort 2. Of 94 different pathogenic variants from both cohorts (seven in SDHA, 75 in SDHB and 12 in SDHC), 13 are reported in ExAC (two in SDHA, nine in SDHB and two in SDHC) accounting for 21% of subjects with SDHA-C variants. Combining data from both cohorts, estimated lifetime disease penetrance was 22.0% (95% CI 15.2% to 30.9%) for SDHB variants, 8.3% (95% CI 3.5% to 18.5%) for SDHC variants and 1.7% (95% CI 0.8% to 3.8%) for SDHA variants. CONCLUSION Pathogenic variants in SDHB are more penetrant than those in SDHC and SDHA. Our findings have important implications for counselling and surveillance of subjects carrying these pathogenic variants.
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Affiliation(s)
- Diana E Benn
- Hormones and Cancer, Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Ying Zhu
- Hormones and Cancer, Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia,Department of Cancer Services, Northern Sydney Local Health District Familial Cancer Service, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Katrina A Andrews
- Department of Medical Genetics, University of Cambridge and NIHR Cambridge Biomedical Research Centre and Cancer Research UK Cambridge Centre and Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Mathilda Wilding
- Department of Cancer Services, Northern Sydney Local Health District Familial Cancer Service, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Emma L Duncan
- School of Biomedical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia,Department of Endocrinology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Trisha Dwight
- Hormones and Cancer, Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Richard W Tothill
- Department of Oncology, The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - John Burgess
- Faculty of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Ashley Crook
- Department of Cancer Services, Northern Sydney Local Health District Familial Cancer Service, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Anthony J Gill
- Department of Medicine, University of Sydney, Sydney, New South Wales, Australia,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Rodney J Hicks
- Department of Oncology, The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Edward Kim
- Hormones and Cancer, Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Catherine Luxford
- Hormones and Cancer, Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Helen Marfan
- Genetic Health Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Anne Louise Richardson
- Hormones and Cancer, Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Bruce Robinson
- Hormones and Cancer, Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia,Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, USA
| | - Arran Schlosberg
- Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Rachel Susman
- Genetic Health Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Lyndal Tacon
- Hormones and Cancer, Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia,Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, USA
| | - Alison Trainer
- Department of Oncology, The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Katherine Tucker
- Department of Clinical Genetics, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Eamonn R Maher
- Department of Medical Genetics, University of Cambridge and NIHR Cambridge Biomedical Research Centre and Cancer Research UK Cambridge Centre and Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Michael Field
- Department of Cancer Services, Northern Sydney Local Health District Familial Cancer Service, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Roderick J Clifton-Bligh
- Hormones and Cancer, Cancer Genetics Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, New South Wales, Australia,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia,Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, USA
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Gild ML, Tsang V, Samra J, Clifton-Bligh RJ, Tacon L, Gill AJ. Hypercalcemia in Glucagon Cell Hyperplasia and Neoplasia (Mahvash Syndrome): A New Association. J Clin Endocrinol Metab 2018; 103:3119-3123. [PMID: 30032256 DOI: 10.1210/jc.2018-01074] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/13/2018] [Indexed: 12/28/2022]
Abstract
CONTEXT Hyperglucagonemia in the absence of glucagonomas is rare. Biallelic-inactivating mutations in the glucagon receptor gene (GCGR) cause glucagon cell hyperplasia and neoplasia (GCHN), also termed Mahvash syndrome. Here, we report the first case to our knowledge of GCHN presenting with hypercalcemia and demonstrate a unique relationship between calcium and α-cell hyperplasia. CASE DESCRIPTION A 47-year-old man presented with severe PTH-independent hypercalcemia, 13.95 mg/dL (3.48 mmol/L). Imaging and extensive pathology tests yielded no conclusive cause. Glucagon levels >300 times the upper limit of normal were discovered. Subtotal pancreatectomy identified α-cell hyperplasia and neoplasia with metastatic disease in lymph nodes. Genomic analysis confirmed a homozygous missense variant in GCGR (Asp63Asn). This is a previously described pathologic variant and has a known association with GCHN. CONCLUSIONS Inactivating mutations of the glucagon receptor gene lead to nonfunctional hyperglucagonemia and are associated with GCHN. Homozygous or compound heterozygous GCGR mutations are associated with α-cell hyperplasia, a known precursor to pancreatic neuroendocrine tumors that can metastasize. Hypercalcemia is an unreported consequence of GCHN with an unclear mechanism.
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Affiliation(s)
- Matti L Gild
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Venessa Tsang
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Jaswinder Samra
- University of Sydney, Sydney, New South Wales, Australia
- Department of Surgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Roderick J Clifton-Bligh
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Lyndal Tacon
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Anthony J Gill
- University of Sydney, Sydney, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
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Bakhsh AD, Ladas I, Hamshere ML, Bullock M, Kirov G, Zhang L, Taylor PN, Gregory JW, Scott-Coombes D, Völzke H, Teumer A, Mantripragada K, Williams ED, Clifton-Bligh RJ, Williams NM, Ludgate ME. An InDel in Phospholipase-C-B-1 Is Linked with Euthyroid Multinodular Goiter. Thyroid 2018; 28:891-901. [PMID: 29897006 DOI: 10.1089/thy.2017.0312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Euthyroid multinodular goiter (MNG) is common, but little is known about the genetic variations conferring predisposition. Previously, a family with MNG of adolescent onset was reported in which some family members developed papillary thyroid carcinomas (PTC). METHODS Genome-wide linkage analysis and next-generation sequencing were conducted to identify genetic variants that may confer disease predisposition. A multipoint nonparametric LOD score of 3.01 was obtained, covering 19 cM on chromosome 20p. Haplotype analysis reduced the region of interest to 10 cM. RESULTS Analysis of copy number variation identified an intronic InDel (∼1000 bp) in the PLCB1 gene in all eight affected family members and carriers (an unaffected person who has inherited the genetic trait). This InDel is present in approximately 1% of "healthy" Caucasians. Next-generation sequencing of the region identified no additional disease-associated variant, suggesting a possible role of the InDel. Since PLCB1 contributes to thyrocyte growth regulation, the InDel was investigated in relevant Caucasian cohorts. It was detected in 0/70 PTC but 4/81 unrelated subjects with MNG (three females; age at thyroidectomy 27-59 years; no family history of MNG/PTC). The InDel frequency is significantly higher in MNG subjects compared to controls (χ2 = 5.076; p = 0.024. PLCB1 transcript levels were significantly higher in thyroids with the InDel than without (p < 0.02). CONCLUSIONS The intronic PLCB1 InDel is the first variant found in familial multiple papilloid adenomata-type MNG and in a subset of patients with sporadic MNG. It may function through overexpression, and increased PLC activity has been reported in thyroid neoplasms. The potential role of the deletion as a biomarker to identify MNG patients more likely to progress to PTC merits exploration.
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Affiliation(s)
- Ameen D Bakhsh
- 1 Division of Infection and Immunity, Cardiff University , Cardiff, United Kingdom
| | - Ioannis Ladas
- 1 Division of Infection and Immunity, Cardiff University , Cardiff, United Kingdom
| | - Marian L Hamshere
- 2 Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University , Cardiff, United Kingdom
| | - Martyn Bullock
- 3 Kolling Institute of Medical Research and Department of Endocrinology, University of Sydney , Royal North Shore Hospital, Sydney, Australia
| | - George Kirov
- 2 Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University , Cardiff, United Kingdom
| | - Lei Zhang
- 1 Division of Infection and Immunity, Cardiff University , Cardiff, United Kingdom
| | - Peter N Taylor
- 1 Division of Infection and Immunity, Cardiff University , Cardiff, United Kingdom
| | - John W Gregory
- 1 Division of Infection and Immunity, Cardiff University , Cardiff, United Kingdom
| | - David Scott-Coombes
- 4 Department of Endocrine Surgery; Cardiff University , Cardiff, United Kingdom
| | - Henry Völzke
- 5 Institute for Community Medicine, Study of Health in Pomerania, Ernst Moritz Arndt University , Greifswald, Germany
| | - Alexander Teumer
- 5 Institute for Community Medicine, Study of Health in Pomerania, Ernst Moritz Arndt University , Greifswald, Germany
| | - Kiran Mantripragada
- 2 Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University , Cardiff, United Kingdom
| | - E Dillwyn Williams
- 6 Thyroid Carcinogenesis Research Group, Strangeways Research Laboratory , Wort's Causeway, Cambridge, United Kingdom
| | - Roderick J Clifton-Bligh
- 3 Kolling Institute of Medical Research and Department of Endocrinology, University of Sydney , Royal North Shore Hospital, Sydney, Australia
| | - Nigel M Williams
- 2 Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University , Cardiff, United Kingdom
| | - Marian E Ludgate
- 1 Division of Infection and Immunity, Cardiff University , Cardiff, United Kingdom
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Tsang VH, Clifton-Bligh RJ, Long GV, Guminski AD, Menzies AM. A case series of immune checkpoint inhibitor induced diabetes mellitus (ICI-DM). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e22080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Venessa H Tsang
- Department of Endocrinology, Royal North Shore Hospital; Sydney Medical School, University of Sydney, Sydney Australia., St Leonards NSW 2065, AU
| | - Roderick J Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital; The University of Sydney, Sydney Australia., St Leonards NSW 2065, AU
| | - Georgina V. Long
- Melanoma Institute Australia, The University of Sydney, Mater Hospital, and Royal North Shore Hospital, Sydney, Australia
| | - Alexander David Guminski
- Melanoma Institute Australia, Royal North Shore Hospital, The University of Sydney, Sydney, Australia
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Gild ML, Topliss DJ, Learoyd D, Parnis F, Tie J, Hughes B, Walsh JP, McLeod DSA, Clifton-Bligh RJ, Robinson BG. Clinical guidance for radioiodine refractory differentiated thyroid cancer. Clin Endocrinol (Oxf) 2018; 88:529-537. [PMID: 29095527 DOI: 10.1111/cen.13508] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 10/25/2017] [Accepted: 10/27/2017] [Indexed: 12/26/2022]
Abstract
Prognosis from differentiated thyroid cancer is worse when the disease becomes refractory to radioiodine. Until recently, treatment options have been limited to local therapies such as surgery and radiotherapy, but the recent availability of systemic therapies now provides some potential for disease control. Multitargeted kinase inhibitors (TKIs) including lenvatinib and sorafenib have been shown to improve progression-free survival in phase III clinical trials, but are also associated with a spectrum of adverse effects. Other TKIs have been utilized as "redifferentiation" agents, increasing sodium iodide symporter expression in metastases and thus restoring radioiodine avidity. Some patients whose disease progresses on initial TKI therapy will still respond to a different TKI and clinical trials currently in progress will clarify the best options for such patients. As these drugs are not inexpensive, care needs to be taken to minimize not only biological but also financial toxicity. In this review, we examine the basic biology of radioiodine refractory disease and discuss optimal treatment approaches, with specific focus on choice and timing of TKI treatment. This clinical field remains fluid, and directions for future research include exploring biomarkers and considering adjuvant TKI use in certain patient groups.
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Affiliation(s)
- Matti L Gild
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital Sydney, St Leonards, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
| | - Duncan J Topliss
- Department of Endocrinology and Diabetes, The Alfred, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - Diana Learoyd
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital Sydney, St Leonards, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
| | - Francis Parnis
- Department of Oncology, Adelaide Cancer Centre, Kurralta Park, SA, Australia
- Adelaide University, Adelaide, SA, Australia
| | - Jeanne Tie
- Division of Systems Biology and Personalized Medicine, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
- Department of Medical Oncology, Western Health, Melbourne, VIC, Australia
| | - Brett Hughes
- Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Medicine, The University of Queensland, St Lucia, Brisbane, QLD, Australia
| | - John P Walsh
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- School of Medicine and Pharmacology, The University of Western Australia, Crawley, WA, Australia
| | - Donald S A McLeod
- Department of Endocrinology, Diabetes Royal Brisbane and Women's Hospital, Herston, QLD, Australia
- Population Health Department QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Roderick J Clifton-Bligh
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital Sydney, St Leonards, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
- Cancer Genetics Laboratory, Hormones and Cancer Group, Kolling Institute of Medical Research, Sydney, SW, Australia
| | - Bruce G Robinson
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital Sydney, St Leonards, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
- Cancer Genetics Laboratory, Hormones and Cancer Group, Kolling Institute of Medical Research, Sydney, SW, Australia
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Bullock M, Lim G, Li C, Choi IH, Kochhar S, Liddle C, Zhang L, Clifton-Bligh RJ. Thyroid transcription factor FOXE1 interacts with ETS factor ELK1 to co-regulate TERT. Oncotarget 2018; 7:85948-85962. [PMID: 27852061 PMCID: PMC5349888 DOI: 10.18632/oncotarget.13288] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 11/06/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although FOXE1 was initially recognized for its role in thyroid organogenesis, more recently a strong association has been identified between the FOXE1 locus and thyroid cancer. The role of FOXE1 in adult thyroid, and in particular regarding cancer risk, has not been well established. We hypothesised that discovering key FOXE1 transcriptional partners would in turn identify regulatory pathways relevant to its role in oncogenesis. RESULTS In a transcription factor-binding array, ELK1 was identified to bind FOXE1. We confirmed this physical association in heterologously transfected cells by IP and mammalian two-hybrid assays. In thyroid tissue, endogenous FOXE1 was shown to bind ELK1, and using ChIP assays these factors bound thyroid-relevant gene promoters TPO and TERT in close proximity to each other. Using a combination of electromobility shift assays, TERT promoter assays and siRNA-silencing, we found that FOXE1 positively regulated TERT expression in a manner dependent upon its association with ELK1. Treating heterologously transfected thyroid cells with MEK inhibitor U0126 inhibited FOXE1-ELK1 interaction, and reduced TERT and TPO promoter activity. METHODOLOGY We investigated FOXE1 interactions within in vitro thyroid cell models and human thyroid tissue using a combination of immunoprecipitation (IP), chromatin IP (ChIP) and gene reporter assays. CONCLUSIONS FOXE1 interacts with ELK1 on thyroid relevant gene promoters, establishing a new regulatory pathway for its role in adult thyroid function. Co-regulation of TERT suggests a mechanism by which allelic variants in/near FOXE1 are associated with thyroid cancer risk.
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Affiliation(s)
- Martyn Bullock
- Cancer Genetics Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Grace Lim
- Cancer Genetics Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Cheng Li
- Cancer Genetics Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - In Ho Choi
- Cancer Genetics Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Shivansh Kochhar
- Cancer Genetics Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Chris Liddle
- University of Sydney, Sydney, Australia.,Storr Liver Centre, Westmead Millennium Institute for Medical Research, Westmead Hospital, Sydney, Australia
| | - Lei Zhang
- Institute of Molecular and Experimental Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Roderick J Clifton-Bligh
- Cancer Genetics Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia.,Department of Endocrinology, Royal North Shore Hospital, Sydney, Australia
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Scott ES, Long GV, Guminski A, Clifton-Bligh RJ, Menzies AM, Tsang VH. The spectrum, incidence, kinetics and management of endocrinopathies with immune checkpoint inhibitors for metastatic melanoma. Eur J Endocrinol 2018; 178:173-180. [PMID: 29187509 DOI: 10.1530/eje-17-0810] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/24/2017] [Accepted: 11/28/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Endocrine immune-related adverse events (endocrinopathies) are increasingly prevalent with the use of immune checkpoint inhibitors for the treatment of metastatic melanoma and other malignancies. There are no evidence-based guidelines for the screening or management of such patients. To describe the spectrum, incidence, kinetics and management of endocrinopathies with immune checkpoint inhibitors. DESIGN A prospective study conducted at Melanoma Institute Australia between April 2014 and October 2015. METHODS A total of 177 patients were treated with (a) ipilimumab (n = 15), (b) anti-PD-1 (nivolumab, pembrolizumab) (n = 103) or (c) combination ipilimumab and anti-PD-1 (n = 59) and were screened and managed for the subsequent endocrinopathies. The main outcome measures were the incidence and kinetics of endocrinopathy by immunotherapy drug class. RESULTS Thirty-one patients (18%) developed an endocrine immune-related adverse event (thyroid dysfunction: 14%, hypophysitis: 6% and autoimmune diabetes: 0.6%). Combination immunotherapy was more likely to result in a single or multiple endocrinopathy compared to anti-PD-1 monotherapy (27% vs 9% and 7% vs 0% respectively, P < 0.01). Endocrinopathies occurred after a median of 8 weeks from treatment commencement (range: 12-225 days), with combination immunotherapy resulting in significantly earlier onset compared to ipilimumab (median: 30 vs 76 days, P = 0.046). The majority of endocrinopathies were identified in asymptomatic patients with hormonal screening. There were no baseline predictors for endocrinopathy. CONCLUSIONS Combination immunotherapy has a greater risk of development of endocrinopathy compared to anti-PD-1 monotherapy. Regular biochemical profiling of patients, particularly within the first twelve weeks, results in early detection of endocrinopathy to minimise morbidity.
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Affiliation(s)
- Emma S Scott
- Department of Endocrinology, Royal North Shore Hospital, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Georgina V Long
- Sydney Medical School, The University of Sydney, Sydney, Australia
- Melanoma Institute Australia, Sydney, Australia
- Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Alexander Guminski
- Sydney Medical School, The University of Sydney, Sydney, Australia
- Melanoma Institute Australia, Sydney, Australia
- Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Roderick J Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Alexander M Menzies
- Sydney Medical School, The University of Sydney, Sydney, Australia
- Melanoma Institute Australia, Sydney, Australia
- Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Venessa H Tsang
- Department of Endocrinology, Royal North Shore Hospital, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
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