Bedeutung des humanen Gens icb-1 für die antiproliferative Wirkung von Antiöstrogenen in Mammakarzinomzellen

Das Gen icb-1 („induced by contact to basement membrane 1“) ist in Differenzierungsprozesse von Krebszellen involviert und nimmt eine wichtige Rolle in Proliferationsprozessen, Apoptoseverhalten und Progression gynäkologischer Tumore ein. Aufbauend auf eine aktuelle Studie von Knudsen et al, welche das Gen icb-1 als Teil einer Signatur zur Prädiktion des Ansprechens auf das Antiöstrogen Fulvestrant (Faslodex, ICI 182,780) identifizierte (133), wurde in dieser Arbeit nun die Bedeutung von icb-1 für östrogenabhängige Zellproliferation und die Wirkung von Antiöstrogenen bei Brustkrebszellen genauer untersucht. Hierfür wurde repräsentativ die östrogensensitive Brustkrebszelllinie T-47-D verwendet. Verglichen wurden jeweils knockdown Zellen, bei denen mittels Transfektion einer spezifischen siRNA das icb-1 Gen transient ausgeschaltet wurde, und Zellen mit normaler icb-1 Expression. Die Zellen wurden mit einer Kombination aus 17-β Östradiol und Antiöstrogenen ICI 182,780, 4-OH-Tamoxifen bzw. Endoxifen behandelt. An den entsprechenden Messtagen wurde die Proliferationsrate der Zellen direkt via CTB-Assay detektiert. Auf molekularer Ebene wurde die Expression proliferations- und östrogenassoziierter Gene bei den knockdown- und den Kontrollzellen mittels RealTime qPCR im LightCycler bestimmt. Das Ausschalten von icb-1 wirkte eindeutig proliferationssteigernd auf die Brustkrebszellen. Zudem konnte ein signifikant verbessertes Östrogenansprechen im Sinne einer verstärkten Proliferation bei den icb-1 knockdown Zellen beobachtet werden. Eine Erklärung für diesen östrogenassoziierten proliferationssteigernden Effekt bietet vermutlich die Hochregulation der ERα mRNA-Expression durch den knockdown von icb-1. Dieses verstärkte ERα-vermittelte Östrogenansprechen führte nämlich auf molekularer Ebene zu einer gesteigerten Expression der Proliferationsgene nach Behandlung mit 17-β Östradiol. Weiterhin ergaben die Versuchsreihen dieser Arbeit, dass der icb-1 knockdown mit einem signifikant gesteigerten antiproliferativen Effekt von ICI 182,780 auf die T-47-D Zellen einhergeht. Im Falle von 4-OH-Tamoxifen konnte generell kein ausreichendes Ansprechen der T-47-D Zellen erzielt werden und somit ergab sich auch kein signifikanter Unterschied in der Wirkung des Antiöstrogens bei den icb-1 knockdown Zellen und den Zellen mit normaler icb-1 Expression. Obwohl sich für Endoxifen, Metabolit von Tamoxifen, ein leicht verbessertes Ansprechen der Zellen im Allgemeinen zeigte, war auch für dieses Antiöstrogen kein signifikanter Unterschied in der Wirkung bei den knockdown- und den Kontrollzellen zu erkennen. Zusammenfassend bestätigen die Ergebnisse dieser Studie die Rolle des Gens icb-1 als inhibierende Komponente zellulären Östrogenansprechens bei den Brustkrebszellen T-47-D und lassen icb-1 antiproliferationshemmende Eigenschaften für ICI 182,780 bei den Zellen zukommen. Die Identifizierung des Gens icb-1 als essentielles Element für das Ansprechen von Brustkrebszellen auf Antiöstrogene gibt Anlass für weiterführende Studien, um die Bedeutung von icb-1 für die endokrine Krebstherapie mit Antiöstrogenen genauer zu erforschen

Radiotherapy for pediatric adrenocortical carcinoma – review of the literature

none13Background and purpose Pediatric adrenocortical carcinoma (pACC) is a rare disease with poor prognosis. Publications on radiotherapy (RT) are scarce. This review summarizes the current data on RT for pACC and possibly provides first evidence to justify its use in this setting. Materials and methods We searched the PubMed and Embase database for manuscripts regarding RT for pACC. Results We included 17 manuscripts reporting on 76 patients treated with RT, after screening 2961 references and 269 full articles. In addition, we added data of 4 unreported pACC patients treated by co-authors. All reports based on retrospective data. Median age at first diagnosis was 11.1 years (70% female); 78% of patients presented with hormonal activity. RT was mostly performed for curative intent (78%). 88% of RT were administered during primary therapy. The site of RT was predominantly the local tumor bed (76%). Doses of RT ranged from 15 to 62 Gy (median 50 Gy). Information on target volumes or fractionation were lacking. Median follow-up was 6,9 years and 64% of the patients died of disease, with 33% alive without disease. In 16 of 48 patients with available follow-up data after adjuvant RT (33%) no recurrence was reported and in 3 of 9 patients palliative RT seemed to induce some benefit for the patient. Conclusions Our first systematic review on RT for pACC provides too few data for any general recommendation, but adjuvant RT in patients with high risk might be considered. International collaborative studies are urgently needed to establish better evidence on the role of RT in this rare malignancy.noneWiegering, Verena; Riedmeier, Maria; Thompson, Lester D.R.; Virgone, Calogero; Redlich, Antje; Kuhlen, Michaela; Gultekin, Melis; Yalcin, Bilgehan; Decarolis, Boris; Härtel, Christoph; Schlegel, Paul-Gerhardt; Fassnacht, Martin; Timmermann, BeateWiegering, Verena; Riedmeier, Maria; Thompson, Lester D. R.; Virgone, Calogero; Redlich, Antje; Kuhlen, Michaela; Gultekin, Melis; Yalcin, Bilgehan; Decarolis, Boris; Härtel, Christoph; Schlegel, Paul-Gerhardt; Fassnacht, Martin; Timmermann, Beat

Isosexual precocious pseudopuberty during mitotane treatment in a child with adrenocortical carcinoma:A case report

Background Mitotane is employed as adjuvant therapy in managing adrenocortical carcinoma in pediatric patients. While various adverse effects, such as estrogen-like manifestations, are well-documented in adults, there is limited knowledge regarding pediatric-specific toxicity. This report details an uncommon case of isosexual precocious pseudopuberty induced during childhood due to the estrogen-like effects of mitotane. Case report A 2.8-year-old female diagnosed with adrenocortical carcinoma (pT4 pN0 M0) underwent adjuvant treatment with mitotane and cytotoxic chemotherapy following incomplete resection (tumor stage III). Approximately eight months into mitotane treatment, she exhibited signs of puberty (Tanner stage 2), including progressive breast development, uterine enlargement, vaginal discharge, and an advancement of bone age by nearly two years. Gonadotrophin-dependent puberty and endogenous estrogen production were ruled out. The precocious pseudopuberty was attributed to previously reported estrogen-like effects of mitotane therapy. Subsequent administration of the aromatase inhibitor anastrozole in combination with mitotane led to a reduction in clinical signs of puberty. Conclusion Monitoring for estrogen-like effects of mitotane is crucial, particularly in pre-pubertal children, to avert potentially irreversible changes associated with precocious pseudopuberty. Aromatase inhibitors may serve as a prompt therapeutic option, enabling the continuation of mitotane treatment

Icb-1 expression inhibits growth and fulvestrant response of breast cancer cells and affects survival of breast cancer patients

Purpose Human gene icb-1 recently has been reported to be part of a gene expression score predicting response to antiestrogen fulvestrant in breast cancer patients. In the present study, we examined to what extent icb-1 expression would affect the response of breast cancer cells to this antiestrogen in vitro and investigated underlying molecular mechanisms. Using open access mRNA data, we elucidated the significance of icb-1 expression for survival of breast cancer patients. Methods Icb-1 gene expression was knocked down by RNAi. Breast cancer cell growth after treatment with fulvestrant was assessed using the Cell Titer Blue assay. Gene expression was analyzed by Western blot analysis or RT-qPCR. Survival analyses were performed using bioinformatical online tools and data. Results Knockdown of icb-1 in T-47D breast cancer cells significantly increased growth of this cell line and also elevated the growth-stimulatory effect of E2 (p < 0.001). After treatment with different concentrations of fulvestrant, icb-1 knockdown cells exhibited a significantly enhanced response to this drug (p < 0.01). On the molecular level, icb-1 knockdown led to elevated expression of ESR1 and its target gene TFF1 (pS2) and enhanced E2-triggered up-regulation of proliferation genes. Finally, bioinformatical meta-analysis of gene expression data of 3951 breast cancer patients revealed that high icb-1 expression increases their relapse-free survival (HR = 0.87, p < 0.05). Conclusion The presented data further support a tumor-suppressive role of icb-1 in breast cancer and suggest an inhibitory effect of this gene on fulvestrant action, which both are suggested to be mediated by suppression of cellular E2 response

Adrenalectomies in children and adolescents in Germany – a diagnose related groups based analysis from 2009-2017

Background Adrenalectomies are rare procedures especially in childhood. So far, no large cohort study on this topic has been published with data on to age distribution, operative procedures, hospital volume and operative outcome. Methods This is a retrospective analysis of anonymized nationwide hospital billing data (DRG data, 2009-2017). All adrenal surgeries (defined by OPS codes) of patients between the age 0 and 21 years in Germany were included. Results A total of 523 patient records were identified. The mean age was 8.6 ± 7.7 years and 262 patients were female (50.1%). The majority of patients were between 0 and 5 years old (52% overall), while 11.1% were between 6 and 11 and 38.8% older than 12 years. The most common diagnoses were malignant neoplasms of the adrenal gland (56%, mostly neuroblastoma) with the majority being younger than 5 years. Benign neoplasms in the adrenal gland (D350) account for 29% of all cases with the majority of affected patients being 12 years or older. 15% were not defined regarding tumor behavior. Overall complication rate was 27% with a clear higher complication rate in resection for malignant neoplasia of the adrenal gland. Bleeding occurrence and transfusions are the main complications, followed by the necessary of relaparotomy. There was an uneven patient distribution between hospital tertiles (low volume, medium and high volume tertile). While 164 patients received surgery in 85 different “low volume” hospitals (0.2 cases per hospital per year), 205 patients received surgery in 8 different “high volume” hospitals (2.8 cases per hospital per year; p<0.001). Patients in high volume centers were significant younger, had more extended resections and more often malignant neoplasia. In multivariable analysis younger age, extended resections and open procedures were independent predictors for occurrence of postoperative complications. Conclusion Overall complication rate of adrenalectomies in the pediatric population in Germany is low, demonstrating good therapeutic quality. Our analysis revealed a very uneven distribution of patient volume among hospitals

Assessment of prognostic factors in pediatric adrenocortical tumors: a systematic review and evaluation of a modified S-GRAS score

ObjectivePediatric adrenocortical carcinoma (pACC) is rare and prognostic stratification remains challenging. We summarized the clinical prognostic factors of pACC and determined the prognostic value of the pediatric scoring system (pS-GRAS) in adaption to the recommendation (S-GRAS) of the European Network for the Study of Adrenal Tumors for the classification of adult ACC. DesignAnalysis of pACC patients of 33 available retrospective studies in the literature. MethodsWe searched the PubMed and Embase databases for manuscripts regarding pACC. The pS-GRAS score was calculated as a sum of tumor stage (1 = 0; 2-3 = 1; 4 = 2 points), grade (Ki67 index/rate of mitosis 0-9%/low = 0; 10-19%/intermediate = 1; >= 20%/high = 2 points), resection status (R0 = 0; RX = 1; R1 = 2; R2 = 3 points), age (= 4 years = 1 point), hormone-related symptoms (androgen production = 0; glucocorticoid/mixed/no hormone production = 1 point) generating 10 scores and 4 groups (1: 0-2, 2: 3-4, 3: 5, 4: 6-9). The primary endpoint was overall survival (OS). ResultsWe included 733 patients. The median age was 2.5 years and >85% of pACC showed hormone activity (mixed 50%, androgen 29%, glucocorticoid 21%). Androgen production was associated with a superior OS. Increasing age correlated with higher rates of inactive or only glucocorticoid-producing tumors, advanced tumor stage, and case fatality. Especially infants < 4 years showed more often low-risk constellations with an increased OS for all tumor stages. The pS-GRAS score correlated with clinical outcome; median OS was 133 months (95% CI: 36-283) in group 1 (n = 49), 110 months (95% CI: 2.9-314) in group 2 (n = 57), 49 months (95% CI: 5.8-278) in group 3 (n = 18), and 16 months (95% CI: 2.4-267) in group 4; (n = 11) P < 0.05). ConclusionThe pS-GRAS score seems to have a high predictive value in the pACC patients, may serve as a helpful tool for risk stratification in future studies, and should be evaluated prospectively in an international context

Adrenocortical Carcinoma in Childhood: A Systematic Review

Simple Summary Pediatric adrenocortical tumors are rare. Little information is available on the incidence, risk factors, prognostic factors, treatment, and overall survival. In this systematic review, we performed a search of the current literature. The most common reported risk factors are age > 4 years, high pathological tumor score, and advanced stage in which prognosis is poor. Treatment options are surgery, radiation, or chemotherapy, but ongoing randomized trials are lacking. International prospective studies must be the next step to implement standardized clinical stratifications and risk-adapted therapeutic strategies. Adrenocortical tumors are rare in children. This systematic review summarizes the published evidence on pediatric adrenocortical carcinoma (ACC) to provide a basis for a better understanding of the disease, investigate new molecular biomarkers and therapeutic targets, and define which patients may benefit from a more aggressive therapeutic approach. We included 137 studies with 3680 ACC patients (~65% female) in our analysis. We found no randomized controlled trials, so this review mainly reflects retrospective data. Due to a specific mutation in the TP53 gene in ~80% of Brazilian patients, that cohort was analyzed separately from series from other countries. Hormone analysis was described in 2569 of the 2874 patients (89%). Most patients were diagnosed with localized disease, whereas 23% had metastasis at primary diagnosis. Only 72% of the patients achieved complete resection. In 334 children (23%), recurrent disease was reported: 81%-local recurrence, 19% (n = 65)-distant metastases at relapse. Patients < 4 years old had a different distribution of tumor stages and hormone activity and better overall survival (p < 0.001). Although therapeutic approaches are typically multimodal, no consensus is available on effective standard treatments for advanced ACC. Thus, knowledge regarding pediatric ACC is still scarce and international prospective studies are needed to implement standardized clinical stratifications and risk-adapted therapeutic strategies

International consensus on mitotane treatment in pediatric patients with adrenal cortical tumors: indications, therapy, and management of adverse effects.

OBJECTIVE: Mitotane is an important cornerstone in the treatment of pediatric adrenal cortical tumors (pACC), but experience with the drug in the pediatric age group is still limited and current practice is not guided by robust evidence. Therefore, we have compiled international consensus statements from pACC experts on mitotane indications, therapy, and management of adverse effects. METHODS: A Delphi method with 3 rounds of questionnaires within the pACC expert consortium of the international network groups European Network for the Study of Adrenal Tumors pediatric working group (ENSAT-PACT) and International Consortium of pediatric adrenocortical tumors (ICPACT) was used to create 21 final consensus statements. RESULTS: We divided the statements into 4 groups: environment, indications, therapy, and adverse effects. We reached a clear consensus for mitotane treatment for advanced pACC with stages III and IV and with incomplete resection/tumor spillage. For stage II patients, mitotane is not generally indicated. The timing of initiating mitotane therapy depends on the clinical condition of the patient and the setting of the planned therapy. We recommend a starting dose of 50 mg/kg/d (1500 mg/m²/d) which can be increased up to 4000 mg/m2/d. Blood levels should range between 14 and 20 mg/L. Duration of mitotane treatment depends on the clinical risk profile and tolerability. Mitotane treatment causes adrenal insufficiency in virtually all patients requiring glucocorticoid replacement shortly after beginning. As the spectrum of adverse effects of mitotane is wide-ranging and can be life-threatening, frequent clinical and neurological examinations (every 2-4 weeks), along with evaluation and assessment of laboratory values, are required. CONCLUSIONS: The Delphi method enabled us to propose an expert consensus statement, which may guide clinicians, further adapted by local norms and the individual patient setting. In order to generate evidence, well-constructed studies should be the focus of future efforts