Diagnosis, Pathophysiology And Molecular Biology Of Pheochromocytoma

嗜铬细胞瘤的诊断、病理生理学和分子生物学

• 批准号: 8553901
• 负责人: Karel Pacak
• 金额: $ 117.38万
• 依托单位: EUNICE KENNEDY SHRIVER NATIONAL INSTITUTE OF CHILD HEALTH & HUMAN DEVELOPMENT
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/8553901
• 关键词: Address; Adolescence; Adrenal Gland Neoplasms; Adrenal Glands; Affect; Age; Animal Model; Basic Science; Benign; Biochemical; Biological Markers; Capsaicin; Catecholamines; Cells; Chemistry; Childhood; Clinical; Collaborations; DNA; Data; Development; Diagnosis; Dimensions; Disease; Etiology; Female; Functional disorder; Gatekeeping; Gene Mutation; Genes; Genetic; Genetic Counseling; Genetic Markers; Genetic screening method; Germ-Line Mutation; Goals; Gold; Head and neck structure; Hereditary Disease; Image; Incidence; Induction of Apoptosis; Inherited; Institutes; Interdisciplinary Study; International; Knowledge; Laboratories; Link; Location; MAX gene; Magnetic Resonance Imaging; Malignant Neoplasms; Malignant Pheochromocytoma; Measures; Medical; Medical center; Messenger RNA; Metastatic Neoplasm to the Bone; Metastatic Pheochromocytoma; Methods; Molecular; Molecular Biology; Mutation; NF-kappa B; Necrosis; Neoplasm Metastasis; Neuroendocrinology; Norepinephrine; Nuclear; PC12 Cells; PET/CT scan; Paraganglioma; Pathogenesis; Pathway interactions; Patients; Phenotype; Pheochromocytoma; Prevalence; Primary Neoplasm; Proteins; Research Personnel; Retroperitoneal Space; Risk Factors; Sensitivity and Specificity; Sequence Analysis; Series; Site; Specificity; Staging; Susceptibility Gene; Syndrome; Technology; Testing; Time; Translational Research; United States National Institutes of Health; Up-Regulation; VHL mutation; Work; base; clinical Diagnosis; clinical application; clinically relevant; driving force; effective therapy; fluorodeoxyglucose positron emission tomography; improved; in vivo; inhibitor/antagonist; male; metaiodobenzylguanidine; molecular marker; novel; patient oriented; patient oriented research; preclinical evaluation; single photon emission computed tomography; transmission process; triptolide; tumor; tumorigenesis; uptake

The Section is conducting patient-oriented research about the etiology, pathophysiology, genetics, diagnosis, and treatment of pheochromocytoma (PHEO) and paraganglioma (PGL). Projects include not only translational research-applying basic science knowledge to clinical diagnosis, pathophysiology, and treatment-but also reverse translation research where appreciation of clinical findings leads to new concepts that basic researchers can pursue in the laboratory. In order to achieve our goals, the strategy of the Section is based on the multidisciplinary collaborations among investigators from multiple NIH Institutes and outside medical centers. Our Section links together a patient-oriented component with two bench-level components. The patient-oriented component (Medical Neuroendocrinology) is currently the main driving force for our hypotheses and discoveries. The two bench-level components (Tumor Pathogenesis and Chemistry & Biomarkers) emphasize first, technologies of basic research tailored for pathway and target discovery and second, the development of the discoveries into clinical applications. Clinical aspects of PHEO/PGL Recently, we have presented data on the high rate of SDHB mutations in patients with metastatic PHEO/PGL whose initial tumor presentation was in childhood or adolescence. From 2000 - 2010, 263 PHEO/PGL patients were evaluated through NIH. Of those 263 patients, 125 presented with or were found to have metastatic disease; of these 125 patients, 32 presented with a tumor prior to age 20. An additional 17 patients presented with a tumor prior to age 20 but demonstrated no development of metastatic disease. Genetic testing for mutations in the VHL, RET, and SDHB/C/D genes was performed on patients without previously identified genetic mutations. Of the 32 patients who presented with metastatic disease and had their primary tumor in childhood or adolescence, sequence analysis of germline DNA found SDHB mutations in 23 (71.9%), SDHD mutations in 3 (9.4%), VHL mutations in 2 (6.3%), and absence of a known mutation in 4 (12.5%). The majority (78.1%) of these 32 patients presented with primary tumors in an extra-adrenal location (retroperitoneum and head and neck). We concluded that the majority of patients with metastatic PHEO/PGL who presented with a primary tumor in childhood or adolescence had primary extra-adrenal tumors and harbored SDHB mutations. Except for primary tumors located in the head and neck where SDHD genetic testing is advised, we recommend that patients presenting with metastatic PHEO/PGL with primary tumor development in childhood or adolescence undergo SDHB genetic testing. In another study we identified 41 subjects with metastatic PHEO and 108 subjects with apparently benign PHEO. We assessed the dimensions and biochemical profile of the primary tumor, age at presentation, and time to develop metastases. Subjects with metastatic PHEO presented at a significantly younger age (41.414.7 vs. 50.213.7 years; P<0.001), with larger primary tumors (8.383.27 cm vs. 6.182.75 cm; P<0.001), and more frequently secreted norepinephrine (95.1% vs. 83.3 %; P=0.046) compared to subjects with apparently benign PHEOs. No significant differences were found in the incidence of genetic mutations in both groups of subjects (25.7% in the metastatic group and 14.7% in the benign group; P=0.13). From available histopathologic markers of potential malignancy, only necrosis occurred more frequently in subjects with metastatic PHEO (27.6% vs. 0%; P<0.001). The median time to develop metastases was 3.6 years, with the longest interval 24 years. In conclusion, regardless of a genetic background, the size of a primary PHEO and age of its first presentation are two independent risk factors associated with the development of metastatic disease Hereditary PHEO/PGL MAX has been recently identified as the 10th susceptibility gene for PHEO. However, its clinical relevance was not addressed. An international study, based on an outstanding series of 1694 unrelated patients with PHEO or PGL, has ascertained the prevalence of MAX mutations in PHEO patients, extended the spectrum of MAX&#8208;related tumors to PGL, uncovered contributions of somatic MAX mutations to sporadic disease, and defined an intermediate catecholamine phenotype that may guide testing for the MAX gene in patients with PHEO/PGLs. This study also confirmed a preferential paternal mode of transmission with important consequences for genetic counseling. We established that MAX germline mutations were responsible for the disease in 1.12% of cases, similarly to the genes recently described, such as TMEM127, SDHAF2, or SDHA, and now recommend that MAX be considered in the genetic work&#8208;up of affected patients. Imaging of PHEO/PGL We performed a study aimed to establish the sensitivity and specificity of 18F-FDG PET/CT for tumor localization and staging of PHEO/PGL as compared to conventional imaging by 123I-MIBG SPECT and CT/MRI. 216 patients (106 males, 110 females, meanSD age 45.214.9 years) with (suspected) PHEO/PGL were consecutively studied. There were 60 cases of non-metastatic PHEO/PGL, 95 cases of metastatic PHEO/PGL, and 61 PHEO/PGL-negative patients. Besides CT or MRI, patients underwent 18F-FDG PET/CT and 123I-MIBG SPECT/CT. For non-metastatic tumors, the sensitivity was 95.7% for CT/MRI, 76.8% for 18F-FDG (p<0.001 versus CT/MRI), and 77.0% for 123I-MIBG (p=0.002 versus CT/MRI, not significant versus 18F-FDG). The specificity was 90.2% for 18F-FDG, 91.80% for 123I-MIBG, and 90.2% for CT/MRI. Cut-off values for 18F-FDG uptake to distinguish between PHEO/PGL and normal adrenal glands were 1.1 (100% sensitivity, 73% specificity) and 4.6 (100% specificity, 82% sensitivity). 18F-FDG uptake was higher in SDH- and VHL-related tumors than in MEN2-related tumors. For metastases, sensitivities were 74.4% for CT/MRI, 82.5% for 18F-FDG (p<0.001 versus 123I-MIBG), and 50.0% for 123I-MIBG (p<0.001 versus CT/MRI). For bone metastases, the highest sensitivity was reached by 18F-FDG: 93.7%, versus 76.7% for CT/MRI (p<0.05) and 61.5% for 123I-MIBG (p<0.001). Compared to 123I-MIBG SPECT and CT/MRI, which are all considered the gold standard for PHEO/PGL imaging, metastases were better detected by 18F-FDG PET. 18F-FDG PET is highly specific in cases with a biochemically established diagnosis of PHEO/PGL. Quantification of 18F-FDG uptake distinguishes well between PHEO/PGL and normal adrenal glands and provides important clues for a hereditary syndrome. Treatment of PHEO/PGL Although PHEOs/PGLs are intensively studied, a very effective treatment for metastatic PHEO or PGL has not yet been established. Preclinical evaluations of novel therapies for these tumors are very much required. Therefore, in another study we tested the effect of triptolide (TTL), a potent nuclear factor-kappaB (NF-&#954;B) inhibitor, on NET, considered to be the gatekeeper for 131I-MIBG. We measured changes in the mRNA and protein levels of NET and correlated them with proapoptotic factors and metastasis inhibition. The study was carried out on three different stable pheochromocytoma cell lines. We found that blocking NF-&#954;B with TTL or capsaicin increased both NET mRNA and protein levels. Involvement of NF-&#954;B in the upregulation of NET was verified by mRNA silencing of this site and also by using NF-&#954;B antipeptide. Moreover, MIBG transport was increased in TTL-treated cells and in vivo treatment with TTL significantly reduced metastatic burden in an animal model of metastatic pheochromocytoma. This study showed for the first time how NF-&#954;B inhibitors could be successfully used in the treatment of metastatic PHEO/PGL by a significant upregulation of NET to increase the efficacy of 131I-MIBG and by the induction of apoptosis.

该科正在以患者为中心开展有关嗜铬细胞瘤（PHEO）和副神经节瘤（PGL）的病因学、病理生理学、遗传学、诊断和治疗的研究。项目不仅包括转化研究——将基础科学知识应用于临床诊断、病理生理学和治疗——还包括逆向转化研究，其中对临床发现的理解导致基础研究人员可以在实验室中追求的新概念。 为了实现我们的目标，该科的战略基于来自多个 NIH 研究所和外部医疗中心的研究人员之间的多学科合作。我们的部分将面向患者的组件与两个工作台级组件连接在一起。以患者为导向的部分（医学神经内分泌学）目前是我们的假设和发现的主要驱动力。两个实验室级组成部分（肿瘤发病机制和化学与生物标志物）首先强调为途径和靶标发现量身定制的基础研究技术，其次强调将发现发展为临床应用。 PHEO/PGL 的临床方面 最近，我们提供了关于初次肿瘤表现在儿童或青春期的转移性 PHEO/PGL 患者 SDHB 突变率较高的数据。从 2000 年到 2010 年，263 名 PHEO/PGL 患者通过 NIH 进行了评估。在这 263 名患者中，125 名出现或被发现患有转移性疾病；在这 125 名患者中，有 32 名在 20 岁之前就患有肿瘤。另外 17 名患者在 20 岁之前就患有肿瘤，但没有表现出转移性疾病的发展。对先前未发现基因突变的患者进行了 VHL、RET 和 SDHB/C/D 基因突变的基因检测。在 32 名患有转移性疾病并在儿童或青少年时期患有原发肿瘤的患者中，对种系 DNA 的序列分析发现，23 名患者 (71.9%) 存在 SDHB 突变，3 名患者 (9.4%) 存在 SDHD 突变，2 名患者 (6.3%) 存在 VHL 突变，4 名患者 (12.5%) 不存在已知突变。这 32 名患者中的大多数（78.1%）原发肿瘤位于肾上腺外（腹膜后和头颈部）。我们的结论是，大多数在儿童期或青春期出现原发性肿瘤的转移性 PHEO/PGL 患者患有原发性肾上腺外肿瘤并携带 SDHB 突变。除了建议进行 SDHD 基因检测的位于头颈部的原发性肿瘤外，我们建议在儿童或青春期出现原发性肿瘤的转移性 PHEO/PGL 患者接受 SDHB 基因检测。 在另一项研究中，我们确定了 41 名患有转移性 PHEO 的受试者和 108 名患有明显良性 PHEO 的受试者。我们评估了原发肿瘤的尺寸和生化特征、发病年龄以及发生转移的时间。与患有转移性 PHEO 的受试者相比，患有转移性 PHEO 的受试者发病年龄明显更年轻（41.414.7 岁 vs. 50.213.7 岁；P<0.001），原发肿瘤较大（8.383.27 cm vs. 6.182.75 cm；P<0.001），且分泌去甲肾上腺素的频率更高（95.1% vs. 83.3 %；P=0.046）。具有明显良性 PHEO 的受试者。两组受试者基因突变发生率无显着差异（转移组为25.7%，良性组为14.7%；P=0.13）。根据现有的潜在恶性肿瘤的组织病理学标志物，只有坏死在转移性 PHEO 受试者中发生的频率更高（27.6% vs. 0%；P<0.001）。发生转移的中位时间为3.6年，最长间隔为24年。总之，无论遗传背景如何，原发性 PHEO 的大小和首次出现的年龄是与转移性疾病发生相关的两个独立的危险因素 遗传性 PHEO/PGL MAX最近被确定为PHEO的第10个易感基因。然而，其临床相关性并未得到解决。一项国际研究以 1694 名无关的 PHEO 或 PGL 患者为基础，确定了 PHEO 患者中 MAX 突变的患病率，将 MAX 相关肿瘤的范围扩展到 PGL，揭示了体细胞 MAX 突变对散发性疾病的影响，并定义了一种中间儿茶酚胺表型，可指导 PHEO/PGL 患者的 MAX 基因检测。这项研究还证实了一种优先的父系传播模式，对遗传咨询具有重要影响。我们确定 MAX 种系突变导致了 1.12% 的病例，与最近描述的基因（例如 TMEM127、SDHAF2 或 SDHA）类似，现在建议在受影响患者的基因检查中考虑 MAX。 PHEO/PGL 成像 我们进行了一项研究，旨在确定 18F-FDG PET/CT 与 123I-MIBG SPECT 和 CT/MRI 的传统成像相比，对 PHEO/PGL 肿瘤定位和分期的敏感性和特异性。连续研究了 216 名（疑似）PHEO/PGL 患者（106 名男性，110 名女性，平均 SD 年龄 45.214.9 岁）。非转移性 PHEO/PGL 60 例，转移性 PHEO/PGL 95 例，PHEO/PGL 阴性患者 61 例。除 CT 或 MRI 外，患者还接受 18F-FDG PET/CT 和 123I-MIBG SPECT/CT。对于非转移性肿瘤，CT/MRI 的敏感性为 95.7%，18F-FDG 的敏感性为 76.8%（与 CT/MRI 相比，p<0.001），123I-MIBG 的敏感性为 77.0%（与 CT/MRI 相比，p=0.002，与 18F-FDG 相比不显着）。 18F-FDG 的特异性为 90.2%，123I-MIBG 的特异性为 91.80%，CT/MRI 的特异性为 90.2%。区分 PHEO/PGL 和正常肾上腺的 18F-FDG 摄取截断值为 1.1（100% 敏感性，73% 特异性）和 4.6（100% 特异性，82% 敏感性）。 SDH 和 VHL 相关肿瘤中 18F-FDG 的摄取高于 MEN2 相关肿瘤。对于转移，CT/MRI 的敏感性为 74.4%，18F-FDG 的敏感性为 82.5%（与 123I-MIBG 相比，p<0.001），123I-MIBG 的敏感性为 50.0%（与 CT/MRI 相比，p<0.001）。对于骨转移，18F-FDG 达到最高灵敏度：93.7%，而 CT/MRI 为 76.7% (p<0.05)，123I-MIBG 为 61.5% (p<0.001)。与 123I-MIBG SPECT 和 CT/MRI（均被认为是 PHEO/PGL 成像的金标准）相比，18F-FDG PET 可以更好地检测转移灶。 18F-FDG PET 对于生化诊断为 PHEO/PGL 的病例具有高度特异性。 18F-FDG 摄取的定量可以很好地区分 PHEO/PGL 和正常肾上腺，并为遗传综合征提供重要线索。 PHEO/PGL 的治疗 尽管对 PHEO/PGL 进行了深入研究，但尚未建立针对转移性 PHEO 或 PGL 的非常有效的治疗方法。非常需要对这些肿瘤的新疗法进行临床前评估。因此，在另一项研究中，我们测试了雷公藤内酯醇 (TTL)（一种有效的核因子 kappaB (NF-κB) 抑制剂）对 NET 的影响，NET 被认为是 131I-MIBG 的看门人。我们测量了 NET mRNA 和蛋白质水平的变化，并将其与促凋亡因子和转移抑制相关联。该研究是在三种不同的稳定嗜铬细胞瘤细胞系上进行的。我们发现用 TTL 或辣椒素阻断 NF-κB 会增加 NET mRNA 和蛋白质水平。通过该位点的 mRNA 沉默以及使用 NF-κB 反肽验证了 NF-κB 参与 NET 上调。此外，经 TTL 处理的细胞中 MIBG 转运增加，并且在转移性嗜铬细胞瘤动物模型中，TTL 体内处理显着降低了转移负担。这项研究首次展示了 NF-κB 抑制剂如何通过显着上调 NET 来提高 131I-MIBG 的疗效并诱导细胞凋亡，从而成功用于治疗转移性 PHEO/PGL。