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: 7734764
• 负责人: Karel Pacak
• 金额: $ 122.75万
• 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/7734764
• 关键词: Adrenal Glands; Animal Model; Animals; Basic Science; Benign; Biochemical; Biological Markers; Blood Pressure; Caliber; Cell Count; Cell Line; Cells; Chemistry; Chest; Clinical; Collaborations; Combination Chemotherapy; Consensus; Development; Diagnosis; Disease; Enzymes; Etiology; Excess Mortality; Excision; Functional Imaging; Functional disorder; Gene Mutation; General Population; Genes; Genetic; Genetic Markers; Germ-Line Mutation; Goals; Hypertension; Image; Inherited; Injection of therapeutic agent; Institutes; Interdisciplinary Study; International; Ionizing radiation; Kidney; Knowledge; Laboratories; Length; Lesion; Life; Life Expectancy; Link; Liver; Lung; Magnetic Resonance Imaging; Malignant - descriptor; Malignant Paraganglionic Neoplasm; Malignant Pheochromocytoma; Mediastinal; Medical; Medical center; Metastatic Lesion; Metastatic Neoplasm to the Bone; Metastatic Neoplasm to the Liver; Metastatic Pheochromocytoma; Methods; Minority; Mitochondria; Modality; Modeling; Modification; Molecular; Molecular Biology; Molecular Genetics; Mutation; Neoplasm Metastasis; Neuroendocrinology; Noise; Nuclear; Numbers; Operative Surgical Procedures; Other Finding; Ovary; Paraganglioma; Pathogenesis; Pathway interactions; Patient Participation; Patients; Pelvis; Phenotype; Pheochromocytoma; Physicians; Positron-Emission Tomography; Progressive Disease; RET gene; Radionuclide Imaging; Randomized; Reading; Recurrence; Reporting; Research; Research Personnel; Serial Passage; Site; Staging; Succinate Dehydrogenase; Symptoms; Syndrome; Techniques; Technology; Temperature; Translational Research; Translations; Trypsin; United States National Institutes of Health; Upper arm; VHL mutation; Vertebral column; base; bone; chemotherapy; clinical Diagnosis; clinical application; concept; cyclophosphamide/dacarbazine/vincristine protocol; driving force; follow-up; founder mutation; improved; in vivo; long bone; metastatic process; patient oriented; patient oriented research; programs; response; sacrum; size; symposium; tumor; tumor growth; tumorigenesis

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. Hereditary PHEO and PGL Hereditary PHEO and PGL syndromes result from germline mutations in genes encoding subunits B, C and D of the mitochondrial enzyme succinate dehydrogenase (SDHB, SDHC and SDHD). SDHB-related PGLs are known in particular for their high malignant potential. Recently, however, malignant PGLs were also reported among a small minority of Dutch carriers of the SDHD founder mutation D92Y. Therefore, we investigated which SDHD mutations are associated with malignant PGL. We found that germline SDHD mutations underlying metastatic PGL were G148D, Y114X, L85X, W43X, D92Y, and IVS2+5 G>A. We also found that all mediastinal paragangliomas are related to either SDHB or SDHD gene mutations. We also performed a retrospective analysis of 71 subjects with metastatic PHEO/PGL (30 subjects SDHB gene mutation and 41 subjects without SDHB mutation (including 3 subjects with mutation of the RET gene, 3 subjects with mutation of the VHL gene and 1 subjects with mutation of the SDHD gene). Sixty nine percent presented with bone metastases (77% of those with SDHB mutation and 63% of those without SDHB mutation), 39% with liver metastases and 32% with lung metastases. The most common sites of bone involvement were thoracic spine (80%), lumbar spine (78%), and pelvic and sacral bones (78%). Subjects with SDHB mutation showed significantly higher involvement of long bones (P=0.007) and pelvic and sacral bones (P=0.04) than those without the mutation Imaging of PHEO and PGL Different imaging methods were compared in various PHEOs/PGLs. Out of 11 non-metastatic lesions detected by any technique, 8 lesions were detected by 18F-DOPA positron emission tomography (PET), 7 by 18F-FDA PET/CT, 8 by 18F-FDG PET/CT, and 9 by 123I-MIBG scintigraphy. CT and/or MRI identified 108 lesions in 19 patients with metastatic PGL. Functional imaging identified 80 additional lesions. Discrepant readings between the two nuclear physicians were solved by consensus for 7 lesions on 18F-DOPA PET and 7 lesions on 18F-FDA PET. Out of 188 metastatic lesions, 116 were detected by 18F-DOPA PET, 110 by 18F-FDA PET/CT, 107 by 18F-FDG PET/CT, and 67 by 123I-MIBG scintigraphy (P<0.001 versus all other techniques). In reference to lesions detected by CT and/or MRI, sensitivities were 52% for 18F-DOPA PET, 64% for 18F-FDA PET/CT, 72% for 18F-FDG PET/CT (*P<0.05 versus all other techniques, except 18F-FDA), and 54% for 123I-MIBG scintigraphy. Sensitivities in reference the total number of lesions detected by any technique were 62% for 18F-DOPA PET, 59% for 18F-FDA PET/CT, 57% for 18F-FDG PET/CT, and 36% for 123I-MIBG scintigraphy (P<0.001 versus all other techniques). The best overall sensitivity in detecting bone metastases was 18F-FDA PET (90%), followed by bone scintigraphy (82%), CT/MRI (78%) and 123/131I-MIBG scintigraphy (71%). In subjects with SDHB mutation, imaging modalities with best sensitivities for detecting bone metastases were CT/MRI (96%), bone scintigraphy (95%) and 18F-FDG PET (92%). In subjects without SDHB mutation, the modality with the best sensitivity for bone metastases was 18F-FDA PET (100%). We concluded that bone scintigraphy should be used in the staging of patients with malignant PHEO/PGL, particularly in patients with SDHB mutation. As PET imaging modality, 18F-FDG PET was highly recommended in SDHB mutation patients, whereas 18F-FDA PET was recommended in patients without the mutation. Other findings Patients who undergo successful surgery for apparently benign PHEO were found to have a reduced life expectancy as compared to the general population. The excess mortality was explained by the fact that patients may still develop metastatic disease during post-surgical follow-up. Hypertension persisted in two-thirds of recurrence-free patients. Life-long follow-up is therefore warranted in these patients. We also conducted a long-term follow up of the 18 patients with a diagnosis of PHEO/PGL treated with a combination of cyclophosphamide, vincristine and dacarbazine (CVD chemotherapy). This was a non-randomized, single arm trial. Combination chemotherapy with CVD produced objective tumor responses in patients with advanced malignant PHEO/PGL. No difference in overall survival between patients whose tumors objectively shrank and those with stable or progressive disease. However, patients reported improvement in symptoms, had objective improvements in blood pressure and had tumor shrinkage that made surgical resection possible. We concluded that CVD therapy was not indicated in every patient with metastatic PHEO/PGL, but should be considered in the management of patients with symptoms and where tumor shrinkage might be beneficial. An animal model of PHEO Recently, we have found that microCT and MRI were approximately equal in their ability to detect hepatic metastases at a size threshold of 350 m. In the lungs, MRI was more sensitive than microCT, detecting lesions 0.6 mm in diameter vs 1mm for microCT. Additionally, MRI was more sensitive for lesions in the kidneys, bone, ovaries and adrenal glands. MRI demonstrated higher contrast-to-noise ratio (CNR) than microCT. We concluded that in addition to the advantage of not exposing the animal to ionizing radiation, MRI provided a more complete assessment of the extent of metastases in this model, compared to microCT. In another study, we have enhanced this model by modifying the number of cells injected, length of trypsin treatment, and temperature for cells storage before injection and by removal of metastatic lesions, serial passage and re-selection of metastases. We evaluated the effect of these modifications on tumor growth using in vivo MRI. These results show that number of cells injected, temperature for cell storage before injection and length of trypsin treatment are important factors to produce faster-growing, more aggressive tumors that yielded secondary metastatic lesions at other sites. Serial culture and selection of metastatic liver lesions produced even more aggressive PHEO cells that retained their biochemical phenotype. Microarray comparison of these more aggressive cells to the parental cell line identified genes important for their rapid metastatic process. Conferences In line with the spirit of our Program which emphasizes teamwork, collaboration with outside medical centers and patient participation, we are participating in the organization of the 2nd International Symposium on Pheochromocytoma that will be held in Cambridge, UK in September 2008.

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。 遗传性 PHEO 和 PGL 遗传性 PHEO 和 PGL 综合征是由编码线粒体琥珀酸脱氢酶（SDHB、SDHC 和 SDHD）亚基 B、C 和 D 的基因种系突变引起的。 SDHB 相关的 PGL 尤其以其高度恶性潜力而闻名。然而，最近在少数 SDHD 创始人突变 D92Y 荷兰携带者中也报道了恶性 PGL。因此，我们研究了哪些 SDHD 突变与恶性 PGL 相关。我们发现转移性 PGL 潜在的种系 SDHD 突变为 G148D、Y114X、L85X、W43X、D92Y 和 IVS2+5 G>A。我们还发现所有纵隔副神经节瘤都与 SDHB 或 SDHD 基因突变有关。 我们还对 71 名转移性 PHEO/PGL 受试者（30 名 SDHB 基因突变受试者和 41 名无 SDHB 突变受试者（其中 3 名 RET 基因突变受试者、3 名 VHL 基因突变受试者和 1 名 SDHD 基因突变受试者）进行了回顾性分析。69% 出现骨转移（其中 77% 患有 SDHB） 突变的患者占 63%，无 SDHB 突变的患者占 63%），肝转移占 39%，肺转移占 32%。最常见的骨受累部位是胸椎（80%）、腰椎（78%）以及骨盆和骶骨（78%）。具有 SDHB 突变的受试者表现出显着更高的长骨受累（P=0.007）和骨盆 和骶骨（P = 0.04）比没有突变的人 PHEO 和 PGL 成像 在各种 PHEO/PGL 中比较了不同的成像方法。在通过任何技术检测到的 11 个非转移性病灶中，8 个病灶通过 18F-DOPA 正电子发射断层扫描 (PET) 检测到，7 个病灶通过 18F-FDA PET/CT 检测到，8 个病灶通过 18F-FDG PET/CT 检测到，9 个病灶通过 123I-MIBG 闪烁扫描检测到。 CT 和/或 MRI 在 19 名转移性 PGL 患者中发现了 108 个病灶。功能成像发现了另外 80 个病变。两位核医师之间的读数差异通过协商一致解决了 18F-DOPA PET 上的 7 个病灶和 18F-FDA PET 上的 7 个病灶的读数。在 188 个转移性病灶中，18F-DOPA PET 检测到 116 个，18F-FDA PET/CT 检测到 110 个，18F-FDG PET/CT 检测到 107 个，123I-MIBG 闪烁扫描检测到 67 个（与所有其他技术相比，P<0.001）。对于通过 CT 和/或 MRI 检测到的病变，18F-DOPA PET 的敏感性为 52%，18F-FDA PET/CT 的敏感性为 64%，18F-FDG PET/CT 的敏感性为 72%（*与除 18F-FDA 之外的所有其他技术相比，P<0.05），123I-MIBG 闪烁扫描的敏感性为 54%。任何技术检测到的病变总数的参考灵敏度对于 18F-DOPA PET 为 62%，对于 18F-FDA PET/CT 为 59%，对于 18F-FDG PET/CT 为 57%，对于 123I-MIBG 闪烁扫描为 36%（与所有其他技术相比，P<0.001）。检测骨转移的最佳总体灵敏度是 18F-FDA PET (90%)，其次是骨闪烁扫描 (82%)、CT/MRI (78%) 和 123/131I-MIBG 闪烁扫描 (71%)。在具有 SDHB 突变的受试者中，检测骨转移最敏感的成像方式是 CT/MRI (96%)、骨闪烁扫描 (95%) 和 18F-FDG PET (92%)。在没有 SDHB 突变的受试者中，骨转移敏感性最佳的方式是 18F-FDA PET (100%)。我们的结论是，骨闪烁扫描应该用于恶性 PHEO/PGL 患者的分期，特别是 SDHB 突变的患者。作为 PET 成像方式，SDHB 突变患者强烈推荐使用 18F-FDG PET，而无突变患者则推荐使用 18F-FDA PET。 其他发现 研究发现，与一般人群相比，成功接受明显良性 PHEO 手术的患者的预期寿命会缩短。死亡率过高的原因是患者在术后随访期间仍可能出现转移性疾病。三分之二的无复发患者仍存在高血压。因此，对这些患者进行终身随访是必要的。 我们还对 18 名诊断为 PHEO/PGL 并接受环磷酰胺、长春新碱和达卡巴嗪联合治疗（CVD 化疗）的患者进行了长期随访。这是一项非随机、单臂试验。联合化疗与 CVD 在晚期恶性 PHEO/PGL 患者中产生了客观的肿瘤反应。肿瘤客观缩小的患者与疾病稳定或进展的患者之间的总生存率没有差异。然而，患者报告症状改善，血压客观改善，肿瘤缩小，使手术切除成为可能。我们的结论是，并非所有转移性 PHEO/PGL 患者都适合接受 CVD 治疗，但在治疗有症状且肿瘤缩小可能有益的患者时应考虑进行 CVD 治疗。 PHEO动物模型 最近，我们发现 microCT 和 MRI 在检测尺寸阈值 350 m 的肝转移瘤方面大致相同。在肺部，MRI 比 microCT 更敏感，可检测直径为 0.6 毫米的病灶，而 microCT 则为 1 毫米。此外，MRI 对肾脏、骨骼、卵巢和肾上腺的病变更敏感。 MRI 表现出比 microCT 更高的对比噪声比 (CNR)。我们得出的结论是，与 microCT 相比，除了不使动物暴露于电离辐射的优点之外，MRI 还可以更全面地评估该模型中的转移范围。在另一项研究中，我们通过修改注射细胞的数量、胰蛋白酶处理的时间和注射前细胞储存的温度以及去除转移灶、连续传代和重新选择转移灶来增强该模型。我们使用体内 MRI 评估了这些修饰对肿瘤生长的影响。这些结果表明，注射的细胞数量、注射前细胞储存的温度以及胰蛋白酶处理的时间长度是产生生长更快、更具侵袭性的肿瘤的重要因素，这些肿瘤在其他部位产生继发性转移病灶。连续培养和转移性肝病灶的选择产生了更具攻击性的 PHEO 细胞，并保留了其生化表型。将这些更具侵袭性的细胞与亲本细胞系进行微阵列比较，确定了对其快速转移过程重要的基因。 会议 根据我们强调团队合作、与外部医疗中心合作和患者参与的计划精神，我们正在参与组织将于 2008 年 9 月在英国剑桥举行的第二届嗜铬细胞瘤国际研讨会。

项目成果

Is supine rest necessary before blood sampling for plasma metanephrines?

• DOI: 10.1373/clinchem.2006.076489
• 发表时间: 2007-02-01
• 期刊: CLINICAL CHEMISTRY
• 影响因子: 9.3
• 作者: Lenders, Jacques W. M.;Willemsen, Jacques J.;Sweep, C. G. J. (Fred)
• 通讯作者: Sweep, C. G. J. (Fred)

A new concept of unopposed beta-adrenergic overstimulation in a patient with pheochromocytoma.

嗜铬细胞瘤患者无对抗β-肾上腺素能过度刺激的新概念。

• DOI: 10.7326/0003-4819-142-12_part_1-200506210-00023
• 发表时间: 2005
• 期刊: Annals of internal medicine
• 影响因子: 39.2
• 作者: Kantorovich,Vitaly;Pacak,Karel
• 通讯作者: Pacak,Karel

The incidentally discovered adrenal mass.

• DOI: 10.1056/nejmc070612
• 发表时间: 2007-05
• 期刊: The New England journal of medicine
• 作者: K. Pacak;G. Eisenhofer;A. Grossman

Comparison of 6-18F-fluorodopamine PET with 123I-metaiodobenzylguanidine and 111in-pentetreotide scintigraphy in localization of nonmetastatic and metastatic pheochromocytoma.

• DOI: 10.2967/jnumed.108.052373
• 发表时间: 2008-10
• 期刊: Journal of nuclear medicine : official publication, Society of Nuclear Medicine
• 作者: Ilias I;Chen CC;Carrasquillo JA;Whatley M;Ling A;Lazúrová I;Adams KT;Perera S;Pacak K
• 通讯作者: Pacak K

A clinical overview of pheochromocytomas/paragangliomas and carcinoid tumors.

• DOI: 10.1016/j.nucmedbio.2008.04.007
• 发表时间: 2008-08
• 期刊: NUCLEAR MEDICINE AND BIOLOGY
• 影响因子: 3.1
• 作者: Ilias, Ioannis;Pacak, Karel
• 通讯作者: Pacak, Karel