6 181

D Cosentini, G Badalamenti in advanced ACC 181:6 681–689 Clinical Study and others

Activity and safety of temozolomide in advanced patients

Deborah Cosentini1,*, Giuseppe Badalamenti2,*, Salvatore Grisanti1, Vittoria Basile3, Ida Rapa4, Sara Cerri1, Andrea Spallanzani5, Paola Perotti3, Emanuela Musso2, Marta Laganà1, Vittorio D Ferrari1, Gabriele Luppi5, Alberto Dalla Volta1, Lorena Incorvaia2, Sandra Sigala6, Antonio Russo2, Marco Volante4, Massimo Terzolo3 and Alfredo Berruti1

1Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, ASST Spedali Civili, Brescia, Italy, 2Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy, 3Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy, 4Department of Oncology, San Luigi Hospital, University of Turin, Correspondence Orbassano, Turin, Italy, 5Department of Medical Oncology, AOU di Modena, Modena, Italy, and 6Section of should be addressed Pharmacology, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy to A Berruti *(D Cosentini and G Badalamenti contributed equally to this work) Email [email protected]

Abstract

Objective: Temozolomide has shown a significant anti-proliferative activity on adrenocortical cancer (ACC) cells in vitro. Design: On the basis of these results the drug was prescribed as second/third line in advanced metastatic ACC patients in four referral centers in Italy. Methods: We retrospectively collected anagraphic, clinical and pathological data of patients with advanced ACC with disease progression to standard plus mitotane who were treated with temozolomide at the dose of 200 mg/m2/die given for 5 consecutive days every 28 days. The primary endpoint was the disease control rate, defined as objective response or disease stabilization after 3 months. Secondary endpoints were overall survival (OS), progression-free survival (PFS) and drug safety.

European Journal of Endocrinology Results: Twenty-eight patients have been included in the study. Ten patients (35.8%, 95% CI: 17.8–53.8) obtained a disease control from temozolomide treatment. In particular, 1 patient had a complete response, 5 patients a partial response and 4 patients stable disease. Median PFS was 3.5 months and median OS was 7.2 months. Disease response was more frequently observed in patients with methylation of O6-methylguanine-DNA methyltransferase (MGMT) gene. Temozolomide therapy was well tolerated and most toxicities were limited to grade G1–2 according to WHO criteria. Conclusion: Temozolomide was found active in the management of advanced ACC patients. The disease control rate obtained, however, was short-lived and the prognosis of treated patients was poor.

European Journal of Endocrinology (2019) 181, 681–689

Introduction

Adrenocortical carcinoma (ACC) is a rare and aggressive who undergo radical resection (1). This is the reason why tumor with an incidence of 0.7–2 new cases per million adjuvant mitotane therapy is recommended by recent populations per year (1). Surgery is the mainstay of guidelines (2, 3), despite the low evidence of efficacy (1, therapy but a significant proportion of patients have 2, 4, 5, 6). non-resectable tumors at diagnosis; moreover, disease The standard systemic treatment for advanced/ relapse occurs within 2 years in the majority of patients metastatic ACC patients, not eligible to surgery, is

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-19-0570 European Journal of Endocrinology https://eje.bioscientifica.com the followingeligibilitycriteria: age product characteristicsoftemozolomide. Allpatientsmet of criteria wereconsideredalso accordingtothesummary Institutions wereincluded. Inclusionandexclusion 2018atfourItalian 2016toJanuary from January consecutive ACC patients treated with temozolomide This isamulticentric,retrospectivestudy. Twenty-eight Study designandpatients'characteristics Patients andmethods peculiar clinicalsetting. assessment oftemozolomideactivityandtoxicityinthis to standardtherapies.Inthisstudy, wedidaretrospective temozolomide inACCpatientswithdiseaseprogression four Italianreferencecentersforthisrarediseaseused strategies availableinthemanagementofadvancedACC, advanced neuroendocrinetumors( efficacy inpatientswithglioblastoma( (MGMT) gene,whichisassociatedwithtemozolomide (O6-methylguanine-DNA methyltransferase)DNA-repair temozolomide andtheepigeneticsilencingofMGMT association wasfoundbetweenthe apoptosis andcellcyclearrest( effects throughastronginhibitionofcellgrowth, data showedthatthedrughascytotoxicandcytostatic the activityoftemozolomideinACCcells colleagues recentlypublishedapreclinicalstudyexploring pheochromocytoma/paraganglioma ( of neuroendocrinetumors( demonstrated tobeefficaciousalsointhemanagement the treatment of brain tumors ( therapeutic optionsarethereforeneeded. 13 molecular targettherapiesandimmunotherapy( ( currently availableguidelines( andcapecitabine,whichisrecommendedby disease progressionafterEDP-M( ( of14months of treatedpatientswithamedian survival clinical trialreportingadiseaseresponseinabout25% however, islimitedasshownbytheresultsofarandomized (EDP-M regimen) ( in combinationwithetoposide,doxorubicinandcisplatin mitotane. Thisdrugisadministeredeitheralone( 10 8 ). No effective therapies are available for patients with Clinical Study , , Given theseresultsandthelimitedtherapeutic Temozolomide isanalkylatingdruginitiallyusedin 14 11 ), failedtodemonstratesignificantactivity. New ). Othertreatment strategies, including modern 7 ). The efficacy of the EDP-M regimen, 2 , and others D Cosentini,GBadalamenti 15 9 18 3 16 ). Thecombinationof 16 ), ispoorlyefficacious in vitro ). The drug has been ). Moreover, aweak ) andmalignant ). 17 > 18 years;Eastern ). Creemersand 19 cytotoxicityof , in vitro 20 , 21 . Their 1 ) and ), or 12 , failure (ejectionfraction (i.e. steroidsorantiepileptics);decompensatedheart meningeal tumors;seizuredisorderrequiringmedication Criteria CTC V5.0); symptomatic metastatic brain or serious infections(greaterthangrade2,CommonToxicity evidence of disease for at least 3 years; active clinically carcinoma, orothertreatedmalignancieswithno cured non-melanomaskincancer, cured ofpriormalignancy,criteria werehistory exceptfor in premenopausalfemaleandmalepatients.Exclusion ≤ ≤ ≥ (neutrophils marrow reserve (RECIST criteria)measurablelesion;adequatebone atleastoneunidimensional not suitableforsurgery; diagnosis ofACC;locallyadvancedormetastaticdisease 0–2; lifeexpectancyofatleast3months;pathological Cooperative OncologyGroup(ECOG)performancestatus status, routine laboratory tests, endocrine work-up, chest status, routine laboratory medical history, physicalexamination,performance clinical andpathologicaldata werecollected:sex,age, threecycles.Thefollowingdemographic, performed every monitored. Disease re-staging by CT scan and/or MRI was andblooddrug levelswere allowed butnotmandatory 28 days.Maintenanceofpreviousmitotanetreatmentwas dose of 200 mg/m Civili inBrescia(ProtocolNo.3132). approved bytheEthicalReviewBoardofASST-Spedali of allinvolvedInstitutions.Theretrospective study was to thepatientsfreeofchargebyhospitalpharmacy off-label useofthedrug.Temozolomide wasdistributed referral oncology centers whosehospitals approved the Patients residentinothercitieswerereferredtofour label temozolomidetherapywassignedbyeachpatient. was prescribedandawritteninformedconsentforoff- assessing eligibilityfortemozolomidetherapy, thedrug Medical OncologyofASST-Spedali CiviliinBrescia.After starting therapyallpatientswereexaminedatthe treatment with another investigational drug. Before within4weeksofstudystart;concomitant major surgery weeks ofstudystart(palliativeradiotherapywasallowed); radiotherapyduringstudyorwithin3 of studyentry; or immunotherapyduringthestudywithin4weeks with temozolomide;otheranticancerchemotherapy pregnant orbreast-feedingpatients;priortreatment arrhythmia; hypertensionnotcontrolledbymedications; months; unstableanginapectoris;uncontrolledcardiac or revascularization procedure during the last6 Temozolomide inadvancedACC 1.5 theupperlimitofnormal;effectivecontraception 1.5 timestheupperlimitofnormal;serumcreatinine 100 000/mm Treatment consistedintemozolomide attheplanned 3 , hemoglobin 2 /die given for 5 consecutive days every /die given for 5 consecutive days every Downloaded fromBioscientifica.com at09/30/202109:14:12AM ≤ 45%); myocardialinfarction ≥ ≥ 9.0 g/dL);totalbilirubin 1500/mm 181 :6 3 in situ andplatelets cervical cervical 682 via freeaccess European Journal of Endocrinology Q96MA apparatus(Biotage, Uppsala,Sweden)withPCR Sequencing analysiswas performedonPyroMark Ancona, Italy)following manufacturer’s instructions. CE-IVD kit(MGMTplus, DiatechPharmacogenetics, conversion usingacommercial availableandcertified s.r.l). Atotalof500nggDNAwasmodified bybisulfite Maxwell® RSC instrument and tissue DNA Kit (Promega cell enrichment(atleast50%oftumorcells),usingthe FFPE tissuesaftermanualmicrodissection,forneoplastic expression. GenomicDNA(gDNA)wasextractedusing gene exon1andinvolvedintheregulationof (NG_052673.1-chr10:131 265 507-131556)ofMGMT CpG siteswereanalyzed,locatedinthepromoterregion means of pyrosequencing technique. Ten methylated MGMT promotermethylationstatuswasperformedby this studyforwhichtumorsampleswereavailable. promoter methylationinapatientsubsetincluded MGMT (O study,As ancillary weevaluatedthepredictiveroleof tumor samples Assessment ofMGMTpromotermethylationin used toassesstoxicity. status. TheCommonToxicity CriteriaCTCV5.0were defined byKi67 symptoms atdiagnosis;pejorativeincaseofgradingas unfavorable in case of age age by Ki67was parameters wereconsideredfavorableifgradingdefined ( date. ThemENSAT classificationandGRASparameters the dateofdeathfromanycauseorlastknownalive betweenthedateoftreatmentstartand the timeinterval was defined as follow-up examination. Overall survival progressing patientsstillalivewerecensoredatthelast progression ordeathwhatevereventoccurredfirst.Non- from thebeginningoftreatmentuntildisease treatment toxicity. PFSwasdefinedasthetimerelapsing (OS)and (PFS),overallsurvival progression-free survival endpointsweretheevaluationof version 1.1.Secondary 3 monthsoftemozolomidetherapy, usingRECISTcriteria, objective tumorresponseorstabilizationatCTscanafter rate, definedastheproportionofpatientsobtaining temozolomide treatment. CT, MRI, bone scan) performed at baseline and during and abdominal CT scan, other imaging data (i.e. brain 22 Clinical Study ) wereusedtoassessprognosis.Inparticular, GRAS The study primary endpointwasthediseasecontrol The studyprimary < 50 yearsandabsenceofsymptomsatdiagnosis; 6 < -methylguanine–DNA methyltransferase) 20%, primary R0resectionstatusattained, 20%, primary > 20% and/or primary R1-2resection 20% and/orprimary > 50 years, or presence of and others D Cosentini,GBadalamenti estimate theactivityoftherapyintermsproportion endpointofthestudywasto log-rank test.Theprimary with theKaplan–Meiermethodandcompared werecalculated when indicated. The PFS andOS curves variables wereassessedbyachi-squareortheFishertest clinical characteristics.Differencesbetweencategorical Descriptive statisticswereusedtoanalyzethepatient Statistical analysis properly usedtotakecontrolofallworkflow. samples. Methylated and unmethylated controls were to define ‘methylated’ ( 5% (mean of the CpG islands) of methylation was used ten CpGmethylatedislandsforeachcase.Acut-offof software (Biotage), obtaining a mean percentage of the according tothemanufacturer’s instructions. and sequencingprimerssuppliedintheMGMTpluskit disease, 9(32.2%)stageIV-B, 3(10.7%)stageIV-C. GRAS classification, 16patients (57.1%)hadastageIV-A had aperformancestatus starting temozolomide,the majority ofpatients(71.4%) of metastaticdisease.Atbaselineconditions,before first-line cytotoxictherapiesadoptedafterthediagnosis both administeredinassociationwithmitotane,werethe (42.9%) receivedpostoperativeadjuvantmitotane. patients was19.9months(range5–49).Twelve patients of surgicaltreated (R0). Mediandisease-freesurvival and 20ofthem(71.4%)obtainedacompleteresection asthefirsttreatment surgery primary (92.8%) underwent (35.7%) hadCushingsyndrome.Twenty-six patients hormone-secreting tumoratdiagnosisandtenofthem years (range31–72).Thirteenpatients(46.4%)hada summarized in The characteristics of the 28 enrolled patients are Patients' characteristics Results analyses (SPSSInc.). P an alphaerrorof0.05.Statisticalsignificancewassetat of thetherapyasadiseasecontrolrate40%;given clinical benefitrateof15%(p0)andtoassesstheactivity recruited, this study has a potency of 80% to refuse a of patientsattainingaclinicalbenefit. With 28patients Temozolomide inadvancedACC

<

0.05. SPSSv17.0softwarewasusedforthestatistical aloneortheEDPcombinationregimen, Data analysiswasperformedusingthePyroMarkCpG Table 1 . Medianageatbaselinewas54 > Downloaded fromBioscientifica.com at09/30/202109:14:12AM 5%) and ‘unmethylated’ ( ≤ 1. AccordingtomENSAT https://eje.bioscientifica.com 181 :6 683 ≤ 5%) via freeaccess European Journal of Endocrinology https://eje.bioscientifica.com (53.6%) andfourth-lineapproach in2(7.1%).Allpatients in 11 patients (39.3%), third-line therapy in 15patients Temozolomide wasadministeredassecond-linetherapy Treatment administered andactivity (32.2%) andpejorativein13(46.4%)patients. parameters werefavorablein6(21.4%),unfavorable 9 tumor organs,IV-Cincaseof defined asIV-Awhentumorinvolvestwoorgans,IV-Bincaseofthree ***mENSAT stageassessedatthebeginningoftemozolomidewas Status secECOGassessedatthebeginningoftemozolomidetherapy. Ki67 parameters areclassifiedaspejorativeincaseofgradingdefinedby case ofage of symptomsatdiagnosis.GRASparametersareclassifiedunfavorable in < *GRAS parametersareconsideredfavorableifgradingdefinedbyKi67is Data areexpressedasmedianandrangeifnototherwisespecified. Stage IV-C Stage IV-B Stage IV-A mENSAT***, 0–1 ECOG PS**, Mitotane inadvancedsetting, Gemcitabine pluscapectitabine Cisplatin only Second-line metastatictreatment, Cisplatin only EDP-M First-line metastatictreatment, Disease freesurvival,months Adjuvant mitotane, R0 Primary surgery, Pejorative Unfavorable Favorable GRAS*, Weiss Score Mitotic Rate(n/50HPF) Ki67 Ki67 Ki67, % Histological characteristicsatdiagnosis Non secretingtumors Androgen excess excess Secreting atdiagnosis, Females Males Sex, Age, years Total numberofpatients Characteristics Table 1 20%, primaryR0resectionstatusperformed,age Clinical Study > 1 > n 20% and/orprimaryR1-2resectionstatus.**ECOGPSPerformance (%) n (%) ≥ < > Patients characteristics. 20% 20% 50 yearsorpresenceofsymptomsatdiagnosis.GRAS n n (%) (%) n (%) n (%) n (%) > 3 tumororgans. n (%) n (%) n (%) and others D Cosentini,GBadalamenti < 50 yearsandabsence 19.9 (5–49) 6.5 (3–9) 16 (57.1) 20 (71.4) 28 (100) 15 (53.6) 21 (75) 12 (42.9) 20 (71.4) 26 (92.8) 13 (46.4) 10 (2–66) 13 (46.4) 15 (53.6) 20 (2–50) 15 (53.6) 10 (35.7) 13 (46.4) 11 (39.3) 17 (60.7) 54 (31–72) 3 (10.7) 9 (32.2) 8 (28.6) 2 (7.1) 7 (25) 9 (32.2) 6 (21.4) 3 (10.7) Values 28 Patients' outcome patients receivedcisplatinassingleagent. received gemcitabineandcapecitabine,whereastwo administered insixpatients;particular, fourpatients 10 patients(35.8%)(95%CI:17.8–53.8)( (95% CI:6.5–27.5)andadiseasecontrolwasobtainedin progression ( stabilization. However, 18patients(64.2%)haddisease 5 patients(17.9%),and4(14.3%)obtaineddisease in RECIST 1.1 criteria, while partial response was observed (3.6%) obtainedcompleteclinicalresponseevaluatedby temozolomide cycleswas4(range2–16).Onepatient given for 5 consecutive days and median number of therapeutic rangein10(35.7%)ofthem. administration andthedruglevelswerewithin continued mitotanetherapyduringtemozolomide 1.4–24.2 vs 3.5 months, range 1.2–15.8, respectively, further lineoftreatment(medianPFS3.9months,range of whethertheyreceivedtemozolomideassecondor difference inPFSwasseenstratifyingpatientsonthebasis OS was7.5months(range2–38.8)( Median PFSwas3.5months(range:1.2–24.2)( baseline sumLD. sum oftheLDtargetlesions, takingasreferencethe defined byRECISTcriteriaasat leasta30%decreaseinthe sum LDsincethetreatmentstarted. PR,partialresponse, increase toqualifyforPD,taking asreferencethesmallest neither sufficientshrinkagetoqualifyforPRnor lesions. SD,stabledisease,definedbyRECISTcriteriaas treatment startedortheappearanceofonemorenew as referencethesmallestsumLDrecordedsince the sumoflongestdiameter(LD)targetlesions,taking disease, definedbyRECISTcriteriaasatleasta20%increase in Waterfall plotoftemozolomideresponses.PD,progressive Figure 1 Temozolomide inadvancedACC At diseaseprogression,furtherchemotherapywas Median doseoftemozolomidewas250mg/die Fig. 1 ). The overall response rate was21.5% Downloaded fromBioscientifica.com at09/30/202109:14:12AM Fig. 2B 181 :6 Table 2 ). Nosignificant Fig. 2A ). 684 ) and via freeaccess European Journal of Endocrinology temozolomide. temozolomide. (B)Overallsurvival inpatientstreatedwith (A) Progression-freesurvivalin patientstreatedwith Figure 2 months, range:2.6–38.8vs3.22.0–7.5, 0-1 had longer OS than those with PS 2 (median: 10.5 and tumorcharacteristics.ThepatientswithECOGPS potential prognosticsignificanceofseveralpatient 7.1 months(range2–33.3)inthosewhodidnot( (range 3.6–38.8)inpatientsattainingaclinicalbenefitvs did nothaveanypositiveimpactonOS:median8.1 P Clinical benefit Overall responserate Progressive disease Stable disease Partial response Complete response Table 2

= Clinical Study 0.62). In addition, the attainment of a clinical benefit Additional analyses were done to explore the Treatment response. 10 (35.8%,95%CI:17.8–53.8) 6 (21.5%,95%CI:6.5–27.5) and others D Cosentini,GBadalamenti 18 (64.2%) 4 (14.3%) 5 (17.9%) 1 (3.6%) P =0.78). vs mENSAT A was notimprovedbytheadditionofGRAS(mENSAT P 2.0–38.8, vsmENSAT B-C:6.9months,range:2.6–33.3, to beassociatedwithOS(mENSAT A:7.5months,range: GRAS score(datanotshown).However, mENSAT failed were similarinpatientswithunfavorableandpejorative not statistically significant ( months, range:2.0–38.8),althoughthedifferencewas 5.5–33.3) thanunfavorable/pejorativeGRAS(median:6.9 associated with a longer OS(median:12.2 months, range: respectively, favorable vsunfavorableorpejorative ( ( (A) Overallsurvivalonthebasis ofECOGperformancestatus Figure 3 Temozolomide inadvancedACC P

= 0.001).(B)Overallsurvivalonthe basisofGRASparameters: + 0.82); andtheprognosticsignificanceofmENSAT GRAS AmedianOS:12.2months,range:5.5-24.2, + P 0.001) ( =0.001) GRAS B-C:7.5months, range: 2.0–38.8, Fig. 3A Downloaded fromBioscientifica.com at09/30/202109:14:12AM P .7 ( =0.17) ). FavorableGRASscorewas https://eje.bioscientifica.com P 181 0.17). Fig. 3B :6 ). OS curves ). OS curves 685 via freeaccess European Journal of Endocrinology ( Overall survivalonthebasisof circulatingmitotanelevels Figure 4 https://eje.bioscientifica.com whereas nodosereductionwasprescribed. of anewcyclewasneededin12patientsduetotoxicity, 21.4% of patients, respectively. A 1-week delay in the start impairment andthrombocytopenia,involving25% toxicitieswererenal 3 neutropenia.Theotherobserved 3 in7.2%of cases. Only 1patient (3.6%) developed grade in25%ofpatients,beinggrade Liver toxicitywasobserved 3 in14.3%and10.7%ofpatients,respectively. respectively. Thesesymptomswereclassifiedasgrade side effects, occurring in 35.8 and 25% of patients, expected, nauseaandvomitingwerethemostfrequent temozolomide toxicitiesaresummarizedin blood count, liver and renal function). The observed (complete clinical examinationandbloodchemistry Patients wereevaluatedaftereachcyclewithboth Treatment toxicity P which thedrugwasbelow14µg/L( 6.9 months(range:2.4–38.8)respectivelyinthose µg/L), while they were 3.3 months (range: 2.4–15.8) and blood mitotanewaswithinthetherapeuticrange(14–20 (range: 4.4–33.3),respectivelyinpatientswhich OS were4.4months(range:2.9–24.2)and12.7 according tomitotaneplasmaconcentrations,PFSand P P

= = 0.37). Clinical Study 0.37 forOS)( 0.56) (data not shown). Finally, stratifying patients Fig. 4 ). and others D Cosentini,GBadalamenti P .6 o PFS, for =0.36 Table 3

. As

not shown). MGMT methylation( 2.1–15.8; medianOS:notreached,range:3.2–38.8) respectively) orwithout(medianPFS:3.9months,range: range: 2.1–24.2; median OS: 6.9 months, range: 3.1–12.7, comparing patientswith(medianPFS:4.4months, ( a stable disease and the others had progressive disease had apartialresponse,whereas1patient(14.3%) methylated MGMTgroup,only1patientoutof7(14.3%) and 3hadapartialresponse.Conversely, inthenon- disease response, in particular, 1 had a complete response MGMT group,4patientsoutof8(50.0%) obtained a showing MGMTpromotermethylation.Inthemethylated MGMT statuswasevaluatedin15patients,eightofthem drug activity MGMT statusandrelevantcorrelationwith observed in 20%ofpatients,whereasabout35%hada observed number ofpatients(21.4vs 13.7%) ( for thrombocytopeniawhich wasfoundinahigher less frequentthanpreviously seeninothertumors,except toxicities were manageable. In particular, toxicities were patients, temozolomidewasasawholewelltoleratedand plus mitotane.Inthisretrospectiveevaluationofthese line chemotherapywithcisplatin-containingregimens die inACCpatientswithdiseaseprogressionafterfirst- label administration of the drug at dose of 200 mg/m reference centersobtainedtheauthorizationforoff- antitumor effectonACCcells findings showingthattemozolomideexertedapotent agents inthemanagement of ACC and the preclinical currently availableguidelines( is stillrecommendedasapossiblesecond-linetherapyby Sz isnotgenerallyusedasfirst-lineapproach.However, it trial ( best treatmenttobetestedagainstEDPintheFIRM-ACT ( in 40advancedACCassessedretrospectivelySweden streptozotocyn (Sz)demonstratedaresponserateof35% in twoheavily pre-treated patients ( of oralcyclophosphamideonametronomicschedule aclinicalbenefitoftheadministration group observed Alkylating agentshaveshownsomeactivityinACC.Our Discussion Temozolomide inadvancedACC Table 4 24 ). Onthebasisoftheseresults,Szwasconsideredas Due tothedemonstratedactivityofalkylating Tumor responsesaccordingtoRECISTcriteriawere 8 ). SincethiscombinationappearedinferiortoEDP, ). No differences in PFS or OS were observed ). No differences in PFS or OS were observed P =0.55, Downloaded fromBioscientifica.com at09/30/202109:14:12AM 2 P , .8 epciey (data respectively) =0.08 in vitro 3 ). 16 181 , ( 25 :6 18 23 ). ), fourItalian ). Moreover, 686 via freeaccess 2 /

European Journal of Endocrinology CR, completeresponse;PD,progressive disease;PR,partialresponse;SD,stableUND,undetermined, objectiveresponse. 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 n Table 4 methylate DNA.ThismethylationdamagestheDNA,thus benefit oftemozolomidedependsonitsabilitytoalkylate/ our seriesalowpotencytotesttheseprognosticfactors. scores. Thelownumberofpatientsenrolledconferredto significance thaneitherunfavorableandpejorative in termsofPFSandOSwithoutattainingthestatistical Favorable GRASscorewasassociatedwithbetteroutcome whereas mENSAT stagefailedtocorrelatewithPFSandOS. status wasthestrongestnegativeprognosticfactor, populations withdifferentprognosis( which disease response usually discriminates two patient inchemotherapytrials, what itiscommonlyobserved only of7monthsonaverage.Thisfindingisincontrastto whichwas lived anddidnotinfluencepatientssurvival, response and stabilization to temozolomidewereshort- disease controlrate( (about 4%)whilesimilardatawereseeninterms of obtained bytheassociationgemcitabinepluscapecitabine seem tobebetterintermsofresponseratethanthose trials havetobeconsideredwithcaution,theseresults disease control. Although comparisons between different Neutropenia Thrombocytopenia Renal toxicity Liver toxicity Table 3 = 17 Clinical Study It wasfoundinothermalignanciesthatthetherapeutic In thesepre-treatedACCpatients,poorperformance MGMT methylationassessment. Temozolomide toxicity. MGMT methylation 10 , 11 13 10 58 12 5 2 8 6 5 2 3 7 6 3 2 (% sitesofmethylation) ). Unfortunately, disease 10 (35.8%) and others D Cosentini,GBadalamenti 5 (17.9%) 6 (21.4%) 7 (25%) 7 (25%) 7 (25%) All grades 26 ). MGMT methylationwithkit-score 2 (7.1%) 4 (14.3%) 4 (14.3%) 4 (14.3%) 1 (3.6%) 4 (14.3%) G1 this findingisconsistentwiththepotentialroleofMGMT in methylated ACC vs 14% innon-methylated ACC, and the lownumbers,objectiveresponseratewasof50% were abletoassessMGMTexpressionin15cases.Despite of temozolomidetumorcellsensitivity. Inourseries,we ( tumors isoftendirectlyrelatedtohighMGMTexpression temozolomide inglioblastomaandneuroendocrine resistanceto triggering celldeathbyapoptosis.Primary recommended assecond-linetherapyinunselectedACC of thesedata,webelievethattemozolomideshouldnotbe Onthebasis lived anddidnotinfluencepatientsurvival. wereshort- be efficacious,sincetheresponsesobserved non-negligible activity, thedrugfailedtodemonstrate shrinkage inaboutoneoutoffivepatients.Despitethis second-line approachinACC,inducedasignificanttumor main limitations. design andthesmallnumberofpatientsincludedare of temozolomideinACCpatients,theretrospective ACC patients. inactivation in favoring temozolomide cytotoxicity in Temozolomide inadvancedACC 16 YES YES YES YES YES YES YES YES Toxicity, NO NO NO NO NO NO NO , In conclusion,temozolomide,administeredas This studyprovidesforthefirsttimedataonactivity 19 ). SoMGMTinactivationbymethylationisamarker n = 28 (100%) 2 (7.2%) 2 (7.2%) 3 (10.7%) 1 (3.6%) 3 (10.7%) 2 (7.2%) Objective response G2 Downloaded fromBioscientifica.com at09/30/202109:14:12AM PD PD PD PD PD PD PD PD SD SD CR PR PR PR PR https://eje.bioscientifica.com 181 :6 24.2 20.5 20.4 12.2 12.7 33.3 38.8 1 (3.6%) 0 (0%) 0 (0%) 2 (7.2%) 3 (10.7%) 4 (14.3%) OS 5.1 4.4 6.9 8.1 6.0 8.6 3.1 3.2 G3 687 24.2 15.8 PFS 2.1 4.4 2.8 3.9 3.9 3.5 7.1 2.9 4.5 2.1 2.5 6.6 7.0 via freeaccess European Journal of Endocrinology https://eje.bioscientifica.com References ENS@T the at poster a as part in presented Meeting, 2018. was research This Acknowledgements This thisstudywassupportedinpartbyFIRMonlus,Cremona,Italy. Funding be could that interest of conflict perceived asprejudicingtheimpartialityofthisstudy. no is there that declare authors The Declaration ofinterest medicine approachinadvancedACC. and thismayrepresentafirststeptowardpersonalized patients withgoodPSbearingMGMTmethylatedACC, patients. However, thedrugcouldbeapotentialoptionin 8 7 6 5 4 3 2 1 Clinical Study Fassnacht M, Terzolo M, Allolio B, Baudin E, Haak H,Berruti A, Berruti A, Terzolo M, Sperone P, Pia A,DellaCasa S,Gross DJ, Berruti A, Fassnacht M,Haak H,Else T, Baudin E,Sperone P, Kroiss M, Terzolo M, Baudin AE,Ardito A,Kroiss M,Leboulleux S,Daffara F, Berruti A, Grisanti S,Pulzer A,Claps M,Daffara F, Loli P, Mannelli M, Berruti A, Baudin E,Gelderblom H,Haak HR,Porpiglia F, Fassnacht M, Dekkers OM,Else T, Baudin E,Berruti A,deKrijger RR, Terzolo M, Daffara F, Ardito A,Zaggia B,Basile V, Ferrari L& chemotherapy inadvancedadrenocortical carcinoma. 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