Posted on Authorea 28 May 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159069174.47481624 | This a preprint and has not been peer reviewed. Data may be preliminary. lnclmnfsain r aibe n h rgoi fACi fe naoal,epcal todrages older at respectively. especially pressure, unfavorable, blood often is high ACC and of mass), prognosis as muscle the such virilization in and hormones, syndrome, variable, steroid increase Cushing’s more are hirsutism, or of manifestations one pilification, manifestations Clinical of layers clinical pubic production cortical in the acne, three in resulting the (facial increase , of an and one cause androgens, from can ACCs arising , malignancy gland. endocrine adrenal rare the of a is (ACC) carcinoma Adrenocortical Introduction rfieo ioaecnipoetemntrn n ffiayo hsdu nACtetetadcnfrhrpoieuseful provide further can and effects. treatment adverse fewer ACC with in ACC Contents drug against action this specific of with efficacy drugs new and pharmacological of the monitoring development Understanding the the investigation. improve for under toxic information currently can effects, are mitotane therapeutic that treatment of pharmacodynamics, therapeutic mitotane and profile mitotane’s of monitoring perspectives chemistry, the regarding new the reported evidence and have summarized sufficient effects, studies review provide few not this However, first did Therefore, as elimination. they such effects. drug and drug, for this mitotane, of needed of action time aspects adverse of extensive several mechanisms pharmacological and the in ACC. accumulation, in result involved may of tissue are which and pathogenesis metabolism, features necessary, death the pharmacological pass usually important cell are in that involved mitotane inducing suggests of steroids by This doses adrenocortical tissue high effects. of tumor concentration, synthesis on plasma the effects therapeutic controversy inhibiting the cytotoxic reach the by has To despite cells drug 1959, adrenal This since on FDA survival. effects the patient by antisecretory prolonging (ACC) in carcinoma adrenocortical efficacy treating its for regarding approved drug only the is Mitotane Abstract 2020 28, May 2 1 Souza Lauro and Corso Claudia adrenocortical in mitotane carcinoma of effects and profile Pharmacological eea nvriyo Parana of University Federal Pr´ıncipe Pel´e Pequeno Pesquisa de Instituto 12. 11. 10. 1. 3. 2. 9. 14 Elimination 8. 11 Metabolism 7. 9 Distribution 6. 8 Absorption 5. 4. ocuin n uuedirections future and Conclusions e esetvsfrmttn treatment mitotane for perspectives New Introduction Toxicity aspects Pharmacological Chemistry hraoyaisadpamclgcleffects pharmacological and Pharmacodynamics Pharmacokinetics 20 1 lxnr Acco Alexandra , 7 1 5 8 8 2 aiaBach Camila , 25 1 22 1 adoBonatto Sandro , 15 1 oadFigueiredo Bonald , 1 , Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. ioaecngrtosaecaatrzdb h rsneo naymti hrlcro tmta gives that atom carbon chiral asymmetric chlorine an the of of ( presence enantiomeric position the two the to by position on rise characterized the depending are configurations ring: configurations two mitotane benzene in the exists in molecule element mitotane the chemistry, DDT, the Unlike summarized new review of the this and effects Thus, mitotane drugs Chemistry the of new effects of of effects. toxic drug. development understanding toxic and this and therapeutic containing fewer better efficacy and formulations its with Therefore, features, of ACC pharmacodynamic monitoring and against disease. clinical pharmacokinetic the action rare improve specific a to needed with is aspects is pharmacological ACC ACC addressed have on because studies patient mitotane few probably FDA, of 1). by approval in mitotane, (Table evaluation mitotane identified [18,19] of the the levels of plus decades for mitotane five therapy plasma data after mitotane the Even evaluating useful monitored trials have provide seven two advanced may the only for study, EDC library, Among + our Cochrane mitotane future. of controversial the the trials still in clinical in is survival some survival However, registered patient studies. prolonging recently the controlled in prolonging randomized ACC, the mitotane in of of met chemotherapy lack efficacy a plus articles and clinical to mitotane these title due the adjuvant by of Thus, of screened None benefits patients. were eligibility. the of 553 survival of for and meta-analysis assessed duplicated for were were criteria 298 articles has 2019. inclusion OR these, full-text of ACC, Of carcinoma December Thirty-one of and databases. adrenocortical evaluation. November resection the between AND abstract in Scopus after survival and records EDC, Science, AND 851 of + identified “mitotane Web We Cochrane, mitotane for PubMed, adjuvant searched in if we tumor” combined evaluate adrenal mitotane patients, To of for efficacy benefits unclear. after the with However, mortality survival still and combination [17]. is rate metastasis in chemotherapy recurrence distant employed with the without revealed be patients decreased meta-analysis radiotherapy, among also recent without resection A can or tumor [15]. mitotane with avelumab monotherapy fails, and mitotane therapy , that aggressive + line more mitotane treat first , or to when ACC EDC), , progressive However, + less (mitotane for Lysodren [15,16]. monotherapy and product of forms mitotane , ACC reference is , mechanism mitotane surgery as for the the such after (FDA) chemotherapy, as of ACC though plus Administration form for efficacy even treatment Drug tablet line the a and Thereafter, first in Food when The available [13]. the 1959, commercially by patients became approved in male it rapidly published in and was treatment, was reported mitotane was evidence the unclear, ACC was clinical in action of first necrosis treatment The selective the was inducing for mitotane [11,12]. of for effect cortex dogs adrenolytic adrenal The in (DDT). reported dichlorodiphenyltrichloroethane isolated insecticide first (ClinicalTrials.gov was the documented o,p’-DDD, from as well patients. 1940 known ACC in not also pediatric re- were 2,2-dichioroethane], among is [1-(o-chlonophenyl)-1-(p-chIorophenyl) that mainly state Mitotane and effects use of steady ataxia, therapeutic adverse events (confusion, the its adverse other nervous patients, limiting several many central NCT00568139), most experienced and and Identifier: In patients anorexia) [10] [7,8]. Nevertheless, and systems 1/2 [6,9]. , dizziness) stage treatment , of (, daily gastrointestinal recurrence of the months and 3 3/4 after stage ached ACC for children for beAC h al oeuulyrne ewe n pt 0gt ec h da lsaconcentration plasma ideal the reach to g 10 to L up mg inoper- and 14–20 or 2 post-operative is between for which ranges toxicity, treatment, usually adjuvant tolerable children dose or with million single daily as one The drug, ACC. per a approved able 0.3 reaching only of [3], the is incidence adults mitotane worldwide in One Currently, rarer estimated than even [2]. [4]. children an years in is women versus 15 higher children among it than is million common whereas younger incidence per more adults, ACC 3.4–4.2 is the among of it wherein cases/million/year rate cases/million/year); Brazil, 1.7–2.0 Southern (0.2-0.3 is is countries exception ACC most of in children incidence among general The [1,2]. R and S oeue.Cnieigta ioaei vial sarcmcmixture, racemic a as available is mitotane that Considering molecules. ) ortho -1 56.Tema oei day g 4 is dose mean The [5,6]. noern n h position the and ring one in 2 oafasciculata zona -1 para o dlsad4gm g 4 and adults for and naohrrn.These ring. another in oareticularis zona ² (r) /day fthe of [14]. -1 Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. oacmlt anyi dps ise swl si h ie,kde,ban n dea ise[2.Mitotane [32]. tissue [33,34]. adrenal tissue and adrenal tended brain, kidney, mitotane mouse liver, mitotane, and the 1% tumor in containing as diet than well of with as higher days tissue, doses were labeled 80 adipose repeated levels after in concentration of DDA plasma mainly rats, the administration accumulate Nevertheless, In than to the [31]. [26]. higher chemotherapy after 200-fold g was during detected tissue 2 patients barely in adipose in of was in detected concentration dose DDE mitotane be single whereas the However, can a plasma, [30]. mitotane the after of in hours mitotane concentration levels 2–8 by maximum mitotane estimated patients influenced The The more of [29]. time. was plasma long concentration process the a plasma elimination for the the studied Thus, than been high. distribution has relatively compartments was distribution body various of volume in to mitotane tool of distribution a The as used patients. be can among variability model Distribution mitotane the this 3.1.2. measure and Therefore, to mitotane [29]. to proposed of clearance adapted a was absorption and model are is distribution the model pharmacokinetic functions of 3-compartment elucidate mitotane new volumes mitotane The a that the in practice. proposed documented through CYP2W1 clinical [29] of levels was and daily (2015) polymorphism CYP2B6 colleagues in It the and of patients [28]. Kerkhofs individual roles whereas probability mitotane Thus, the rates, clear. reduced however, of yet response 3.1.3); levels a not lower section plasma with (see with high inducer associated and with CYP2B was range correlated CYP2W1 therapeutic was mitotane of CYP2B6 treated ACC and the CYP2B6 polymorphism stage of reaching age, any the polymorphism with of sex, patients the monotherapy, In that index, concentration. mitotane demonstrated mitotane mass [27] plasma with (2013) body higher role al. with important in et correlated an different D’Avolio variability positively play was fact, with might individual In polymorphisms observed basic absorption. (CYP) was mitotane P450 the in concentration cytochrome to Metabolic plasma to activity. due in enzyme due probably metabolic variation probably patients high low, among addition, day is g doses In (2–10 [5,6]. oral doses initiation high the L treatment required mg that about patients (14-20 doubt concentration information Indeed, plasma of no metabolism. therapeutic lack extensive no is the and is there absorption Despite concentration there mitotane, metabolism. poor g since plasma first-pass of 626 bioavailability has ideal approximately pharmacokinetics mitotane mL-1 mitotane of determine the the whether dose mg to reach determine accumulative difficult 0.0016 to to an is extraction of with time it days However, concentration the 116 about [27]. plasma [26], around data patients) was administration maximal 53 patients after from the ACC (data h among reached L-1) 10 g) mg patients) 2 (14 [26]. 9 of tablets from emulsions, dose mitotane oil (data of (single or that chocolate, mitotane to milk, compared by fat Although followed 5-fold high by maximum as DMSO the absorption such or reached lipids its mitotane oil dietary increased tests, olive with which clinical in together In [24,25]. administered dissolved concentrations when often plasma absorption was ideal reach mitotane to studies, buffer, aqueous pre-clinical In Chemical). mL Cayman mg mL (0.1 mg solubility (20 ethanol water poor has Mitotane Absorption 3.1.1. 1B). can o,p’-DDA which metabolite (Fig. the nucleophiles, water to of biological converted presence rapidly for be the affinity via could in DDAC strong (DDA) reactions otherwise, a molecules; two has cellular involves different DDAC acylate drug. (DDAC). metabolism commercial chloride mitotane the acyl in that dichlorodiphenyl present demonstrated are been 1A) hydroxylation. has (Fig. it (R)-(+)-o,p’-DDD Furthermore, and (S)-(-)-o,p’-DDD enantiomers, both 2. 1. Pharmacokinetics aspects Pharmacological nvitro in 14 a oaie anyi the in mainly localized was C α- yrxlto om h eaoieop-D DE,whereas (DDE), o,p’-DDE metabolite the forms hydroxylation -1 netnlasrto,boviaiiyo nrvnul diitrdmttn,o hepatic or mitotane, administered intravenously of bioavailability absorption, intestinal ,dmtysloie(MO 3 gmL mg (30 (DMSO) dimethylsulfoxide ), oafasciculata zona -1 n h taysaewsrahdol bu otsafter months 3 about only reached was state steady the and ) -1 t25 at 3 º ) en etrslbei rai ovnssc as such solvents organic in soluble better being C), -1 ,addmty ommd DF (PubChem; (DMF) formamide dimethyl and ), and oareticularis zona β- yrxlto om o,p’- forms hydroxylation nhmnadrenocortical human in -1 orahthe reach to ) α- and β- Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. omladnolsi dea lnsadwsrltdt etrrsos omttn ramn among treatment mitotane to of response function both better in of exact a observed effects to the was the however, related mRNA CYP2W1 was to xenobiotics; of and line some level glands cell expression of adrenal high this metabolizer Moreover, neoplastic of known unclear. and sensitivity a still normal that higher is is demonstrated ACC promoted colleagues enzyme in and cells CYP2A6 This Murtha H295R Recently, in mitotane. [47]. of mRNA mitotane effects CYP2A6 the DDAC. that of to the to suggesting related silencing of [33,34], tend also that formation CYP11B1 are DDA the theory of CYPs in the inhibitor and Other involved known supporting are mitotane a CYP11B1 [32], (erythromycin), , and decrease by inhibitor CYP11A1 DDE reversed both P450 of partially glutathione was levels a adrenals the of CYP11A1 of the for whereas as addition presence responsible plasma, such is the the is cells, and bond by covalent adrenal P450 tissue In the the reversed fat for in in be [46]. steroidogenesis reaction accumulate to can for The 3.2) important responsible and section [45]. is CYP450 permanent mitotane (see be It specific inactivate not might a can [44]. through is which GSH mediated adrenals that (DDAC), bond the suggesting covalent derivative in (GSH), the chloride reductase macromolecules that acyl mitochondrial out an to point binding metabolite, covalent reactive for extensively intermediate hypothesis. not responsible this an was confirm cell of it to adrenocortical since generation yet H295R the conducted metabolite, on been effect active have cytotoxic The an studies a had additional be and no could 3.1.4) found However, section pathway. further DDE (see deactivation [43]. is feces mitotane that line presence or the its speculated urine, of and plasma, end-product been claimed lipophilic in an authors has found so is DDA other not it that is [30], contrast, suggesting DDA metabolite 3.1.4), fact, In active section In an (see urine was [38]. the it metabolite in inactive that an suggested has was mitotane drug DDA of This that effects [42]. the cells estimating adrenal for cells: in adrenal only of occurring mitochondria β- as the described in previously reactions was two mitotane of important ACC metabolism in is The enantiomer mixture each racemic of the Metabolism features that pharmacological 3.1.3. suggested the also clear. However, (R)-(+)- yet is mitotane. not the it (S)-(-)-o,p’-DDD are of than viability, Thus, treatment effects cell less [41]. therapeutic H295R slightly the mixture decreasing cortisol) for racemic in and the potent [DHEA] and minip- equally the three (dehydroepiandrosterone were o,p’-DDD in of secretion isomers dominant plasma two the hormone was in the S(-)-o,p’-DDD affected dominant Besides, was enan- [39]. R-(+)-o,p’-DDD of chromatography enantiomer [40]. exposure gas the igs patient the whereas by minipigs in improve measured two suggested and of as were plasma placentas efficacy ratios human elimination and and different [35]. to toxicity mitotane mitotane, mitotane tiomers estimate whereas of lipoprotein-bound to enantiomers group, and acid the mitotane. Therefore, lipoprotein-free carboxylic Regarding of quantify [35]. to the to effects important lipids of important is the presence for is it to the affinity However, it to unresponsive chylomicrons. care, high due be to a lipophilic may bound have too found patient not DDE also the is were and DDA DDE that [36], complex and note cells mitotane-VLDL DDA adrenal treated in of bound ACC concentrations the grown the with High conditions, into cells patients hypertriglyceridemic enter in H295R demonstrated Under fraction not in was [38]. active does control shown statins tumor were therapeutically and of mitotane mitotane its rate with higher of was a effects mitotane and proapoptotic medium, lipoprotein-free lipoprotein-free of and that antiproliferative distribution suggesting However, Higher The mitotane, cells. [35,38]. [36]. adrenals of (VLDL) into activity [37], self-uptake lipoproteins formation the its LDL low-density promoted promoted mitotane very Interestingly, probably LDL. to to and adhering plasma and by mitotane diffusion chylomicron of cellular conditions, involves hypertriglyceridemic to proportion mitotane under mitotane mainly whereas higher of albumin, amount bound a and substantial lipoprotein a was as density conditions, high normolipidemic binding to Under bound [35]. lipoprotein was lipoproteins and to chylomicron bound was involved mitotane mitotane of Distribution yrxlto hc ie iet h n-rdc D Fg B.Atog esrmnso lsaDDA plasma of measurements Although 1B). (Fig. DDA end-product the to rise gives which hydroxylation β- yrxlto fmttn a nte motn ucinbyn D omto,wihi the is which formation, DDA beyond function important another has mitotane of hydroxylation α- yrxlto fmttn.I diin cuuainof accumulation addition, In mitotane. of hydroxylation α- yrxlto hc ilsteedpoutDE and DDE, end-product the yields which hydroxylation 4 nvitro in iorti idn inhibited binding lipoprotein , 14 aee ioaein mitotane labeled C Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. ioaecerneadvlm fdsrbto ntesed tt eedtrie n2 ainsa 0.94 as patients 22 in determined were unchanged state The Thus, steady [35]. DDE the [55]. transformation and in days hepatic DDA, to distribution 8 mitotane, due within of However, enriched of volume ± feces be amount mitotane and the excretion. could was the chyle clearance biliary unchanged in 7.1% decreased circulation; mitotane through found rats, of enterohepatic emulsion in largely was 40% undergo or mg) eliminated mitotane also around (100 milk of can be treatment g), in mitotane to 87.8% mitotane (2 oral and appears after whereas form urine mitotane Furthermore, h, tablet the [26]. 12 in 10% in after than excreted dose less feces mitotane to the excreted single in drug a detected of be intake could oral an closely.After monitored be the to necessary, need Elimination drugs is (i.e. 3.1.4. these these drugs clopidogrel) by of such and toxicity metabolized with and combination omeprazole, potent drugs effects in a many , and therapeutic mitotane with , CYP2B of interactions and treatment etoposide, clinical CYP3A4 associative interactionsdoxorubicin, on in when effect drug–drug Therefore, result inducing pharmacokinetic which [52,53,54]. long-lasting of enzymes CYP2C19, a possibility has on drug the effect This pharmacokinetics. thus, inhibitory its discarded. index; in be therapeutic changes and not liver the should narrow via of explaining a circulation, effects to has enterohepatic the crucial Mitotane during understanding is or Therefore, metabolism absorption the mitotane [51]. since to intestine on considered, prior the microbiota liver. be in metabolism gut the also reactions drug in should enzymatic in and DDE metabolism microbial role mitotane and various CYP450) a in DDA, via [50]. plays way microbiome mitotane, same microbiota intestinal (i.e. of the the gut enzymatic in metabolism of liver via the the role investigated liver in the have metabolized plasma Moreover, the is studies the in DDT preclinical in since metabolized detected no reactions be However, [GSH]) barely be glutathione was might might e., compound DDE mitotane Moreover, this (i. that pass non-enzymatic why chyle. indicates explain in intestinal first would This found the which undergoes DDE liver, mitotane [35]. Furthermore, and mitotane the intestinal DDA of in of that feces. hypothesis further concentrations suggests The high metabolized via by This metabolism. eliminated supported and is largely absorption metabolism [25]. mitotane is administration, influence days oral and/or also by 13 could achieved orally microbiome those only administered to for compared when kg days, effects mg metabolism 34 (440 antitumor for a route remained yielded be and intraperitoneal effects which antitumor the could expression the via and days), tissue mice, 48 metabolism the to for mitotane administered however, was in [49]; mitotane debate. role treatment When under a mitotane still play are to might CYP2W1 sensitivity CYP2W1 of of function that marker suggested predictive was potential It [48]. patients n a edvddit ormjrctgre:()ihbto fseodgnss i)edpamcreticulum endoplasmic (ii) 2) steroidogenesis, of (Fig. steroidogenesis inhibition others of antisecretory (iv) (i) Inhibition to and mitochondria categories: death, insensitive adrenal major in cell more mainly (iii) four were place stress, into takes rodents (ER) divided mitotane that of be action suggesting can of and reports mechanism and The (DHEA) besides [25,44,42]. mice, androgens effects and mitotane as dogs such level in plasma production, the reported maintain steroid to decrease is recommendation to μ L current mg is The 7 [6,10]. ACC than death higher cellular in tumor mitotane induce and of cortisol, [26]. effect withdrawn main was The mitotane effects after pharmacological to days attributable and day 159 tissue, Pharmacodynamics g fat and 3.2. in 3–6 18 accumulation at between its lower mitotane to be is characteristics. receiving due rate to lipophilic probably patients its the was found 19 observed clearance, was of elimination mitotane half-life mitotane study in Long-term the a role kg days, In important 30–60 mg elimination. an of biliary (250 plays of mitotane also that elimination with than renal treated Although mice [56]. of feces urine the in )frattmreet 3,7.Temjrfidnso h ehns fato fmttn eefirstly were mitotane of action of mechanism the on findings major The [30,57]. effects antitumor for M) .7Lh L 0.37 -1 n 161 and -1 ( > ± 21.8 8Lkg L 68 μ )t rdc niseodgnceet n ewe 42 gL mg 14–20 between and effects anti-steroidogenic produce to M) -1 ftela oyms,rsetvl 2] nadto,DAwsfound was DDA addition, In [29]. respectively mass, body lean the of 5 -1 .. o oa f9 2]a ela nthe in as well as [24] h 96 of total a for p.o.) , -1 isle noieoil, olive in dissolved , -1 vraperiod a over -1 (43.7–62.5 Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. nseodpouto nAC nti ie oe OT niio AR11 D3312 nevanimibe PD132301-2, (ATR-101, reduction inhibitor the SOAT1 and novel caspases a of line, activity this the In induces ACC. mitotane which on apop- the by production of intrinsic mechanisms steroid inhibition the kinase the the in activated of reticulum Therefore, CHOP one endoplasmic [62]. of underlie R-like death upregulation may cellular kinase The to protein leading pathway, expression. of tosis (CHOP) expression of protein 2 downregulation the factor homologous the induced initiation to C/EBP eukaryotic it due the be phosphorylated persisted, may which induced stress mitotane (PERK) levels by (SREBF) ER acid induced 1 As level production fatty factor . cholesterol steroid and of transcription in inhibition ester element-binding increase the cholesterol regulatory thus, an accumu- free sterol had an in of patients to increase downregulation why [62]. fatty led promoting This explains of mitotane which stress formation [63]. by ER acids, the SOAT1 treatment fatty promotes of that mitotane and ER suppression cholesterol throughout the The free in gene). of located database lation protein intracellular (NCBI an esters is acid-cholesterol SOAT1 [62]. enzyme sterol- enzymes. this of specific function with the occurs inhibited it Mitotane if metabolite assess stress intermediate to (ER) needed the reticulum still between Endoplasmic are reaction compounds chemical mitochondrial mitotane a the adrenal inhibits whether specifically and evaluating enzymes; DDAC mitotane unclear steroidogenic studies several that still Additional in idea is reductions simultaneously. the in it as resulting such However, supports CYP11A1, gene, This regulatory as cells. steroidogenic such enzyme, [62]. adrenocortical key cells in a pathways IMR32 inhibits (EC steroidogenesis and mitotane the HEK293, to affects HepG2, sensitive radicals more HeLa, [45]. free is in action and lower mitotane line this epoxides of cell support as mechanisms adrenocortical to such of the lack The cells, intermediates elucidating liver a reactive in and is other considered there adrenal of be now, human involvement it also until in the However, should adrenals, macromolecules addition, the tissue. to In adrenal bound in on DDAC hypothesis. mainly effect the localized local assessed enzymes has that cells mitotane studies steroidogenic why in are aldosterone, partially decreased in CYPs explain reduction may aforementioned be in symptoms. the to ACC results that found reducing enzymes and Considering also production, these were estradiol beta- of (NCBI and inhibition (HSD3B2) 3 cortex testosterone, The 2 adrenal dehydrogenase DHEA, [46,61]. type the cortisol, hydroxy-delta-5-steroid mitotane and mitochondrial in with CYP17A1, the cortisol (HSD3B1), incubation in to CYP21A2, 1 after localized type addition, is of delta-isomerase In CYP11B1 conversion steroid the species. in reactive gene). that involved suggest of database data is formation These and with the [33,34]. membrane labeled in CYP11B1 inner Mitotane of result and inhibitor [45]. also bovine known mice may a in of metyrapone, CYP11B1 mitochondria by lung the reversed the and partially to liver to was the bind which bind in to to proteins found found and was phospholipids was mitotane to mitotane and when via adrenals confirmed DDAC, dog was as such hypothesis metabolites, this reactive Later, produced mitotane that suggested β- was CYP11A1. mitotane it to with ago, treatment specifically ( years of subunit Many binds h regulatory 24 mitotane following A that reduced kinase was confirms protein steroidogenesis, This of of of activation expression actions [46]. the the antisecretory TSPO in involved addition, and is with In antitumor which incubation ), [59]. the Interestingly, cells protein potentiated H295R significantly domain-containing in [58]. mitotane mitotane mem- AAA (VDAC) with receptor mitochondrial combination channel family 1 in ATPase the anion inhibitor sigma voltage-dependent (StAR), in or and protein complex (ATAD3A), receptor regulatory protein 3A benzodiazepine acute multiple protein/peripheral-type Choles- mito- steroidogenic a 3). translocator outer (TSPO), the the (Fig. transduceosome, from contains CYP11A1 the cholesterol enzyme that of via the brane, transport through CYP11A1 the membrane reaches is mitochondrial steroidogenesis inner terol in the step to rate-limiting membrane the chondrial that known is It yrxlto hog Y40 hc ol oaetybn omtcodilmcooeue [44,60]. macromolecules mitochondrial to bind covalently could which CYP450, through hydroxylation SREBF sagn htsiuae h rncito fseodrgltdgns(CIdtbs gene); database (NCBI genes steroid-regulated of transcription the stimulates that gene a is oafasciculata zona SREBF O ay rnfrs SA1 nH9Rclswihhgl express highly which cells H295R in (SOAT1) 1 transferase -acyl / oareticularis zona seblw;o fmttn ffcsalteseodgncenzymes steroidogenic the all affects mitotane if or below); (see 6 narncria uo n os adrenals, mouse and tumor adrenocortical in 50 α hshrlto (eIF2 phosphorylation 18.1 = μ )weesteEC the whereas M) SREBF eetruhE stress ER through gene α n ciae the activated and ) 50 PRKAR1A a 3-fold was SREBF 14 C Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. ofso,smoec,dpeso,dces eoy uceteos oyerpty n izns [72]. dizziness and polyneuropathy, disturbance, tremors, the speech affected muscle mitotane ataxia, memory, doses, including higher were decrease At manifestations, symptoms depression, [72]. include neuromuscular These more somnolence, or symptoms produced g [71,21,10]. confusion, gastrointestinal 2 and mucositis of system unspecific doses to daily nervous evolve The received central who can patients of which patients. 78% anorexia, in among reported and vary nervous, gastrointestinal, vomiting, can the nausea, involving and those diarrhea, as such systems, unspecific, endocrine are mitotane and of effects side common Even most The ChemIDplus). (NIH-TOXNET; L respectively mg rats, 20 and patients. below mice, maintained pigs, guinea are humans, levels levels in mitotane g plasma 5 though and 4, L 5, mg 17, 20 above concentrations Mitotane resistance Toxicity mitotane overcome at to using pointed phenotype. strategies resistant performed study the develop be The to help should contribute controls. might may collectively nonresistant model which in this homeostasis lipid that Although and mitochondrial to xeno- lipoprotein of to compared in production, changes response absence cells, the steroids and resistant an clearance, adrenal showed mitotane-treated cell of apoptotic in findings downregulation (ERK), biotics The levels, kinase an cholesterol extracellular-signal-regulated established line. of free regulation cell study intracellular and ac- HAC-15 recent in of increased the a mechanisms and using Thus, molecular damage ACC the unknown. in pathways, currently resistance aforementioned are mitotane the resistance affects mitotane mitotane factor quired that growth evidence [46]. transforming the inhibition of Despite CYP11B1 directly expression or can CYP11A1 the that of inhibited strategies independent mitotane of be development A2/B1, (tubulin-b Moreover, the ribonucleoprotein structure for cytoskeleton nuclear [69]. (TGF- targets 27), growth heterogenous good protein represent ACC (prohibitin, proteins shock inhibit tumorigenesis These (NADPH), heat D). and pathways metabolism and cathepsin other profilin-1), cellular VI and alters and in and also involved II II, mitotane proteins I, isoform apoptosis, modulates (peroxiredoxin and Mitotane response stress, stress investigations. ER further steroidogenesis, need of that inhibition to addition [68]. pathways, Despite cells In steroid ACC on [66,67]. in dependent death apoptosis ferroptosis cell cellular mechanisms to of Other of susceptible form induction this also induce were and not cells proliferation did cortical cell disruption, mitotane adrenal chan- tumor membrane that anion of including voltage-dependent evidence c the inhibition SW13), the and cytochrome in and dehydrogenase inducing succinate resulting (H295R 50 as by and in- cells nel, such cells increase (30 to enzymes, adrenocortical chain mitotane H295R to due tumor respiratory that due in also human affecting observed was was IV in been viability apoptosis and alterations has the cell I ical It Moreover, adrenal complexes [66]. in [46]. chain defect apop- decrease apoptosis respiratory oxidase by the cellular death mitochondrial that cellular induced of and found which hibition stress activity, also oxidative 3/7 was induce caspase either It in can cells necroptosis. adrenal and/or to tosis DDAC the of attachment in The efficacy limited had not nevanimibe could death of effect formulation Cell apoptotic current had an [65]. the patients for ACC dose, with the advanced necessary feasible of adults with levels maximum 27% in patients exposure the nevanimibe multicenter response, expected with recent partial of the achieved or a (PK) that be Thus, complete pharmacokinetics given However, a and [64]. experienced safety disease. cells patients the stable adrenal no assess in Although to apoptosis ACC. conducted and metastatic was stress study ER 1 induce phase to demonstrated was HCl) < β ee noigaptn niio fcl rlfrto n trioeei.Hwvr tapae to appeared it However, steroidogenesis. and proliferation cell of inhibitor potent a encoding gene, ) 5m L mg 15 -1 a xeinesvrltxceet,poal u otevraiiyi Y ciiyamong activity CYP in variability the to due probably effects, toxic several experience can nvivo in oeso ioaerssac eoecnutn lncltil [70]. trials clinical conducting before resistance mitotane of models -1 r ihytxc h rlLD oral The toxic. highly are 7 -1 o C ramn,ptet ihplasma with patients treatment, ACC for μ )idcdmtcodilmorpholog- mitochondrial induced M) 50 fmttn eerpre obe to reported were mitotane of nvitro in nvitro in ute studies further , oe of model β 1 Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. ffc,ehneboviaiiy n euetetxceet fmttn 8] he omltosaebeing are formulations Three therapeutic the [80]. improve mitotane to of effects expected micelles. toxic are the nano-formulations reduce poor developed: Mitotane have and bioavailability, that molecules mitotane. enhance lipid effect, as in incorporation such for solubility, strategy attractive water an as a emerged have be Nano-formulations encouraged. might are this studies and clinical slow, further was and Nano-formulations elimination ACC, MeSO of of Overall, treatment rate [76]. using the the patients Investigation for Likewise, MeSO for alternative dosages of [79]. mitotane. appropriate concentrations of effect designing liver to those opposite challenge and than the fat, higher has 18-fold plasma, it and the concentrations that higher showed at minipigs and (5–15 expression, cells H295R CYP11B1 in and this hand, MeSO in other of role and dose the kg and a On mitotane mg plays (50 [77]. both CYP11B1 model secretion cells, xenograft that aldosterone suggesting tumor affect not etomidate, Y-1 did inhibitor adrenocortical MeSO CYP11B1 murine of potent In effect the by [34]. inhibited cell was and cortex degeneration, adrenal mitochondrial MeSO murine mitotane, CYP11B1, MeSO to to the Similar binding in by [34]. humans metabolite death in intermediate mitotane reactive than a doses generated lower the at agent the adrenocorticolytic in bound covalently and up taken option. attractive MeSO an be formu- treatment. new should ACC of metabolites for development MeSO its options the containing potential effects, two toxic compounds discuss less new we with Below or ACC mitotane for containing options therapeutic lations current the improve To treatment may mitotane toxicity treatment. for discontinue mitotane to perspectives together, necessary glu- New Taken be of and may suppression. levels it cortex high adrenal and prescribe adrenal chronic tolerability, with to aggravate or the limit presenting acute may need tumors decrease were potential Mitotane the events in effectively and consider urgent hypothalamus-pituitary-adrenal-axis, adverse insufficiency. may the more clinicians general, mitotane of is that In suppression Because concern mandatory cocorticoids, [73]. This is [71]. patient it replacements. treatment female steroids, mitotane a all in of of [71]. lev- reported cessation synthesis necessary enzyme of also the hepatic if levels was after in the ex- replaced dyspnea increases in reversible well and Recently, and decrease not monitored anemia, a is [71,10]. be thrombocytopenia, to treatment els must impotence, leading mitotane which included hormones, during exact thyroxine, manifestations thyroid pathway Other the free of mevalonate However, and production the the hormone of [37]. influenced thyroid-stimulating activity synthesis mevalonic also the in cholesterol Mitotane in increase hepatic plored. an increase downregulating in the result for of may responsible effect formation, inhibition Mitotane’s oxysterols metabolites cholesterol administration. and in mitotane involved acid during may enzyme documented an SHBG also bilirubin CYP450, was in of levels increase cholesterol increase also in relative may increase and a An treatment steroids Mitotane and [37,71]. gonadal rashes mitotane of [71,10,2]. skin of levels hypogonadism and effect serum D levels primary reducing total vitamin and androgen-synthesis increased and which cause [TBG], the -binding globulin, globulin Thus, human thyroxine-binding binding (i.e [SHBG], cortisol cortisol. globulin globulin and binding binding protein) hormone hormone binding sex sex of [CBG], production globulin hepatic increased Mitotane 2 2 2 DEihbtdcriotrn rdcin u nyMeSO only but production, inhibited -DDE MeSO sulfones. methyl aryl and DDE from derived compound synthetic a is -DDE DE(-ehlufnl22bs4clr-1Cpey)11dclrehn MeSO (3-methylsulfonyl-2,2-bis(4-chloro-[14C]phenyl)-1,1-dichloroethene -DDE (i) efmcomliyn rgdlvr ytm(SMEDDS), system delivery drug self-microemulsifying 2 DE[57] nadto,MeSO addition, In [75,76]. -DDE 2 DEaeipratfcossnea o ocnrtosi a tmlt tri production steroid stimulate can it concentrations low at since factors important are -DDE -1 ..,mttn a oecttxcta MeSO than cytotoxic more was mitotane i.p.), , oafasciculata zona 2 DEihbtdcrio rdcini 25 el,but cells, H295R in production cortisol inhibited -DDE 8 narnlcre nmc 7] MeSO [74]. mice in cortex adrenal in 2 DEwscttxc h cytotoxicity The cytotoxic. was -DDE (ii) 2 ii-ae aoares and nanocarriers, lipid-based DEwr,rsetvl,2,25-, 2-, respectively, were, -DDE 2 DEmyrpeetapotential a represent may -DDE 2 DE[8.Teconcentration The [78]. -DDE μ )adi uemice nude a in and M) 2 -[14C]DDE) 2 DEi selectively is -DDE 2 DEi potent a is -DDE 2 -DDE (iii) Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. h uhr hnst nttt ePsus e´ eun rıcp,Crtb-R n h rzla funding Brazilian the and Pr´ıncipe, Pel´e Curitiba-PR, Pequeno Pesquisa de Instituto of to drug thanks the authors be The to due continues this, it Despite ACC. cells, treatment. with tumor ACC patients Acknowledgements adrenal improve of in to survival mitotane. mitotane field the of of this improving formulations effects in for new antitumor effects, choice studies evaluating and side new studies antisecretory conduct decrease few the to only and to necessary are delivery, is There drug it adrenal system. studied Therefore, bioavailability, gastrointestinal most enhance the the apparently in currently can mainly are improve to they Nano-formulations be option toxicity. since attractive among an to mitotane option, be decrease effects can need and metabolites therapeutic its still the treatment or chemotherapy and mitotane mitotane in containing compounds pharmacokinetic of metabolized or formulations the action New is of of mitotane variability mechanisms that the exact suggest understand of patients. and CYP11A1) acylation to pharmacokinetics the and clarified to the CYP11B1 thoroughly mitochondria lead adrenal However, can to bind this (i.e. to and as mitotane adrenals. enzymes of stress action, ability mitotane the ER steroidogenic Furthermore, of during through via death. mechanism cell species the apoptosis induce there reactive in and induce molecules elucidated, considered be of cellular and well be also formation production not also doses may The should is high steroid CYPs respiration. DDAC, Consequently, action control of mitochondrial of patients. might mechanism of polymorphism among mitotane the inhibition the mitotane Although that addition, of effects. evidence effect In side is ideal therapeutic absorption. several an specific inducing the poor mitotane with employed, of very compounds make are variability new its not the of of do lack in features because a involved pharmacokinetic is ACC there its for since However, treatment drug effects. ACC antitumor for approved and drug antisecretory only the is Mitotane warranted directions are future formulation and injectable Conclusion this of tolerability and consequently safety and the concentration [86]. about plasma mitotane studies improve Additional may efficacy. nano-formulation and this the administration that intravenous suggesting equivalent, for ethanol and suitable Mi- its Haider is loading. with efficacy plasma, drug comparable high in exhibits consequently with mitotane cellar nano-formulation and ability, mitotane water based tissue-penetrating in poly(2-methyl-2-oxazoline)-block-poly(2-butyl-2-oxazoline)-block-poly(2- (pMeOx-pBuOx-pMeOx) solubility release, micelle methyl-2-oxazoline) so- poor drug a aqueous has of developed in mitotane control [86] As copolymers colleagues are [84]. amphiphilic nano-formulation toxicity of this reduced arrangement of and an advantages by The formed [85]. ACC. structures lutions in are nano-formulations micelles enhancing of Polymeric for efficacy [84]. the systems no evaluate delivery However, to [83]. potential yet release (iii) as out [80]. drug NLCs, matrix carried controlling solid in been and a bioavailability, have and use improving studies SLNs that mitotane, additional nanoparticles in of lipid effects loaded of therapeutic type efficiently novel the was a mitotane are NLCs fact, nanoparticles. In lipid or should solid studies either additional of and mitotane of SMEDDS administration (ii) Nevertheless, the regard. optimizing ACC. this for in in tool effects new performed antitumor a be decrease and including system. as gastrointestinal also antisecretory considered studies, the can be the preclinical in can SMEDDS enhance of mitotane if could of evaluate lack SMEDDS solubility to bioavaila- a whether yet poor a is with the performed mitotane, there to been of Moreover, due have solution occurs studies a which no than toxicity, However, faster gastrointestinal much [82]. barrier 3.4% intestinal of the bility The cross [81]. to bioavailability found increasing was and SMEDDS drugs water-soluble Capryol poorly contains of mitotane-SMEDDS rate formulation dissolution the enhancing for useful (i) MDS MDSi napoc oicroaiglpdmlcls rcnetae ireuso is microemulsion Preconcentrated molecules. lipid incorporating to approach an is SMEDDS SMEDDS: ii-ae aoares oi ii aoatce SN)o aotutrdlpdcrir NC)consist (NLCs) carriers lipid nanostructured or (SLNs) nanoparticles lipid Solid nanocarriers: Lipid-based iels ielsaepoiignncrirssesfrdu eiey seilyfrattmragents antitumor for especially delivery, drug for systems nanocarrier promising are Micelles Micelles: ® Tween , 9 ® nvitro in n Cremophor and , and nvivo in ® bevtos oinvestigate to observations, ttesm concentrations. same the at β- yrxlto,sc as such hydroxylation, Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. 4 aztU zsk ,DoaosaD nesadn ioaemd fato.JPyilPharmacol Physiol J action. of mode mitotane Understanding adrenal D. 13–26. of Dworakowska 68: P, suppression https://doi.org/10.1016/B978-1- 2017; Szyszka and U, cancer 341. Waszut adrenal 72: 14. 1959; of Physicians Regression Am al. Assoc et Trans o,p’-DDD. RH, 4832-2866-2.50035-0 by Am Moy men Injection. MB, in ACTH Lipsett to function Dogs DM, of Bergenstal Response 13. Metabolic https://doi.org/10.1152/ajplegacy.1954.176.3.374 on 374–376. Treatment 176: DDD 1954; of Physiol Effect in HD. J Green produced 48: J, damage Nichols 1949; hepatic 12. (Chic) and Pathol (cytotoxic) Arch TDE). atrophy or cortical (DDD 387–394. adrenal 2,2-bis(parachlorophenyl)-1,1-dichloroethane Severe feeding G. by dogs Woodard AA, Nelson 11. adrenocortical in toxicity https://doi.org/10.1677/ERC- 1043–1053. mitotane 15: of evaluation 2008; Prospective Cancer 2000; 08-0103 al. Relat therapeutic et Metab Endocr adjuvantly. G, the treated Endocrinol Reimondo patients achieves S, Clin cancer Francia treatment J De mitotane F, cancer. Daffara monitored adrenocortical 10. Low-dose with patients al. in https://doi.org/10.1210/jcem.85.6.6619 et effects 2234–2238. A, 85: side Bras Berruti manageable Arq A, with Review. Pia range A Tumors: M, Adrenocortical Terzolo Childhood 9. al. 651-658. et Cancer 48: F, Cancer. 2004; Sandrini Metabol Adrenal the E, Endocrinol of in Michalkiewicz cisplatin Study RM, and Pereira the doxorubicin, 8. for etoposide, Group with associated Italian 2194-2000. Mitotane carcinoma. 83: and al. 1998; adrenocortical et etoposide, advanced A, cisplatin, of Pia 513–524. M, treatment with 28: Terzolo 2006; A, Associated Berruti Oncol Mitotane 7. Hematol Pediatr al. J et carcinoma. BH, adrenocortical https://doi.org/10.1097/01.mph.0000212965.52759.1c Oliveira childhood advanced MA, in Pianovski doxorubicin P, Zancanella Endocrinol J 6. Eur follow-up. of months https://doi.org/10.1530/EJE-11-0557 3 261–268. first carcinoma: the 166: adrenocortical during in 2012; measurement strategy mitotane mitotane plasma High-dose of al. analysis et prospective e168. I, pp. Borget 2010, S, pediatric, Maucl`ere-Denost Leboulleux Elsevier; 5. and S, Philadelphia: Adult ed. Endocrinology A.P. sixth Grossman, 2619-2626. gland. In: 31: TP53 adrenal carcinoma, 2013; the The Adrenocortical Oncol for M. Clin Fassnacht Surveillance J B, and Tumors. Allolio Screening Adrenocortical 4. Neonatal Childhood of of Impact Detection https://doi: al. Early 282-326. et on 35: N, Mutation R337H 2014; Filho Kiesel Rev GA, Endocr Parise Cust´odio carcinoma. G, 3. Adrenocortical al. Clin et A, J with Sabolch Registry. children AC, 10.1210/er.2013-1029 Tumor Kim of T, Adrenocortical characteristics Else Pediatric outcome 2. International and Clinical the 838-845. al. 22: from et 2004; report Oncol B, A Figueiredo tumors: R, adrenocortical Sandrini E, Michalkiewicz 1. interest. References of conflicts no declare authors The Interest of 001]. Conflict code [Finance (CAPES) N´ıvel Superior de Funda¸c˜ao Tecnol´ogico Coordena¸c˜ao Pessoal Cient´ıfico (CNPq); Aperfei¸coamento e Desenvolvimento and de de de Arauc´aria-PR; Nacional Conselho agencies: 10 Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. 0 eme G asah ,TrooM ta.Pam ocnrtoso ’pDD o’,p’DDA, Results o’,p’DDD, Carcinoma: of Adrenocortical Concentrations in Plasma Mitotane Mi- to al. of Response et Model Tumor M, Pharmacokinetic of Terzolo 58–65. polymor- a Predictors M, 37: of Fassnacht CYP2B6 as 2015; Development IG, o’,p’DDE Monit the Drug Hermsen and al. Ther of et 30. Carcinoma. H, 293–300. Influence Adrenocortical Ettaieb in LJ, Dosing https://doi.org/10.1097/FTD.0000000000000102 Derijks 23: Personalized Toward TM, al. totane: Kerkhofs 2013; Nucleotide et Single Genomics CYP2B6*6 29. and Cancers V, CYP2W1*6 Study. Pharmacogenet Germline ENSAT Multicenter of 12. A Effects Basile 2020; Carcinoma: al. (Basel) Adrenocortical et in Treatment S, S, Mitotane Herterich mitotane. on S, Polymorphisms Sbiera Francia a B, of Altieri 28. 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(mitotane) 3-Methylsulfonyl-DDE method Bergman Technol BO, HPLC Metabolite Analyt O,p’-DDD Lund simple B O, 9: new Lindhe https://doi.org/10.1016/j.jchromb.2006.04.005 Chromatogr A J 33. 69–75. 1982; patients. 837: al. al. mitotane-treated Pharmacol 2006; et and Sci et 1844–1851. F, animals Chemother Life Zappia in Biomed D, Tests Cancer E, metabolites Pirro 96: Smeenk principal S, two Francia AP, autopsy. 2011; De at Seters Metab 32. and van Endocrinol chemotherapy H, Clin during https://doi.org/10.1007/bf00265384 Slooten J tissues von and Study. 31. Multicenter ENS@T Retrospective https://doi.org/10.1210/jc.2010-2676 a of } iidclrehn op-D)i h os ugadlvr hmBo neat18;70: 1989; Interact Biol Chem liver. and lung mouse the in (o,p’-DDD) -i,i-dichloroethane oafasciculata/Reticularis Zona 12 lnEdcio ea 02 7 1319–1326. 87: 2002; Metab Endocrinol Clin J . { 2-chlorophenyl } -2- { 4- Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. 2 beaS ec ,Leic ,e l ioaeIhbt trlOAy rnfrs rgeigLipid- Triggering 1 Transferase Endocrinology Sterol-O-Acyl Cells. Inhibits htt- Carcinoma Mitotane Adrenocortical 1351–1361. https://doi.org/10.1210/en.2015-1367 al. in 3895–3908. Apoptosis et 13: 156: and G, 2015; Stress 2012; Liebisch Reticulum E, Endoplasmic Pharmacogenomics Leich Mediated study. S, of Sbiera microarray intermediate 62. reactive a T a NCI-H295R: by DR, Szab´o bound 109924– line ps://doi.org/10.2217/pgs.12.116 proteins A, cell Adrenal Zsippai 8: renocortical al. mitochondria-associated https://doi.org/10.1007/s002800050610 et 537–540. 2017; mitotane-induced DE, 61. 39: Oncotarget Identifying 1997; Schteingart Pharmacol RE, Chemother Counsell Cancer al. W, mitotane. approaches. 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Jagodzi´nski expression T, Wrzesi´nski gene https://doi.org/10.3892/mmr.2012.1244 TP, and Lehmann nesis 46. https://doi.org/10.1016/0009-2797(89)90063-x 63–72. . https://doi.org/10.18632/oncotarget.18968 ¨ omb lZ ta.Eet fmttn ngn xrsini h ad- the in expression gene on mitotane of Effects al. et Z, ¨ ol 13 Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. ehlupoy-d,i h adrenal Case Bergman the BMJ effect. in B, side unusual methylsulphonyl-dde, an Lund dyspnoea: Mitotane-induced 74. al. et a T, As Kochar 4619-4629. Mitotane 2018. W, of 27: Rep Amjad Use 2009; AU, the Oncol Farooq and Clin Manifestations 73. J Endocrine Carcinoma. of Adrenocortical Management for T. En- Agent Fojo Clin Chemotherapeutic L, J Nieman Update. I, Veytsman Clinical 72. Carcinoma: 2027–2037. 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Y-1 et in o,p’-DDD A, https://doi.org/10.1007/s00204-007-0206-5 and Bergman 3-methylsulfonyl-DDE V, toxicants 83: Asp cal 2009; V, Toxicol Hermansson Arch molecules. 76. related structurally and 3-methylsulfonyl-DDE https://doi.org/10.1007/s00204-008-0342-6 389–396. by cells Y-1 Lindstr renocortical V, Asp 75. https://doi.org/10.1016/0009-2797(88)90028-2 mV lsnJ,e l yooiiyaddcesdcriotrn rdcini ad- in production corticosterone decreased and Cytotoxicity al. et JA, Olsson V, ¨ om ,Bad .Mtblcatvto n oiiyo dmtblt,3- ddtmetabolite, a of toxicity and activation Metabolic I. Brandt A, ˆ hi ,e l cieseodhroesnhssrnesarncria cells adrenocortical renders synthesis hormone steroid Active al. et F, ¨ ohrig oafsiuata fascicula zona 14 nmc.Ce ilItrc 98 5 25–40. 65: 1988; Interact Biol Chem mice. in Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. 2]5 2Male 72 Male 50 28 Male [21] 47 50 [7] 50 [20] References Loading Drug High with Formulation Tumor Vitro Mitotane in Micellar 3D and e1900178 1 A and 20: Table Nanoscience 2D 2020; al. in Delivery: et Studies Biosci Cytotoxicity Drug S, Macromol and lipid for Kendl Models. Characterization Nanocarriers J, Physico-Chemical mitotane-loaded Schreiner Solubility: and MS, al. of 531-556. Haider et Pages 2019, SIM, coating 86. Elsevier; as Shaluf Amsterdam: 577–581. micelles Hydrophilic AA, Delivery. polymeric Drug Almokdad 630-48. in of 18: HKS, 112: Nanotechnology prospects 2006; Yadav future 2013; Ther al. and Pharmacol Technol 85. achievements, delivery. war- gene et state, Dev and Current drug and Pharm K. SC, for Kataoka nanocarriers mitotane N, Pinho Nishiyama adhesion. of EB, 84. mucosal rate for Souto oral dissolution of studies 366–372. P, improvement https://doi.org/10.3109/10837450.2011.614250 for of Preliminary mitotane Severino 85: of Enhancement microemulsion nanoparticles: https://doi.org/10.3109/03639040903225083 2011; of 421–427. Development Biointerfaces 36: al. 83. al. 2010; B et Pharm A, Ind Surf et Astier Dev I, Colloids Drug T, Ajana bioavailability. D, Wu Attivi Two-in- systems. 82. Y, 5854–5862. microemulsion Enantiomers: Chen 19: using and 2012; Y, by https://doi.org/10.1016/j.colsurfb.2011.03.015 Nanocarriers Chem prepared Lin Lipid Med farin Curr Mitotane of 81. Carcinoma. Development Adreno-Cortical B. Treat Efficiently Menaa https://doi.org/10.2174/092986712804143376 to F, Solution Menaa One 80. lncltil nmttn lsceohrp navne ACC advanced in chemotherapy plus mitotane on trials Clinical . (years) age Mean ainsSex patients of Number (n=48) Female (n=24) (n=18) Female (n=10) (n=26) Female (n=24) +++10I(n=1) I M+E+D+C120 (n=2) II M+E+D+CNA A or M+A regimen Treatment 15 65I Not IV 16.5 (months) up follow- of Duration (n=17) IV (n=30) III (n=24) II (n=20) IV (n=6) III disease of Stage recorded Not recorded Not recorded m L (mg levels Mitotane -1 ) 48.6% 53.5% a A=48% a M+A=48% rate response Overall b b AN NA NA 2.6 NA NA 10.6 Female=38.6 Male=23.6 (months) survival Overall

months years=51.7 [?]2 months years=26.4 [?]2 survival free Disease-

NA months

Progression- free survival Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. u ftepout ftedmnin falmaual ein o tlat1mnh io epnewas response Minor month. the 1 in least decrease at 50% for [?] lesions a at measurable as on all defined was of lesions response dimensions measurable Partial the all [?] weeks. of a of 4 products required dimensions of the response perpendicular minimum of Partial a the sum for evaluations. of disease successive products measurable two the of least of at evaluations; sum 2 on the least tumor prior in the received decrease not of had 50% evidence weeks.; who clinical 4 patients all of in minimum of treatment a etoposide below for of measurements and treatment; lines liver products cisplatin of xiphoid the mitotane sum following of and the sum progression left, in the right, disease 30% in the after of decrease [?] in 50% evidence decrease margins a clinical [?] or costal all required lesions the response of measured Partial disappearance of lesions; weeks. diameters the 4 perpendicular new as and of the defined of M+SzM+E+D+C; minimum size was a appearance or tumor for response the M+E+D+CM+Sz measurable tumor Complete without the the therapy: weeks response. in second-line 4 partial decrease M+Sz; least + for 50% at Complete or metastases a for M+E+D+C osteolytic least metastases therapy: all at osteolytic tumor required first-line of of the response recalcification recalcification of Partial complete 50% evidence clinical weeks. the [?] all 4 and of of radiography disappearance minimum on the a or as defined examination was physical response on Complete response. partial + available; not NA: vincristine, 1: Table Male 304 50 [18] References 1]4. 6Male 36 Male 44.4 45 Male [19] 46.5 37 [23] 54 [22] ,aeua;M ioae ,eooie ,dxrbcn ,csltn z tetztcn V, streptozotocin; Sz, cisplatin; C, doxorubicin; D, etoposide; E, mitotane; M, avelumab; A, (years) age Mean g opee+pril+mnrrsos.Cmlt epnewsdfie sn evidence no as defined was response Complete response. minor + partial + Complete : f opee+prilrsos.Cmlt epnewsdfie stedisappearance the as defined was response Complete response. partial + Complete : ainsSex patients of Number a opee+prilrsos ni rgesv ies rdeath; or disease progressive until response partial + Complete : (n=183) Female (n=121) (n=25) Female (n=11) (n=22) Female (n=23) (n=18) Female (n=19) c M+SzM+E+D+C c M+E+D+CM+Sz regimen Treatment +++3. V1–522% 10–15 IV Not M+E+D+V34.8 e (n=16) E+CM IV E+C NA M+C 16 8III 78 (months) up follow- of Duration AIII NA (n=303) IV (n=1) disease of Stage (n=43) IV (n=2) 42 First- 14-20 recorded L (mg levels Mitotane recorded Not e ioaewsemployed was Mitotane : -1 ) a M+Sz=9.2% a M+E+D+C=23.2% therapy: line 30% rate response Overall 13% b g d f Complete : M+Sz=12 M+E+D+C=14.8 therapy: line First- 35N NA NA 13.5 18N NA NA 11.8 (months) survival Overall 0N NA NA 10 d c

: :

AFirst- NA survival free Disease- line therapy: M+E+D+C=5 months M+Sz=2.1 months Second- line therapy: M+E+D+CM+Sz=5.6 months months M+SzM+E+D+C=2.2

Progression- free survival Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. os ciain inhibition. 3 activation, protein; 3-oxo-5 bols: cy- regulatory SRD5A2, CYP11B2, acute delta-isomerase; hydroxy-delta- steroidogenic 1; steroid HSD173B, and StAR, member 2; beta- B type HSD3B2, 17 family delta-isomerase dehydroepiandrosterone; subfamily dehydrogenase steroid DHEA, P450 5-steroid 11 and mitotane; cytochrome DDD, family beta- CYP19A2, 2; 3 P450 member dehydrogenase 2; B cytochrome hydroxy-delta-5-steroid member subfamily CYP11B1, 11 A family 2; subfamily P450 mem- tochrome member A 21 subfamily A family 17 subfamily family P450 P450 19 cytochrome cytochrome CYP17A1, CYP21A2, 1; 1; member A ber subfamily 11 family P450 cytochrome 3: 1. Figure factor reticulum transcription element-binding endoplasmic regulatory R-like inhibition. sterol activation, kinase SREBF: ER, Symbols: protein 1; mitotane; O-acyltransferase PERK, DDD, sterol dinucleotide; c; SOAT1, cytochrome adenine kinase; c, nicotinamide Cyt NADH, 1; member member ucleotide; A B eIF2 subfamily cy- subfamily 21 reticulum; CYP17A1, 11 family CHOP, P450 1; family endoplasmic cytochrome P450 member 2; CYP21A2, cytochrome A protein 1; CYP11B1, subfamily member lymphoma A 2; 11 B-cell subfamily family 17 Bcl-2, family P450 P450 regulator; cytochrome tochrome adeno- apoptosis CYP11A1, ATP, X protein; diphosphate; homologous adenosine associated ADP, C/EBP BCL2 1; Bax, member triphosphate; G sub-family sine cassette ATP-binding ABCG1, Legend: 2: Figure acid; acetic 1,1-(o,p’-dichlorodiphenyl) 1,1-(o,p’ DDE, β- least 1: at for Figure lesions measurable all of treatment dimensions legends change the Figure treatment; of combination products the + of Symbols: sum month; the 1 in decrease 25-50% as defined yrxlto B.Lgn:op-D,mttn r11(,’dclrdpey)22dcootae o,p’- 1,1-(o,p’-dichlorodiphenyl)-2,2-dichoroethane; or mitotane o,p’-DDD, Legend: (B). hydroxylation ehns neligteattmradatsceoyeet fmttn DD narnlcells. adrenal on (DDD) mitotane of effects antisecretory and antitumor the underlying Mechanism trioei aha n ioae(D)itrcinwt pcfi Ys eed CYP11A1, Legend: CYPs. specific with interaction (DDD) mitotane and pathway Steroidogenic hmclsrcueo ioaeeatoes()adceia ecino ioaevia mitotane of reaction chemical and (A) enantiomers mitotane of structure Chemical - ilrdfnl-, ilreao ,’DA,op ihooihnlay hoie o,p’-DDA, chloride; acyl dichlorodiphenyl o,p’ o,p’-DDAC, dicloroetano, diclorodifenil)-2,2 α, uaytciiito atr2 factor initiation eukaryotic α- OH, α- hydroxylation; β- H 3 OH, 17 β- yrxlto;17 hydroxylation; α β- hshrlto;FD ai dnn din- adenine flavin FAD, phosphorylation; OH, β- hydroxylation. β- H 17 OH: α- tri -eyrgns 2; 4-dehydrogenase steroid β- yrxlto.Sym- hydroxylation. α- and Posted on Authorea 28 May 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159069174.47481624 — This a preprint and has not been peer reviewed. Data may be preliminary. 18