Role of aberrant hormone receptors André Lacroix, MD

Transcription

1 New Mechanisms of Adrenal Tumorigenesis Role of aberrant hormone receptors André Lacroix, MD Professor of Medicine Centre hospitalier de l Université de Montréal (CHUM) Controversias Clinicas en Enfermedades Suprarenales Buenos Aires, May 13, 2011

2 Etiology of endogenous Cushing s syndrome ACTH-dependent: 85-90% Pituitary adenomas: ~ % Ectopic ACTH secretion: ~ 15 % Corticotroph hyperplasia: rare Ectopic CRH secretion: rare ACTH-independent:10-15% Adrenal adenomas: ~ 8-10 % Adrenal carcinoma: ~ 5 % Bilateral micronodular (PPNAD) rare Bilateral macronodular (AIMAH) rare:<1% Cortisol hypersensitivity syndrome very rare Ectopic cortisol secretion (ovarian tumor) very rare Arnaldi et al. J Clin Endocrinol Metab. 88:

3 ACTH-independent Cushing s syndrome Different activation of camp signal?

4 Aberrant hormone receptors in zona fasciculata cells Ectopic receptors ACTHR HTR4 LHCGR Eutopic Receptors GIPR β-adren AVPR1A G s AC G s ATP G s + AC camp ATP camp Cholesterol AC ATP G q/i PLC DAG, IP3 PKA P N M TF mrnas Protein Cortisol M Cortisol ACTHindependent Cushing s syndrome Modified from Lacroix, Endocrine Reviews 22: 75, 2001

5 Activation of camp pathway and steroidogenesis in adrenocortical tumors and hyperplasias Lacroix et al Clin Endocrinol 75:

6 Strategy of in vivo investigation for aberrant receptors Transient modulation of the ligands of potential aberrant adrenocortical hormone receptors Steroidogenic response

7 Initial screening for aberrant responses Blood samples for cortisol, ACTH, steroids/peptides q 30 min Perform under pretreatment with dexamethasone 1 mg q 6 h x 48h if endogenous ACTH not fully suppressed Modified from Lacroix et al The Endocrinologist 9, 9-15, 1999

8 Further investigation Lacroix et al The Endocrinologist 9, 9-15, 1999

9 GIP-dependent Cushing s syndrome Lacroix A. et al. N Engl J Med 327, 974,1992; Endocrine Reviews 22: 75, 2001

10 Vasopressin-responsive Cushing s syndrome Upright Posture Hypertonic saline Adenomas Lacroix A. et al JCEM 82: 2214, 1997

11 β-adrenergic-dependent Cushing s syndrome Upright Posture Insulin-hypoglycemia Stress-Exercise Adenomas Lacroix et al N Engl J Med 337: , 1997

12 Therapy of Cushing s syndrome with β-blockers Adenomas Lacroix et al N Engl J Med 337: 1429, 1997

13 LH/hCG-dependent Cushing s syndrome PREGNANCY Lacroix et al N Engl J Med 341: 1577, 1999

14 Leuprolide acetate therapy for LH-dependent AIMAH Lacroix et al N Engl J Med 341: , 1999

15 Combined serotonin (5-HT4) and LH-dependent AIMAH Lacroix et al N Engl J Med 341: , 1999

16 Initial series of aberrant hormone receptors in adrenal Cushing s syndrome Aberrant receptor: AIMAH Number GIPR 2 β-adrenergic R 1 AVPR1A 1 LHCGR and HTR4 1 β-ar + AVPR1A 1 LHCGR + unknown 1 HTR4-mixed cortisol/aldo 1 8 / 8 (100 %) Unilateral adenoma 3 /14 Unilateral carcinoma 0 / 2 ( 22 %) Mircescu H. et al JCEM 85:3531, 2000

17 ACTH-independent macronodular adrenal hyperplasia Rare: Cushing s syndrome <1% of CS Urinary free cortisol high ACTH low CRH: no response Dexamethasone: no suppression Not rare: sub-clinical CS % incidentalomas are bilateral including AIMAH Normal urinary free cortisol ACTH low-normal CRH: ACTH increase Dexamethasone: partial suppression

18 Can aberrant hormone receptors be present in sub-clinical AIMAH? 6 patients (3 M, 3 F) with: Incidentally found bilateral macronodular adrenal hyperplasia No overt Cushing s syndrome phenotype Urinary free cortisol within normal range Subnormal suppression of plasma cortisol following dexamethasone Plasma ACTH partially suppressed Bourdeau I et al. JCEM, 86:5534, 2001

19 IV dexamethasone-avp tests in sub-clinical AIMAH Plasma cortisol (nmol/l) Dex 1 mg/h iv AVP 10 IU im D2 9 Time (hours) N: < 76 nmol/l Bourdeau I et al. JCEM, 86:5534, 2001

20 Patient with sub-clinical AIMAH Vasopressin Cisapride Desmopressin Metoclopramide GnRH hlh hcg FSH Plasma cortisol (% of basal) 300% 200% 100% 0% Time (minutes) Plasma cortisol (% of basal) 200% 100% 0% Time (minutes) AVPR1A + HTR4 LHCGR Bourdeau I et al. JCEM, 86:5534, 2001

21 Summary of aberrant hormone receptors in sub-clinical AIMAH Aberrant receptors: Number LHCGR + HTR4 + AVPR1A 2 AVPR1A + HTR4 1 AVPR1A 3 Total: 6 / 6 (100%) Bourdeau I et al. JCEM, 86:5534, 2001

22 Aberrant hormone receptors in sub-clinical unilateral cortisol secreting incidentalomas? 21 patients (9 M, 12 F); mean age: 59 y.o. with: Incidentally found unilateral adrenal incidentaloma (mean 3.3 cm) Unilateral iodocholesterol uptake No overt Cushing s syndrome phenotype Urinary free cortisol > 276 nmol/l Subnormal suppression of plasma cortisol following dexamethasone (> 58 nmol/l) Plasma ACTH partially suppressed (< 3.3 pmol/l) Reznik et al. Clinical Endocrinology 61: 311, 2004

23 Cortisol response to various tests in unilateral sub-clinical incidentaloma Reznik et al. Clinical Endocrinology 61: 311, 2004

24 Overall aberrant responses in unilateral sub-clinical incidentalomas Under dexamethasone suppression (2 mg q 6h) 21/21 (100%) had at least 1 abnormal response 18/21 to multiple stimuli 3 = 19%; 4 = 29%; > 4 = 10% Terlipressin: 70% Cisapride: 62% Upright posture: 24% Meal: 19% LHRH-TRH-GHRH-CRH: 52% Glucagon: 19% Angiotensin II: 37% Reznik et al. Clinical Endocrinology 61: 311, 2004

25 Hsiao et al, J Clin Endocrinol Metab 94: , 2009

26 Hsiao et al, J Clin Endocrinol Metab 94: , 2009

27 Systematic study of aberrant GPCR in AIMAH 10 patients with Cushing s syndrome and AIMAH 22 patients with sub-clinical Cushing s syndrome and AIMAH 23 woman (71.8%) and 9 men (28.2%)

28 Aberrant responses of cortisol in AIMAH Libe R et al, Eur J Endocrinol 163: , 2010

29 Aberrant responses of cortisol in AIMAH Main results and conclusions: At least one aberant response in 28/32 (87%) 75% had at least two aberrant responses Upright posture: 67% Metoclopramide: 56% Glucagon: 56% Mixed meal only in CS (12%) Inhibition by octreotide test in 92% of SCS The presence of aberrant responses supports diagnosis of AIMAH Provides opportunity for targeted pharmacological therapy Inhibition by Octrotide may be indicative of aberrant GIP- or glucagon receptors, inhibition of adrenal cytokines or direct effects on somatostatin receptors in AIMAH Libe R et al, Eur J Endocrinol 163: , 2010

30 In vivo aberrant responses in AIMAH or unilateral incidentalomas with sub-clinical or overt Cushing s syndrome 59 patients: 48 AIMAH, 11 unilateral adenoma 95% had at least 1 aberrant response 98% in AIMAH and 82% in unilateral adenoma 12/13 in CS; 44/46 SCCS Vasopressin: 71% Cisapride/metoclopramide: 35% Upright posture: 25% Isoproterenol: 8 patients LHRH: 6 patients; LH: 4 patients GIP, desmopressin, TRH: 2 each Mixed aldosterone co-secretion: 11 patients Grunenwald, Mazzuco, Bourdeau, Lacroix: Endo Society 2010

31 Paris, Grenoble, Rouen, FRANCE α2a adrenergic receptor (ADRA2A) Assie, G. et al. J Clin Endocrinol Metab 95:E253-E262, 2010

32 JCEM 88:

33 ACTHR Autocrine loop of production of ACTH by aberrant hormone receptors in AIMAH ACTHR AT P G s AC G s AC + AMPc ATP Cholesterol PKA P N M FT mrnas M Protein Cortisol Cortisol Lefebvre et al Adrenal cortex meeting 2010 Abstract

34 Autocrine loop of production of ACTH by aberrant hormone receptors in AIMAH Ectopic receptors ACTHR HTR4 LHCGR Eutopic Receptors GIPR β-adren AVPR1A ACTHR G s AC AT P ATP G s + AC camp G s AC ATP camp Cholesterol G s AC ATP G q/i PLC DAG, IP3 PKA P N M TF mrnas M ACTH Protein Cortisol Cortisol CS Lefebvre et al Adrenal cortex meeting 2010 Abstract

35 Serotonin and vasopressin expression in AIMAH 5-HT IHC AVP IHC Bertherat, Lefebvre JCEM. 90:1302, 2005

36 Familial AIMAH: Aberrant adrenal receptors 10 families (Findlay 1993, Minami 1996, Nies 2002, Miyamura 2002, Imohl, 2002, Lee 2005, Vezzosi 2007, Gagliardi 2009) Autosomal dominant transmission Aberrant hormone receptors in familial AIMAH: AVPR1A and β-ar (Miyamura 2002) β-ar (Imohl 2002) AVPR2 and AVPR1B (Lee 2005) HTR4, AVPR1A and AVPR2 (Vezzosi 2007) AVPR1A (Gagliardi et al 2009)

37 β-adrenergic-dependent Cushing s syndrome yo man Cushing s syndrome AIMAH Lacroix A, N Engl J Med 337: 1429, 1997

38 β-adrenergic-dependent Cushing s syndrome Cortisol secretion stimulated by upright posture, insulin tolerance test, and isoproterenol Cortisol secretion mediated by catecholamines Plasma cortisol (% of basal) 300% 200% 100% 0% Upright posture ITT Isoproterenol Time (minutes) Lacroix A, N Engl J Med 337: 1429, 1997

39 10 years later 2005 His 56 yo brother Bilateral macronodular adrenal hyperplasia found incidentally Phenotype suggesting of Cushing s syndrome Normal urinary free cortisol ACTH: 1.1 pmol/l (N: 2-11) Cortisol post 1 mg overnight dexamethasone: 589 nmol/l (N:< 50)

40 β-adrenergic-dependent subclinical Cushing s syndrome 300% Upright posture ITT Isoproterenol 300% Upright posture ITT Isoproterenol Plasma cortisol (% of basal) 200% 100% Plasma cortisol (% of basal) 200% 100% 0% Time (minutes) 0% Time (minutes) Patient 1 Patient 2

41 Family screening protocol Family members of the propositus >18 yo 1-mg dexamethasone supression test (DST) Adrenal CT-Scan < 50 nmol/l > 50 nmol/l 1-mg DST To repeat every 5 years Normal 4-mg IV DST Abnormal in vivo protocol of aberrant adrenal receptors

42 Family tree Clinical CS Sub-clinical CS Normal 1-mg DST I? II Age N 333 N N Plasma AM cortisol post 1 mg dexamethasone; Normal: <50 nmol/l

43 Isoproterenol infusion 20ng/kg/min Cortisol (nmol/l) Time (minutes) Patient 1 Patient 2 Patient 3 Patient 4 Patient 6 Dexa 1 mg q 6h >48 h

44 Upright posture with β-blocker Cortisol (nmol/l) Basal Time (minutes) Propranolol

45 I Clinical CS Sub-clinical CS Abnormal 1-mg DST Normal 1-mg DST II III

46 Summary of familial screening Cushing s syndrome Subclinical Cushing s syndrome Abnormal suppresion to 1mg-DST to investigate Normal suppression to 1mg-DST Total Generation II Generation III Affected individuals 5/8 9/21 14/29 7M:7F (48%)

47 Therapy of Cushing s syndrome with β-blockers Lacroix et al N Engl J Med 337: 1429, 1997

48 Long-term treatment with β-blockers

49 Long-term treatment with β-blockers Patient 1: Atenolol 50 mg daily x 1997 Normal UFC, no Cushing s symptoms Stable adrenal size Patient 2: Nadolol 80 mg daily x 2005 Normal UFC, weight loss, normal BP Patient 3: Nadolol 80 mg daily x 2006 Normal UFC, normal BP Patients 4,5,6: Nadolol 40 mg daily x 2006; one had to decrease to 20 mg daily because of bradycardia and eventually required adrenalectomy

50 Linkage studies using Affymetrix Genome Wide Human SNP Array 6.0 in 10 affected and 7 non affected members of AIMAH-CS-β-AR/AVPR1A family 159 SNPs and clusters of SNPs significant after Bonferroni correction (p< 7.07 x 10-8 ) for linkage with sex and age as covariates 69 SNPs 4 SNPs 1 SNP 1 SNP 1 SNP 1 SNP 1 SNP 1 SNP 21 SNPs

51 Genetic studies in AIMAH-CS-β-AR/AVPR1A family HG U133 Plus 2.0 Array GWH SNP 6.0 Array _at t-test uneqvar, p-value: Fold change: E36: Adrenal tumor from Patient_01_A E196: Adrenal tumor from Patient_12_A SNP_A p-value.cov_sex_age: 9.87E-25

52 Proliferative effect of ectopic GIPR Transfection GIPR Longo-Mazzuco T, Chabre O, Feige JJ, Thomas M, Endocrinology 147:782-90, 2006

53 Proliferative effect of ectopic GIPR Longo-Mazzuco T, Chabre O, Feige JJ, Thomas M, Endocrinology 147:782-90, 2006

54 Asynchronous GIP-dependent AIMAH 31 yo woman with early bilateral AIMAH and 2 large adrenal nodules in right adrenal GIPRmRNA Nodules 1 2 Adjacent hyperplasia + C N1 N2 H NA CA P N Diaye et al, JCEM 84:

55 Gene profiling in asynchronous nodules of GIP-dependent AIMAH 55 genes over-expressed in nodules, ratio >2 (11 related to sub-units of linker histone H1) 39 genes repressed in nodules compared to AIMAH RXRα Cyclin D2 (CCND 2) Lampron A et al J. Clin. Endocrinol. Metab 91, , 2006

56 JCEM 96 ahead of print Jan 2011 B-catenin

57 Hypothesis of sequential genetic events in AIMAH LHCGR LHCGR Pregnancy Hyperplasia Menopause LHCGR Initial embryonic aberrant receptor Additional somatic events LHCGR Nodular Hyperplasia Macronodular Hyperplasia

58 Hypothesis of sequential genetic events leading to unilateral tumors or bilateral macronodular adrenal hyperplasia (AIMAH) expressing aberrant receptors Lacroix et al, Clin Endocrinol, 75:1-15, 2010

59 GIP-dependent androgen secreting adenoma Tsagarakis, S. et al. J Clin Endo Metab 86:583-9, 2001

60 GIP-dependent aldosteronoma Lacroix et al TEM 15: , 2004 J Clin Endocrinol Metabolism 93: , 2009

61 Therapy of AIMAH Sub-clinical disease: evaluate annually for progression, HBP, diabetes, osteoporosis Cushing s syndrome: inhibit adrenal steroidogenesis ketokonazole (liver toxicity, male hypogonadism) metyrapone (hirsutism, high blood pressure) Block aberrant receptor Surgical therapy in absence of specific medical therapy Bilateral adrenalectomy for severe disease Unilateral adrenalectomy for mild disease (UFC< 2-3 ULN)

62 Long-term follow-up of AIMAH with sub-clinical CS Grunenwald, Mazucco, Bourdeau, Lacroix, Endo Society 2010

63 Long-term follow-up of AIMAH with sub-clinical CS Grunenwald, Mazucco, Bourdeau, Lacroix, Endo Society 2010

64 Long-term follow-up of AIMAH with sub-clinical CS Grunenwald, Mazucco, Bourdeau, Lacroix, Endo Society 2010

65 Vasopressin stimulation tests over 9 years follow up mg Dexa Vasopressin h00 11h00 12h00 13h00 14h00 14h30 15h00 15h30 16h00 18h00 20h00 09h Grunenwald, Endo Society 2010

66 Aberrant Adrenal Hormone Receptors Therapeutic Potential Aberrant receptor GIP β-adrenergic LH/hCG V 1 -vasopressin Serotonin R4 Angiotensin II TSH Therapy Somatostatin/GIPR blocker β-blockers GnRH analogs AVPR1A antagonist HTR4 antagonist AGTR1 antagonist L-thyroxine

67 59 yo woman 2 yr virilisation Total testo:5.2 nm/l UFC and DHEAS: N LHCGR in situ hybridation Goodarzi, JCEM 88:73, 2003

68 Horm Metab Res. 43: , 2011

69 CONCLUSIONS 1) Aberrant adrenal hormone receptors are frequently implicated in the pathophysiology of AIMAH and unilateral adenomas secreting cortisol; this also applies to aldosterone- and androgen-secreting lesions 2) The aberrant regulation of steroidogenesis can be modulated by ectopic receptors or by increased activity of eutopic receptors 3) Single or multiple adrenal receptors can be expressed aberrantly

70 CONCLUSIONS 4) Aberrant receptors can also be found in familial forms of AIMAH 5) The identification of aberrant hormone receptor can allow new specific pharmacological therapeuties and long-term correction of hypercortisolism 6) Further studies on the potential role of pharmacological blockade of aberrant receptors on the progression of familial AIMAH will be of great interest

71 Aknowledgments Co-investigators Isabelle Bourdeau Pavel Hamet Johanne Tremblay Lab Endocrine Pathophysiology Antoine Lampron M H Soares Costa Tania Mazzuco Solange Grunenwald Livia Mermejo Sylvie Oble CHUM Endocrinology Ariane Godbout J-M Boutin Pierre D Amour Hortensia Mircescu Marie-T Caron Shirley Ferguson Sylvie Blaquière Chantal Dejou Philippe Arjane Walter Schurch Other centers Andrée Boisselle Pierre Larochelle Hervé Lefebvre Philippe Caron Funding Grant MA Canadian Institutes of Health Research

72 Thank you My spring garden in Montreal

73 Clinical Endocrinol, 72:744, 2010 mir130a mir382