Pituitary signalling : from Zebrafish to Clinical Therapy. Pituitary Tumorigenesis. Shrink or ablate mass. Surgery Medical Rx Radiation

Transcription

1 24/1/215 Pituitary signalling : from Zebrafish to Clinical Therapy Hypothalamic releasing and inhibiting hormones Superior hypophysial artery Portal vein S.Melmed October 215 UCSF CME Hypophysial vein Inferior hypophysial artery Li-Ng JCEM 28 Melmed NE 26 Pituitary Tumorigenesis Pituitary compression Parasellar compression Hormone hypersecretion Hypogonadism Thyroid failure Adrenal failure Visual field disturbance Headache Cranial nerve palsy Parasellar invasion FSH/LH TSH Mixed Acromegaly Cushing Prolactinoma Nonsecreting TSHoma Oncogene activation Tumor suppressor inactivation Cell cycle dysregulation Mutations Stromal and epigenetic events Mutations Unknown changes Replace deficient hormone Shrink or ablate mass Co-morbidities Mortality Surgery Medical Rx Radiation Normal pituitary Microadenoma Macroadenoma Aggressive Humoral factors Hyperplasia Proliferative restraint Senescence Melmed JCI 23 Melmed Nat Rev Endocrinol 211 1

2 24/1/215 Pituitary Tumor Signalling Pathways Receptor subtype expression (%) Number of tumors SSTR1 SSTR2 SSTR3 SSTR4 SSTR Proliferative constraints Mitogenic hormones and growth factors Ben-Shlomo, Trends Endocr Metab, 21 RHR, CHRHR, GNRHR p15, p16 p18, p19 CDK inhibitors p21, p27 p57 Senescence p53 Chromosomal instability G DNA damage CDK4 Cyclin D CDK6 P P P CDK2 Cyclin E P P P P P Rb P P P P G 1 E2Fs CDK2 S Cyclin A G 2 M CDK1 Cyclin B Cell cycle disruptors SSTR Hormone Cell proliferation Melmed, JCI, 29 (µg/l) µg Octrotide or placebo M M M Before 1 8am pm pm 2 4 6am Control day Octreotide After Lamberts, JCEM, 1985 Melmed Nat Rev Endocrin 211 Cell Origin and Receptor Profile Acidophil Stem Cell Adenoma Gigantism 15-year-old female, height 179 cm Headaches, diplopia, sleepy Shoe size 11, tight rings Primary amenorrhea, no galactorrhea Jaw prognathism, incisor gap Acidophil Stem cell Tumor receptor expression Cabergoline.5 SRL Surgery 1 5 Θ sstr2 Θ D2 M mg 3 mg Acidophil Stem cell Clonal expansion 1 mg/l 12 IGF-1 4 Mammosomatotroph Somatotroph Lactotroph : Baseline 64 2-h OGTT 71 ng/ml IGF-1: 845 (<66) : 87 (<23) α subunit: 3.7 (<) α subunit Age (years) Maheshwari JCEM 2 2

3 24/1/215 STAT3 Activates Promoter STAT3 Inhibitor Suppresses Potential STAT binding site Rat Gh promoter -24/ / /165 Primer 1 Primer 2 Primer 3 STAT3 inhibitor (µm) -fold ChIP Input IgG STAT3 Primer 1 Primer 2 Primer STAT3 P-STAT3 ng/ml/1 3 3 cells ng/ml/1 3 3 cells luc activity ZsGreen STAT3 luc activity S µm β-actin control (µm) STAT3 inhibitor control (µm) STAT3 inhibitor pgl / / / /167 Zhou JCI 215 Zhou JCI 215 STAT3 Inhibitor Suppresses h Secretion in vitro STAT3 Inhibitor Suppresses -tumor Proliferation and in vivo RT-PCR mrna Western N=15 2. P<.1 N=17 P< RIA mrna N= N= mrna Western S3I-21 (mm) P-STAT3 STAT3 Staining (%) -fold WST-1 S3I-21 (µm) BrdU 5 1 S3I-21 (µm) mm treated control Control S3I-21 Volume Days Serum 3. mg Tumors Control Weight Serum IGF-1 Rx -fold Stat3 Control Rx N=13 P< STAT3 inhibitor (mm) 1..5 N= STAT3 inhibitor (mm) S3I-21 (mm) p<.5; p<.1; p<.1 Zhou JCI 215 -fold Control Rx Control Rx -fold Zhou JCI 215 3

4 24/1/215 Targeted Prolactinoma Therapy Decreases HER2CA Tumor Size and Prolactin Levels HER2-3 (ng/ml) Vlotides Cancer Res 29 EGF Y168 Y145 Y186 Y92Y891 EGFR Y71 Y71 Y891 Y92 Y145 Y168 Y186 Y168 Y145 Y186 HER2 Y71 Y92Y891 HRG Y71 Y891 Y92 Y145 Y168 Y186 HER3 (ng/ml) > Lactation Impotence Normal potency Bromocriptine Time (months) Tumor volume (mm 3 ) Tumor volume Time (days) mrna (%) Time (days) mrna vehicle gefitinib lapatinib P<.5, P<.1 vs vehicle Fukuoka Mol Endocrinol 211 Decreases Tumor Size and Prolactin Levels in Estrogen-induced Prolactinoma Suppresses Both Prolactin mrna and Secretion in Human Prolactinomas 17β-estradiol 25 Pituitary weight H&E EGFR HER2 Fischer 344 rat (ng/ml) Serum (ng/ml) Serum 1 Weight (mg) P<.5 mrna (%) mrna (µm) secretion (%) secretion (µm) P<.5, P<.1 vs vehicle H&E, hematoxylin and eosin Fukuoka Mol Endocrinol 211 Fukuoka Mol Endocrinol 211 4

5 24/1/215 Aggressive Prolactinoma: Lapatanib 125 mg/day Cushing Disease mm (ng/ml) mm 3 Harvey Cushing, MD mm Time (months) Pre-Rx Rx 6 months Cooper Endocr 213 Minnie G. 191 Cushing Bull Johns Hopkins Hosp Stewart Best Pract Res Clin Endocrinol Metab. 29 Cushing Disease Challenges in Diagnosis and Treatment of Cushing Disease Imaging Average tumor size ~6 mm ~4% tumors not visible 1% of normal population microadenoma Median survival 4.6 years if inadequately controlled Hormone hypersecretion cortisol Obesity Hypertension Diabetes Osteoporosis Hirsutism Muscle weakness Moon face Acne Surgery Medical Rx Radiation Central mass effects Pituitary hormone deficiencies Visual field disturbance Headache Parasellar invasion Melmed JCI 23 Therapy Life expectancy no different than in 193 Surgery: 6 7% initial remission 2 6% recurrence Pituitary radiation: Hypopituitarism Adrenalectomy or cortisol synthesis inhibitor: Side effects and morbidity Physical and biochemical diagnosis Signs, symptoms and hypercortisolemia overlap with other illnesses Cyclic or intermittent hypercortisolemia 5

6 24/1/215 Medical Therapies for Cushing Disease Targeted Therapy in Cushing Disease Pasireotide Cabergoline Dopamine receptor agonists Small studies reported efficacy Long-term data conflicting Therapeutic escape Ketoconazole Steroidogenesis inhibitors Reduce cortisol levels Do not target underlying corticotroph tumor Safety concerns Pituitary tumor Adrenal glands Hypothalamus Cortisol G2 receptors (peripheral tissues) Glucocorticoid receptor antagonist Increased and UFC levels AEs -- hypokalemia and endometrial thickening Does not target underlying corticotroph tumor Mifepristone EGF Y168 Y145 Y186 Y71 Y92Y891 EGFR Depression Impairment of cognitive function Infectious disease Sepsis Y71 Y891 Y92 Y145 Y168 Y186 HER2 Stroke Systemic arterial hypertension Left ventricular hypertrophy Myocardial infarction METABOLIC SYNDROME Visceral obesity Diabetes mellitus Dyslipidemia Thrombosis diathesis Pivonello Endo Rev, 215 Tyrosine kinase inhibitors targeting EGFR and/or HER2 Action on Tumors in vivo (Iressa) EGF (Tykerb) HRG EGFR-AtT2 (ng/ml) Body weight Body weight (g) Control EGFRWT Control EGFRWT Y145 Y186 Y168 EGFR Y92 Y891 Y71 Y71 Y891 Y92 Y145 Y168Y186 HER2 Y145 Y186 Y168 Y92 Y891 Y71 Y71 Y891 Y92 Y145 Y168Y186 HER3 Body weight (g) Tumor weight Control EGFRWT Corticosterone (ng/ml) Corticosterone Control EGFRWT Glucose (mg/dl) Omental fat Glucose Control EGFRWT Fukuoka H et al. Mol Endocrinol 211;25:92 13 P<.5, P<.1 Fukuoka JCI 211 6

7 24/1/215 Suppresses in Canine Cushing s Tumors Pituitary Tumor Signalling Pathways POMC Proliferative constraints Mitogenic hormones and growth factors (%) Dog 1 Dog 2 Dog 3 Dog 4 Dog 5 POMC (%) CDK inhibitors Senescence p53 p15, p16 p18, p19 p21, p27 p57 CDK4 Cyclin D CDK6 P P P CDK2 Cyclin E P P P P P Rb P P P P RHR, CHRHR, GNRHR SSTR µm µm P<.5, P<.1 POMC, proopiomelanocortin Chromosomal instability DNA damage G G 1 M E2Fs CDK2 S Cyclin A G 2 CDK1 Cyclin B Cell cycle disruptors Hormone Cell proliferation Fukuoka JCI 211 Melmed Nat Rev Endocrin 211 Transgenic Zebrafish Pituitary Lineage Tracing αgsu.pttg: Pituitary Hyperplasia and Adenoma αgsu promoter hpttg 1 IRES EGFP Poly A 32 hpf 72 hpf αgsu. PTTG QuickTime and a decompressor are needed to see this picture. (relative to WT) 2 1 Serum LH POMC-GFP/-RFP WTαGSU.PTTG 4X Liu Mol Endocrinol 26 Abbud, Mol Endocrinol 25 7

8 24/1/215 Hypercortisolism in Tg:POMC-PTTG Zebrafish Cardiac Hypertrophy in Tg:Pomc-Pttg Fish Tg Posterior cardinal vein WT WT Sibling Tg Adrenal steroidogenic cells 1.6 Cortisol Cortisol (µg/l).8.4 P<.5 n=24 Tg WT Wt Liu PNAS 211 Liu PNAS 211 Metabolic Phenotype in Tg:POMC-PTTG Zebrafish Phenotype 5 Ad lib low-fat, high-carbohydrate diet.5 Weight (mg) Tg:pomc-pttg zebrafish Cushing s disease Blood glucose (mg/dl) WT Tg:pomc-pttg Tg:POMC-PTTG N=72 AUC, P<.1 Weight (mg) Tg WT n=12, P<.1 High cortisol Neoplastic pituitary cells Intra-renal steroidogenic cell hyperplasia Hepatic steatosis Glucose intolerance High cortisol Corticotroph adenoma Adrenal hyperplasia Central obesity Glucose intolerance Time (hours) WT Cardiac hypertrophy Concentric cardiomyopathy Hepatic steatosis Tg Liu PNAS 211 8

9 24/1/215 PTTG Upregulates Corticotroph Cyclin E CDK Inhibitor Screening in Tg:POMC-PTTG/POMC-GFP Embryos mrna (fold) Zebrafish pituitary WT Tg:POMC-PTTG PTTG Cyclin E p27 p21 sirna C PTTG AtT2 cells Fluorescence (fold) POMC Cyclin DCyclin E p21 p27 Rb β-actin Cdk2/cyclin E G1 Cdk2/cyclin A S G2 Cdk1/cyclin A p19, p15, p16, p18 p21, p27, p57 Cyclin D CDK4 CDK2 Cdk4/cyclin D Cdk6/cyclin D Cyclin E M Cdk1/cyclin B p p p p p p prb G1 E2F Transcription Proliferation S Liu PNAS 211 Liu PNAS 211 R-roscovitine (CYC22): Transcriptional CDK Inhibitor Validation of R-roscovitine Action in Mouse Corticotroph Tumors As a CDK inhibitor (R)-(1-ethyl-2-hydroxyethylamino)- 6-benzylamino-9-isopropylpurine Primary CDK targets: CDK2, CDK7, CDK9 Tumor PCNA β-actin V 3 V 1 V 2 V 6 R 6 R 4 R 2 R 3 Plasma (pg/ml) Serum corticosterone 8 (ng/ml) 4 P<.1 Liu PNAS 211 9

10 24/1/215 R-roscovitine Suppresses Human Corticotroph Tumor Signaling R-roscovitine Inhibits Corticotroph Tumor Gene Expression Ponceau (µm) 1 2 Tumor Roscovitne um 2 µm 2 um P<.5 (pg/ml) Tpit Cyclin E Pituitary progenitor PRP-1 NeuroD1 Tpit SF1 GATA-2 TSH GATA-2 Pit1 TSH α-msh LH FSH PitX NeuroD1 Tpit LAMIN Ponceau (µm) 1 2 POMC alpha-gsu.4 Liu JCEM Araki and Cuevas-Ramos Corticotroph-specific R-roscovitine Targets Cyclin E CDK2 Rb-E2F PTTG Senescence p21 p27 P57 Cell cycle exit E2F1 Acknowledgements Cedars-Sinai Ning-Ai Liu Vera Chesnokova Svetlana Zonis Cuiqi Zhou Kolja Wawrowsky Anat Ben-Shlomo Takako Araki Song-Guang Ren Hide Fukuoka Daniel Cuevas-Ramos Odelia Cooper Hide Fukuoka G 1 S Proliferation Tpit hpomc gene Serguei Bannykh Adam Mamelak St. Michael s Hospital, Toronto Kalman Kovacs Fabio Rotondo Hyperplasia/tumor Cushing disease overexpression 1

11 24/1/215 Fons Juventutis.Elixir of Youth Lucas Cranach 1546 Sustained and IGF-1 Suppression 3. Growth Hormone 2.5 IGF-1 (ng/ml) Response <2.5 ng/ml IGF-1 ULN Response <1.3 ULN Baseline First RX End Dose Esc 7 mo 13 mo Baseline First Rx End Dose Esc. 7 mo 13 mo Median control markedly superior to injections, median IGF-1 control comparable to injections 43 11