Genetics of Endocrine Tumours - Familial Isolated Pituitary Adenoma - FIPA
Conditions: Acromegaly, Gigantism, Familial Isolated Pituitary Adenoma, FIPA, Pituitary Adenoma Predisposition, PAP
Sponsor: Barts & The London NHS Trust

                                                                                                                    
 
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JRMO Non-CTIMP Protocol 
Template 
 
TITLE PAGE 
 
 
Full Title  
 
 
 
Genetics of Endocrine Tumours 
 
Short Title/Acronym  
 
Genetics of Endocrine Tumours 
 
Sponsor 
  
 
 
Queen Mary, University of London  
 
 
 
Contact person of the above sponsor organisations is: 
 
 
 
Head of Research Resources 
Joint Research Management Office 
 
5 Walden Street 
 
London 
 
E1 2EF 
 
Phone: 020 7882 7260 
 
Email: Research.Governance@qmul.ac.uk 
 
 
REC Reference 
06/Q0104/133 
 
 
Chief Investigator 
Prof. Marta Korbonits 
 
 

                                                                                                                    
 
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1.1 
Sites 
1. Aintree University Hospitals NHS Foundation Trust, Dr Christina Daousi (Local PI) 
 
2. Alder Hey Children's NHS Foundation Trust, Dr Joanne Blair (Local PI) 
 
3. Aberdeen Royal Infirmary, Grampian NHS, Dr Prakash Abraham (Local PI) 
 
4. Ashford and St Peter’s Hospitals NHS Foundation Trust, Dr Helen Ward (Local PI) 
 
5. Barts Health NHS Trust, Professor Marta Korbonits (Chief PI) 
6. Barking Havering & Redbridge University Hospitals, Dr Khash Nikookam (Local PI) 
7. Belfast Health and Social Care Trust, Dr Steven Hunter (Local PI) 
 
8. Birmingham Children’s Hospital NHS Foundation Trust, Dr Melanie Kershaw (Local PI) 
9. Cambridge University Hospitals Trust, Dr Mark Gurnell (Local PI) 
10. Cardiff University School of Medicine, NHS Wales, Dr Aled Rees (Local PI) 
11. East and North Hertfordshire NHS Trust, Lister Hospital, Dr Felicity Kaplan (Local PI)   
 
12. East Suffolk and North Essex NHS Foundation Trust, Dr Catherine Gouveia (Local PI) 
 
13. Epsom and St Helier University Hospitals NHS Trust, Dr Imran Malik (Local PI) 
14. Great Ormond Street Hospital NHS Trust, Dr Helen Spoudeas (Local PI) 
15. Great Western Hospital NHS Foundation, Dr Vladimir Vaks (Local PI) 
16. Guy's and St Thomas' NHS Foundation Trust, Dr Barbara McGowan (Local PI) 
17. Imperial College Healthcare NHS Trust, Dr Niamh Martin (Local PI) 
18. King’s College NHS Foundation Trust, Dr Simon Aylwin (Local PI)   
19. Lancashire Teaching Hospitals NHS Foundation Trust, Dr Simon Howell (Local PI) 
 
20. Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Dr Robert Murray (Local PI) 
 
21. Liverpool Women's NHS Trust, Dr Astrid Weber (Local PI) 
22. Manchester University NHS Foundation Trust, Dr Steve Ball (Local PI) 
23. NHS Lothian, Edinburgh, Dr Roger Brown (Local PI) 
 
24. Norfolk & Norwich University Hospitals, Dr Francesca Swords (Local PI) 
25. North Bristol NHS Trust, Mr Richard Nelson (Local PI) 
 
26. North Cumbria Integrated Care NHS Foundation Trust, Dr Chandi Idampitiya (Local PI) 
27. Northern General Hospital, Sheffield Teaching Hospitals NHS Trust, Dr John Newell−Price 

                                                                                                                    
 
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(Local PI)  
28. Oxford Radcliffe Hospitals NHS Trust, Dr Aparna Pal (Local PI) 
29. Plymouth Hospitals NHS Trust, Dr Daniel Flanagan (Local PI) 
 
30. Queen's Medical Centre, Nottingham University Hospitals Trust, Dr Ravikanth Gouni (Local PI) 
31. University Hospitals Dorset NHS Foundation Trust, Dr Tristan Richardson (Local PI) 
32. Royal Devon and Exeter NHS Foundation Trust, Professor Sian Ellard (Local PI) 
33. Royal Free Hospital NHS Foundation, Dr Bernard Khoo (Local PI) 
34. Royal Victoria Infirmary Hospital, Newcastle upon Tyne Hospitals, Dr Yaasir Mamoojee (Local 
PI) 
35. Northern Care Alliance NHS Foundation Trust, Dr Tara Kearney (Local PI) 
36. Sheffield Children’s NHS Foundation Trust, Dr Paul Dimitri (Local PI) 
37. Southend University Hospital NHS Foundation Trust, Dr James Ahlquist (Local PI) 
 
38. Surrey and Sussex Healthcare NHS Trust, Dr Julian Emmanuel (Local PI) 
39. Ninewells Hospital and Medical School, Professor Graham Leese (Local PI) 
40. St George's Healthcare NHS Trust, Dr Gul Bano (Local PI) 
41. The Christie NHS Trust, Manchester, Dr Claire Higham (Local PI) 
 
42. The Ipswich Hospital NHS Trust, Dr Damian Morris (Local PI) 
43. The Walton Centre, Dr Catherine Gilkes (Local PI) 
44. University College London Hospital NHS Trust, Ms Joan Grieve (Local PI) 
45. University Hospitals Birmingham, Dr John Ayuk (Local PI) 
46. University Hospitals Bristol, Dr Karin Bradley (Local PI) 
 
47. University Hospitals Coventry and Warwickshire, Professor Martin O Weickert (Local PI) 
 
48. University Hospitals of Derby and Burton NHS Foundation Trust, Dr Roger Stanworth (Local PI) 
 
49. University Hospitals of Leicester NHS Trust, Dr Miles Levy (Local PI) 
50. University Hospitals of North Midlands, Dr Biju Jose (Local PI) 
51. University Hospital Southampton, Dr Justin Davies (Local PI) 
52. West Hertfordshire Hospitals NHS Trust, Dr Colin Johnstone (Local PI) 
53. Yeovil District Hospital NHS Foundation Trust, Dr Alex Bickerton (Local PI) 

                                                                                                                    
 
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1.2 
Laboratories and/or technical departments 
Bart’s Health NHS, Royal Devon & Exeter Hospital NHS, Oxford Medical Genetics 
Laboratory, University of Birmingham and Cambridge, University of Reading, Beatson 
Institute Glasgow, Institute of Cancer Research (London), Charite University Berlin, Ingemar 
Pongratz, Karolinska Institutet, Stockholm, Sweden, University of Antwerp, Histopathology 
Department, Charing Cross Hospital, London, The Francis Crick Institute, London, Brunel 
University and University of Duisburg-Essen Germany.  
  
1.3 
Central facilities 
 Royal Devon & Exeter Hospital Genetics Laboratory 

                                                                                                                    
 
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CONTENTS PAGE 
 
TITLE PAGE .......................................................................................................................... 1 
1.1 
Sites ........................................................................................................................ 2 
1.2 
Laboratories and/or technical departments .............................................................. 4 
1.3 
Central facilities ....................................................................................................... 4 
CONTENTS PAGE ................................................................................................................ 5 
2 
GLOSSARY OF TERMS AND ABBREVIATIONS .......................................................... 6 
3 
SIGNATURE PAGE ....................................................................................................... 7 
4 
SUMMARY/SYNOPSIS .................................................................................................. 8 
5 
INTRODUCTION ............................................................................................................ 9 
6 
TRIAL OBJECTIVES .................................................................................................... 15 
7 
METHODOLOGY ......................................................................................................... 16 
8 
STUDY DESIGN / PLAN – STUDY VISITS .................................................................. 20 
9 
STATISTICAL CONSIDERATIONS .............................................................................. 21 
10 
ETHICS ........................................................................................................................ 21 
11 
SAFETY CONSIDERATIONS: ..................................................................................... 22 
12 
DATA HANDLING AND RECORD KEEPING: .............................................................. 22 
13 
LABORATORIES (if applicable) ................................................................................... 22 
14 
PRODUCTS, DEVICES, TECHNIQUES AND TOOLS ................................................. 23 
15 
SAFETY REPORTING ................................................................................................. 24 
16 
MONITORING & AUDITING ......................................................................................... 24 
17 
TRIAL COMMITTEES .................................................................................................. 24 
18 
FINANCE AND FUNDING ............................................................................................ 24 
19 
INDEMNITY ................................................................................................................. 24 
20 
DISSEMINATION OF RESEARCH FINDINGS: ............................................................ 25 
21 
REFERENCES ............................................................................................................. 26 
22 
APPENDICIES ............................................................................................................. 28 
 

                                                                                                                    
 
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2 
GLOSSARY OF TERMS AND ABBREVIATIONS 
 
AE 
 
 
Adverse Event 
 
 
AR 
 
 
Adverse Reaction 
ASR 
 
 
Annual Safety Report 
CA 
 
 
Competent Authority 
CI 
 
 
Chief Investigator 
CRF 
 
 
Case Report Form 
CRO  
 
Contract Research Organisation 
DMC  
 
Data Monitoring Committee 
EC 
 
 
European Commission 
GAfREC 
Governance Arrangements for NHS Research Ethics Committees 
ICF 
 
 
Informed Consent Form 
JRMO  
 
Joint Research Management Office 
NET 
 
 
Neuroendocrine tumour 
NHS REC 
 
National Health Service Research Ethics Committee 
NHS R&D 
 
National Health Service Research & Development   
Participant 
 
An individual who takes part in a clinical trial 
PI 
 
 
Principal Investigator 
PIS 
 
 
Participant Information Sheet  
QA 
 
 
Quality Assurance 
QC 
 
 
Quality Control 
RCT 
 
 
Randomised Controlled Trial 
REC 
 
 
Research Ethics Committee 
SAE 
 
 
Serious Adverse Event 
SDV 
 
 
Source Document Verification 
SOP 
 
 
Standard Operating Procedure  
SSA 
 
 
Site Specific Assessment 
TMG  
 
Trial Management Group 
TSC 
 
 
Trial Steering Committee 
 
 
 
 
 
 
 
 

                                                                                                                    
 
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3 
SIGNATURE PAGE 
 
 
Chief Investigator Agreement 
 
 
The clinical study as detailed within this research protocol (Version 17, dated 03/03/2021), 
or any subsequent amendments will be conducted in accordance with the Research 
Governance Framework for Health & Social Care (2005), the World Medical Association 
Declaration of Helsinki (1996) and the current applicable regulatory requirements and any 
subsequent amendments of the appropriate regulations. 
 
Chief Investigator Name: Prof. Marta Korbonits 
Chief Investigator Site: Barts and the London, WHRI, QMUL 
Signature and Date: 
03/03/2021 
 
 
 
 
 
 
Principal Investigator Agreement (if different from Chief investigator) 
 
 
The clinical study as detailed within this research protocol (Version 17, dated 03/03/2021), 
or any subsequent amendments will be conducted in accordance with the Research 
Governance Framework for Health & Social Care (2005), the World Medical Association 
Declaration of Helsinki (1996) and the current applicable regulatory requirements and any 
subsequent amendments of the appropriate regulations. 
 
Principal Investigator Name: Prof. Marta Korbonits 
Principal Investigator Site: Barts and the London, WHRI, QMUL 
Signature and Date: 
03/03/2021 
 

                                                                                                                    
 
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4 
   SUMMARY/SYNOPSIS 
 
 
Short Title 
Genetics of Endocrine Tumours  
 
Methodology 
 
Type of study: observational, non-randomised 
 
Research Sites 
 
48 NHS Trusts  
Objectives/Aims 
 
Brief statement of key primary objectives 
To identify genes which are involved in the development 
of endocrine tumours and tumours related to the 
endocrine system. 
 
Number of 
Participants/Patients 
Approximately 10,000, recruitment will continue for 20 
years. 
 
Main Inclusion Criteria 
 
Subjects: Patients with endocrine tumours or tumours 
related to endocrine system 
Controls: patients with other conditions who could serve 
as controls for patients with endocrine tumours 
Healthy volunteers: patients with no known condition who 
can serve as an unaffected control 
No restrictions on age or gender 
 
Statistical 
Methodology and 
Analysis (if applicable) 
 
Descriptive statistics for cohort 
 
 
Proposed Start Date 
 
14/02/2007 
 
Proposed End Date 
Approximately September 2037 
Study Duration 
 
30 years  
 
 
 
 
 
 
 
 
 
 
 

                                                                                                                    
 
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5 
INTRODUCTION  
Background 
The endocrine system comprises a network of cells, glands and tissues which, when 
stimulated, secrete hormones to regulate numerous physiological processes ranging from 
metabolism, growth and sexual development to sleep and mood.  These glands are often 
intimately related to the nervous system (neuroendocrine tissue) and are widely distributed 
all over the body. Tumours arising in endocrine tissue (particularly neuroendocrine glands) 
are often in surgically challenging sites, and both the local effects of the tumour itself plus 
the local and / or systemic sequelae of treatment may have long lasting consequences for 
the patient.  Advances in the field of molecular genetics have made it possible, in some 
cases, to identify specific causative genetic defects for both familial and sporadic tumours.  
Many of these mutations affect cell signalling pathways relating to cell growth and 
development, leading to aberrant up regulation of proteins that are thought to be related to 
tumorigenesis.  It is vital to identify which genes are mutated, since recently developed small 
molecule inhibitors offer a potential adjuvant treatment to the standard approach of surgery 
and chemo-radiotherapy, and early screening of potentially affected relatives may impact on 
the clinical course of disease.  Many of these tumours are extremely rare, which makes 
research on an isolated disease very difficult.  However, these tumours often have features 
in common, and discoveries pertaining to a specific tumour can often lead to a breakthrough 
in a related field.  This project targets a number of endocrine and neuroendocrine tumours 
with a view to identifying novel treatments to improve outcomes in this difficult to treat group.   
 
Pituitary 
The pituitary gland, a neuroendocrine organ, releases hormones into the circulation in 
response to neuroendocrine regulation from the hypothalamus. Pituitary tumours comprise 
around 15% of all intracranial neoplasms, and present with distinct clinical characteristics, 
usually in terms of local space-occupying effects, or secondary to tumoral hypersecretion or 
its consequences. Acromegaly and gigantism are due in more than 99% of cases to a 
somatotroph adenoma, which has been demonstrated to be monoclonal in the great majority 
of instances1. It has been suggested that there are 6 major features of oncogenesis which all 
need to be present in cases of cancer2, but only 3 of these (activation of an oncogene, 
inactivation of a tumour suppressor gene [TSG], inhibition of apoptosis) appear to be 
relevant to pituitary tumorigenesis; these tumours are usually benign adenomas, and the 
formation of new blood vessels and the capacity for metastasis are uncommon, although 
some way of evading senescence may be important. It has therefore been suggested that a 
very small number of mutations in oncogenes and/or TSG’s may be causally responsible for 
pituitary adenomas. This makes them an excellent model for the early stages of 
tumorigenesis. However, while much has been established regarding the molecular 
pathology of these tumours, including extensive studies from our own laboratory3-7, the 
initiating mutation or mutations responsible for tumorigenesis have to date defied analysis.  
 
Early work established that some 30% of patients with acromegaly had one of 2 mutations of 
the alpha-subunit of the receptor-associated G protein, leading to constitutive activation, but 
it has been difficult to show that this has relevant biological consequences. We have 
identified a partial failure of the feedback regulation on somatotroph tumours, but no 
mutations of the relevant genes have been recorded6, 8. We and others have also explored 
the possibility that there are somatic mutations in sporadic somatotroph tumours of genes 

                                                                                                                    
 
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identified in some hereditary syndromes 
associated with acromegaly (MEN-I, Carney syndrome), but these appear to be extremely 
rare9. However, we have collaborated with a Chicago group who have been seeking to 
identify the gene responsible for familial acromegaly, a very rare dominant condition10-14. 
Some 46 families have been described worldwide over the last 40 years, and from a cohort 
of 8 families a region on chromosome 11q13 has been identified: we have sought to use 
data from our microarray studies15 to pinpoint the abnormal gene in these patients, but so far 
unsuccessfully. Our recent work has suggested that there are abnormalities of the cell cycle 
in pituitary adenomas, especially down-regulation of the cyclin-dependent kinase inhibitor 
p27 and activation of cyclin E, and that this is secondary to a putative abnormal growth 
factor receptor(s), but specific mutations of these receptors are absent16. 
 
In 2006 a Finnish group have identified a dominant gene of very low penetrance which 
appears to segregate with familial somatotroph and prolactin-secreting tumours17. This lies 
at or near position 11q13, but it remains unclear as to whether this is indeed the same gene 
identified in our families with a much more strongly penetrant condition. The gene codes for 
AIP (= aryl hydrocarbon receptor interacting protein, also known as XAP2 hepatitis B virus 
X-associated protein 2 or ARA9 = AhR (aryl hydrocarbon receptor)-activated protein 9. AIP 
has 330 amino acids and has a PPIase-like domain FKBP12 and four tetratricopeptide 
repeats (TPRs), probably important for protein-protein interactions.  
 
 
 
 
 
 
AIP is a putative activating partner for the aryl hydrocarbon receptor, probably increasing the 
function of AhR. AhR has been linked to the induction of hepatic detoxifying gene products in 
response to environmental toxins such as dioxin18. However, an additional function appears 
to be regulation of the cell cycle, suppressing cyclin E and increasing expression of p2719. 
The AhR also has been shown to interact with cyclic AMP. In this latter instance, the 
interaction with cAMP appears to compete with the dioxin-dependent pathway, such that 
AhR has enhanced transport into the nucleus with transcriptional effects quite separate to 
those stimulated by dioxin and related ligands. As cAMP is an important second messenger 
in somatotroph tumours, this may be the relevant pathway underlying the apparent activity of 
AIP as a tumour suppressor.  
 
There is therefore a priori reason to believe that AIP may indeed function as a TSG in 
pituitary adenomas, and loss of heterozygosity for 11q13 has been seen in tumours in 
familial cases17. However, the initial Finnish data was based on only 3 families, and we now 
plan to investigate our entire cohort of families with acromegaly and prolactinomas, as well 
as further families that we are in the process of collecting.  We have contacted many 
endocrinologists throughout the UK, and we have identified a small number of additional 
families. Finally, in the initial study some of the patients were apparently isolated cases of 
acromegaly, but presenting at an unusually young age, especially with gigantism. In such 
cases mutations of the AIP gene have also been recorded.  
 

                                                                                                                    
 
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Recent data suggest that AIP is in the 
secretory vesicles and released into the circulation and our preliminary data suggests that it 
can be measured in the serum. Therefore, we would like to compare circulating AIP levels in 
patients with familial and sporadic pituitary adenoma. In addition, since AIP is expressed in 
other tumours and organs such as the heart, circulating AIP levels could be relevant to 
conditions affecting other organs. Therefore, we would like to collect samples from patients 
with other endocrine, cardiological and oncological conditions as well as healthy volunteers 
for comparison.  
 
Novel data has suggested that AhR plays an important role in the development of a recently 
identified cell type the Th17 lymphocytes. Lack of AhR function in mice results in impaired 
Th17 differentiation with reduced levels of IL17A and IL2220. This has effect on the innate 
immune function of the individual. We would like to study the function of Th17 cells in 
patients with AIP mutations and appropriate controls, especially since this system also plays 
a role in the response to environmental toxins. 
 
There are increasing data suggesting that environmental factors can influence the 
manifestation of various neoplastic conditions as well as genetic diseases. This could be 
particularly relevant to pituitary disease, as AIP is a known co-chaperone of AhR, the 
receptor for the environmental toxin dioxin and other organohalogens. Two recent 
independent studies from northern Italy21 and from Sicily22 suggested this in humans, and 
more recently corresponding data has been published in cats23, who are prone to develop 
acromegaly. In addition, environmental changes can alter methylation pattern of the DNA, 
and abnormal methylation has already been shown to influence pituitary tumorigenesis24. In 
view of these data we would like to collect DNA, serum and environmental pollutant samples 
from patients with pituitary disease. As controls we would like to use their spouses or other 
adult relatives living in the same household and a separate control group with no known 
pituitary disease. We will collect blood samples for DNA, hormone and organohalogen 
measurements and household dust (collected from hoover bag contents).  
 
We plan to screen all known families with a history of acromegaly and/or prolactinomas, as 
well as other pituitary tumour families to be identified in the UK, for mutations of the AIP 
gene or other genes causing endocrine tumours. As the data suggest that early onset, 
aggressive, seemingly sporadic cases of acromegaly or prolactinoma could also be caused 
by germline mutations, we will include patients with clinically sporadic but early-onset 
aggressive disease.  
 
Pheochromocytoma / Paraganglioma 
Some of the signalling pathways that may prove important in growth of pituitary tumours are 
currently being studied in other neouroendocrine tumours (NETs). Our group has 
investigated these pathways in pheochromocytoma (PCC - a tumour of the adrenal gland) 
and demonstrated that combined treatment with small molecule inhibitors against proteins 
involved in the mTOR signalling pathway was able to inhibit tumour growth in vitro using 
mouse tumour cell lines and in vivo using a mouse pheochromocytoma model 25-27. We now 
plan to focus on paraganglioma (PGL - related to pheochromocytoma but arising in extra-
adrenal paraganglia). The genetics of familial and sporadic PCC/PGL is complicated and at 
present mutations in at least 15 genes have been linked to the disease28. These mutations 
are grouped into those affecting the tyrosine kinase signalling pathways leading to mTOR 

                                                                                                                    
 
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activation (typical in PCC) and those 
affecting energy metabolism and hypoxia signalling including mutations in the succinate 
dehydrogenase complex (SDH) subunit proteins A-D (PGL)28. Distinct clinical phenotypes 
related to the different causative germline and somatic mutations have been identified and 
the syndromes they cause are well defined.  We plan to focus initially on two syndromes – 
PGL1 (caused by mutations in SDH-D) and PGL4 (mutations in SDH-B).  PGL 1 is 
associated with multiple (usually benign) head and neck PGL (H&N PGL) as well as PCCs.  
Although the tumours are slow growing, significant morbidity occurs as the tumour burden 
increases in size.  H&N PGL arise close to the skull base and often may compromise cranial 
nerves or major vessels due to pressure effects.  Surgery to treat them carries major risks of 
damaging these vital structures, and for patients with bilateral disease alternatives such as 
gamma knife radiotherapy are usually indicated but are unlikely to ultimately halt the disease 
process.  Patients with PGL4 typically show early onset disease, can develop PCC or PGL, 
have a higher risk of malignancy and are at risk of additional neoplasms including thyroid 
tumours and renal cell carcinoma.  In cases of aggressive malignant or metastatic disease, 
survival remains poor despite recent advances in chemotherapy. We have established a 
method of generating primary culture of PGL and plan to use this to investigate treatment 
combinations with a view to describing novel treatment options for these patients.  
 
Adrenal cortical adenoma and carcinoma 
Benign or malignant adrenal cortical adenomas secreting steroid hormones (cortisol, 
androgens, aldosterone, deoxycortisol etc) or having no identifiable secretory activity are 
relatively commonly diagnosed. They can be part of a genetic syndrome such as the 
classical Carney complex, McCune-Albright, MEN1 or p53-related syndrome or can harbour 
germline or somatic mutations in ARMC5, potassium channel, ATP- or PKA-related 
pathways29-32. The genomic landscape of somatic mutations of adrenocortical carcinomas 
has also been recently characterised33, 34. These mutations can influence clinical course and 
severity, sensitivity for treatment and prognosis as well as predisposition to other family 
members. We will study these tumours for the currently known gene variants and will exploit 
the identification of new genetic alterations both at germline and somatic level. We have 
established a method of generating primary culture of adrenal specimens (tumours and 
normal adjacent) and plan to use this to investigate adrenal stem cells, cancer-stem cells 
and to test novel treatments options through in vitro and in vivo experiments.    
 
Olfactory neuroblastoma 
Olfactory neuroblastoma (ONB) is a rare neuroendocrine tumour affecting all ages with no 
race, sex or geographical predilection.  It arises high in the nasal cavity at the site of 
olfactory mucosa, usually close to the cribriform plate.  Initial symptoms are very non-specific 
and patients typically have a drawn out investigation schedule, resulting in many cases 
being locally advanced at the time of definitive diagnosis35.   Long term studies have shown 
that patients with advanced local disease, orbital involvement, neurological involvement and 
regional or distant metastatic disease have a very poor prognosis with currently available 
treatments36.  When the disease occurs in children, it is almost always advanced at the time 
of diagnosis, and the consequences of surgery and / or radiotherapy to the developing mid-
face and brain can be significant – including visual disturbance, craniofacial abnormalities 
and pituitary hypofunction37.  Population studies have highlighted the risk of radiation 
induced second primary tumours and this is greatest in patients undergoing treatment as a 
child or young adult38.  ONB has a tendency to recur even in localised cases and can 

                                                                                                                    
 
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present 
as 
recurrence 
or 
metastatic 
disease even 20 years after initial treatment, therefore patients require lifelong surveillance. 
Cytogenetic characterisation studies and comparative genomic hybridisation studies have 
highlighted regions of the genome that are frequently involved in ONB.  Although many 
genes map to these regions, a subsequent whole genome sequencing revealed mutations in 
genes coding for signalling pathway proteins related to the mTOR pathway when the 
somatic genetic mutations were run through ingenuity pathway analysis (IPA).  An unrelated 
study also demonstrated up-regulation of the Hedgehog signalling pathway in ONB tumours.    
As yet there have been no studies focused on targeting the mTOR pathway in ONB – we 
plan to study this with a view to defining new treatment regimens that can be used as an 
adjunct to currently available methods.  We will be testing novel small molecule inhibitors 
against ONB, which if effective may lead to human trials in cases of inoperable metastatic 
disease.  We may expand this area of study to include other NETs which show mutations / 
upregulation of the relevant signalling pathways, including PGL, MTC and pituitary.  One 
major benefit of studying nasal tumours is that it is easily possible to obtain control tissue 
samples from unaffected patients for comparison purposes, making it easier to identify 
genes specifically upregulated in the tumour. 
 
Medullary thyroid carcinoma 
Medullary thyroid carcinoma (MTC) is a rare malignant tumour arising from the calcitonin-
producing parafollicular cells (C cells) of the thyroid accounting for 5–10% of all thyroid 
cancers and for 13.4% of all thyroid cancer-related deaths. MTC can occur in a familial 
setting in 25% of cases, either as MTC alone (familial MTC, fMTC) or associated with 
pheochromocytomas and/or primary hyperparathyroidism, configuring the multiple endocrine 
neoplasia type 2 syndrome (MEN2). Most MEN2 families (about 98%), as well as fMTC 
kindreds (90-95%), bear germline mutations in the proto-oncogene RET, that encodes a 
receptor tyrosine-kinase involved in the regulation of cell proliferation, growth, differentiation, 
migration, survival, and apoptosis39. Up to 5-10% of fMTC families do not have any 
detectable RET mutation and, in these cases, the disease-causing gene(s) are yet to be 
identified. Moreover, somatic RET mutations are found in approximately 40% of sporadic 
MTC, while somatic RAS mutations have been found in 12.9% of sporadic MTC (meta-
analysis of 14 studies)40. The best treatment option in MTC is surgical resection; however, 
biochemical cure can be achieved only in 30-40% of patients with regional lymph node 
metastases, and this severely affects the prognosis of these patients41. As medical treatment 
options are quite limited, a better understanding of the pathways involved could provide new 
drug targets for MTC.   
 
Insulinoma and insulinomatosis 
Insulinomas are pancreatic NETs arising from β cells and represent the most common cause 
of pancreatic hyperinsulinaemic hypoglycaemia in adults42. Approximately 10% of 
insulinomas are multiple, and half of these are associated with the MEN1 (multiple endocrine 
neoplasia type 1) syndrome43, 44. In a large insulinoma series, 5% of patients presented with 
insulinomatosis, defined as multicentric insulin-secreting tumours without clinical and genetic 
evidence of MEN145. Insulinomatosis can arise in a familial setting45, 46, and has been 
reported to be associated paradoxically with the occurrence of diabetes within the same 
family5. The pathogenesis of insulinomatosis is currently unknown. Through our network of 
collaborators, we have been collecting DNA samples from patients with either familial or 
sporadic insulinomatosis, and we aim to employ next generation sequencing to identify the 

                                                                                                                    
 
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disease-causing 
mutations 
in 
these 
patients. As we believe that the diabetes observed in some family members may recognise 
the same genetic cause as the insulinomatosis, we also aim to study the features of these 
patients’ diabetes and screen the unaffected family members for the presence of 
hyperglycaemia or impaired glucose tolerance. The understanding of the molecular 
mechanisms underlying the pathogenesis of insulinomatosis could reveal novel pathways 
involved in neuroendocrine tumorigenesis and β cell proliferation. 
 
Craniopharyngiomas 
Craniopharyngioma (CP) is a neuroepithelial intracerebral neoplasm arising from the 
pituitary and is associated with significant morbidity and mortality. Located in or just above 
the sella turcica, CPs are difficult to remove surgically because of their infiltrative behaviour, 
which affects surrounding vital structures including the hypothalamus, visual pathways and 
cranial nerves. Treatment for these tumours is currently limited to surgery with or without 
radiotherapy, both of which are associated with significant adverse effects. Most tumours 
have a high recurrence rate after resection, and all tumours have significant morbidity and 
mortality. The disease and/or treatment-related consequences are in themselves life-
threatening or life-reducing. CPs are subdivided into two types, the adamantinomatous 
craniopharyngioma (ACPs), which affect mainly children (90% of cases) and the papillary 
form (PCPs), which affect both young adults and adults. Histologically and molecularly, 
these two subtypes are different: ACPs present with keratin nodules, epithelial 
differentiation, cholesterol deposits and have cystic appearance. The molecular mechanisms 
and the causative mutations for ACPs remained elusive making it difficult to identify novel 
treatment strategies for ACPs tumours. Recently somatic mutations in the phosphorylation 
sites that promote degradation of β-catenin were observed in 65-70 % ACPs47. These 
mutations lead to strong nuclear accumulation of β-catenin, however whether β-catenin has 
a primary role in these tumours remains unclear. PCPs consist of squamous cells and they 
are less differentiated tumours compared to ACPs. Although equally aggressive and leading 
to high morbidity, nothing is known about the molecular aetiology PCPs, in part, due to the 
lack of a suitable animal model and the lack of identification of causative mutated genes. In 
2014, a human exome-sequencing study has identified the activating mutation V600E in the 
BRAF1 oncogene in a cohort of PCP patients48. We plan to use tumour tissue to identify of 
novel genes causative of both ACPs and PCPs by using the protocols specified herein.  
 
In addition to the above specific studies we may need to assess tumour tissue from other 
endocrine tumours – particularly those related to the diseases outlined above.  Data from our 
pituitary study which started in 2006 revealed that some of the families with familial 
acromegaly might have a second tumour. Among others these have included thyroid, breast, 
testis, adrenal, adipose tissue and tumours related to the endocrine system (non-specified 
tumour and hamartomas).  PCC, PGL and MTC are also linked to a number of other 
tumours, and the number of associated tumours may increase as the genetic background is 
studied further.  The rare tumours ONB and CP do not have any known associated tumours 
as yet, but this may change over the course of this study.  It is therefore essential to include 
these other tumours in our study, since this data will contribute to our overall understanding 
of pathogenesis of endocrine tumours. 
 
 
 

                                                                                                                    
 
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Population Study 
A special additional pituitary study has been initiated. We have established that one 
particular gene abnormality is prevalent in patients with Irish origin, especially from the 
Tyrone, Northern Ireland area49. Our current Ethics permission allows screening of all 
patients with acromegaly or prolactinomas in Northern Ireland. We would like to screen the 
general population of Northern Ireland overall and specifically the Tyrone area. For the 
overall general population, we would like to include general population samples from Ireland 
and compare it with general population samples from Scotland and England so we can 
establish the background frequency for the R304X mutations. These screens will be 
performed according to the ethics permission valid for the general population cohorts we will 
collaborate with. 
 
For the local area screening subjects will be recruited via GP surgeries and via leaflets in 
public places and churches. GPs will be notified about the study in advance. We envisage 
that this screening will identify a number of carriers who could be formally referred to 
appropriate genetic clinic and we hope (and have data already from identified families) early 
disease recognition will lead to easier treatment and better cure.  
 
6 
TRIAL OBJECTIVES 
- Primary Objectives  
 
• 
To identify genes which are involved in the development of endocrine tumours and 
tumours related to the endocrine system 
• 
To establish the phenotype of patients with genetic alterations in endocrine tumours 
compared to patients with no such changes and to normal controls 
• 
To study family members of patients, screening for genetic alteration and signs of 
development of disease 
• 
To establish the mechanism of effect of such genetic alterations 
 
- Secondary Objective  
• 
To identify potential therapeutic targets and test them in vitro and in vivo where possible 
• 
To assess the anti-tumour efficacy of novel small molecule inhibitors for 3 purposes: 
o To establish new treatment options for advanced disease 
o To establish a novel adjuvant treatment to complement the current gold standard 
for localized disease 
o To improve understanding of the complex system of signalling pathways involved 
in oncogenesis of many endocrine tumours 
• 
To establish animal models where we can further explore the genetic basis of these 
tumours, and test our in vitro findings 
 
- Primary Endpoint  
• 
New genes identified in families or sporadic patients 
• 
Disease phenotype established 
• 
Mechanism of effect of novel genes identified  
 

                                                                                                                    
 
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- Secondary Endpoint  
• 
New drug target proven and taken forward to human trial stage 
• 
New disease model established  
 
7 
METHODOLOGY  
Following patient consent, clinical notes, images and investigations are reviewed, patient’s 
symptoms recorded using questionnaires (see appendix for headache questionnaire) and 
symptom scores as appropriate. 
Samples will either be processed in the laboratory at Barts or handled anonymously in one 
of the collaborating departments listed below. Patients either recruited prospectively to the 
study or retrospectively when the samples will be anonymised, so that there is no link 
between the data we generate and the patients themselves.   
 
 
Patient tumour samples will be collected for DNA, RNA and protein analysis including gene 
and protein expression, next generation sequencing techniques (e.g. whole genome 
sequencing, whole exome sequencing, RNAseq and DNA methylation studies).   
In the future and independent of our current study aims, it is likely that analysis of a person’s 
whole DNA genetic code will become much more feasible in research, due to rapidly 
advancing technology.  We may wish to do this with the samples of this study and link the 
results to clinical data.  This may provide some useful knowledge about how genes and 
medical conditions are connected in more general terms.  Any such analysis would be 
carried out on the samples only in an anonymised form, meaning that the samples etc. are 
identified only by a code number, so the research teams would not know patient identity.  
Data will not be returned to patients as identity would not be known to the researchers.  
There is a very small chance that patient could be identified as the donor of that sample if 
the DNA was analysed again for some other reason separately from our study, and the 
genetic codes compared.  We consider this to be extremely unlikely to occur without patient 
knowledge and approval.  Our data will not be used for forensic testing. 
We would like to study (for gene sequence and expression changes) blood or saliva samples 
and sporadic or familial tumours of these organs as well as skin, bowel, liver, bone, brain, 
prostate, kidney, lung, pancreas, lymphoid tissue for expression of AIP and other related 
endocrine tumorigenesis genes.  We would also like to use hair and urine samples to 
perform innovative hormone assessment.  Organohalogen exposure will be measured from 
nail clippings. For patients with familial insulinomatosis (including unaffected carriers), we 
would like to collect blood samples both in the fasting state and after stimulus with a 
standard oral glucose load (75 grams) and a mixed meal, in order to investigate their 
glucose metabolism and screen these subjects for the presence of diabetes mellitus. These 
tests are very well established and extensively used in clinical practice. Age-, gender- and 
BMI-matched healthy volunteers will also undergo the same studies with the purpose of 
comparing the results to those obtained in the patients. Immunohistochemistry will be 
performed on paraffin embedded tumours and control tissue to demonstrate up regulation of 
target proteins in the tumour cells.  DNA and RNA will be extracted from formalin fixed 
tissues and subjected to PCR for mutational analysis.  RNA may also be subjected to RT-
PCR and qPCR to confirm expression of activated forms of key proteins of interest, which 
can then be targeted with siRNA techniques and / or transfection studies to further explore 
their role in the disease process.  From selected patients cell lines will be created according 
to standard NHS routine in accredited NHS laboratories (appropriate consent form from the 

                                                                                                                    
 
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laboratory will be signed by the patient and 
filed in notes).  We will also generate primary cultures direct from tumour tissue, to 
investigate protein expression and evaluate response to targeted treatments using western 
blot analysis of protein expression and cell viability / apoptosis / cell cycle assays.  Where 
primary culture proves very difficult and with samples from very rare tumours, patient derived 
xenografts in SCID / Nude mice will be generated, by fully trained individuals in an approved 
facility with appropriate personal, project and site licensing as required by Home Office 
guidelines, to facilitate propagation of tumour cells for evaluation of responses to treatments.  
If appropriate, immortalisation of the cell line may be attempted to facilitate certain 
experiments and longer-term research. Serum/plasma samples will be analysed for novel 
circulating DNA, RNA, metabolites and proteins, which could act as tumour markers for the 
disease.  Peripheral blood cells will be studied in immunological experiments. From selected 
patients, skin biopsies may be taken to examine the mosaic nature of the disease or to gain 
patient-derived fibroblast for study. This procedure is commonly used in clinical and research 
practice. 
 
 
In addition, where appropriate (e.g. pituitary, MTC, PGL syndromes) affected family 
members will be identified, as well as first-degree relatives both affected and unaffected.  
Patients identified with genetic abnormalities will be referred to appropriate clinical services. 
At the same time, all apparent mutations or polymorphisms of novel genes will be tracked in 
a cohort of at least 100 germline blood samples from normal volunteers for assessment of 
the background gene frequency in order to assess their relationship to disease status.  
 
 
Tissue samples: 
 
Affected patients: 
Samples collected will include blood, serum / plasma, peripheral lymphocytes, saliva, hair, 
urine, teeth, bones, nail clippings and tumour tissue (fresh, frozen and formalin fixed / 
paraffin embedded).   
 
Wherever possible, samples will be collected by designated GCP-trained members of the 
study based at Queen Mary University of London or Bart’s and the London Hospital Trust. 
Where this is not possible, permission is given by the chief investigator for samples to be 
collected by designated GCP-trained staff from the collaborating institutions listed in this 
document. 
 
 
Control samples: 
For comparison studies healthy volunteer blood and saliva samples (as well as hair, urine 
and tissue samples) will also be collected and subjected to the same analysis as detailed 
above.  Since many endocrine disorders affect multiple systems of the body, we would also 
like to collect DNA/RNA/protein, saliva and serum samples from patients with other 
endocrine, cardiological and oncological conditions for comparison.  Samples will be treated 
as already detailed above.  To study adenomatous pituitary or other tumour tissues 
comparison with normal tissue is essential: as some of these tissues, especially normal 
pituitary tissue, is very difficult to access during surgery, the only source of such material is 
from autopsy or cadaveric specimens. This is therefore required for our studies. For other 
tumour types studied, control tissues samples are also required. This would apply to all body 

                                                                                                                    
 
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sites 
involved 
in 
the 
above 
project 
(including but not limited to, thyroid, breast, testis, adrenal, adipose tissue, skin, bowel, liver, 
bone, brain, prostate, kidney, lung, pancreas, lymphoid tissue and head and neck sites). 
Where possible, we want to use fresh adjacent normal tissue / marginal biopsies from 
surgical resections (performed for non-NET related reasons) or where appropriate and in 
cases which will not result in harm to the patient, to obtain control tissue specimens from 
patients undergoing surgery for non-related conditions (for example biopsy of nasal mucosa 
in patients undergoing nasal reconstruction surgery) or a small biopsy from a healthy 
volunteer24. The tissue will be processed in an identical manner to the tumour tissue 
processing detailed above.  Patients who would be suitable to act as control sample donors 
are identified either by the nature of their operation (e.g. nasal surgery for correction of nasal 
deformity but not to treat underlying pathology) and approached either at clinic review, pre-
assessment or on the day of surgery to explain the nature of the study and request 
permission to use some of their tissue sample as control.  A similar process may apply to 
patients undergoing thyroid and other endocrine gland surgery for non-malignant indications.  
In such cases the patients are identified as suitable by their surgical team and recruited by 
their team who will also gain consent. In the case of children, parental consent will be 
obtained before any approach is made to their child. In cases where control blood or saliva 
samples are required patients are identified when they attend non-endocrine medical / 
surgical clinics (such as cardiology) if they need tests anyway as part of their work up for 
their underlying condition.  They are recruited to the study by the consultant’s team they are 
being treated by, and if they consent, additional samples are taken for the study on the same 
day that they attend for their routine tests.  In each case the donor is asked to sign 
appropriate consent forms and given an information leaflet explaining the remit of this study 
(please see ‘Gaining consent SOP’).  They are also provided with contact information and 
are able to withdraw consent at any stage should they change their mind. 
 
Collaborating clinical departments: 
 
Tissue accrual: 
The patients will be recruited from Endocrinology Departments from collaborating NHS 
Trusts (Bart’s Health, UCLH, Royal Free and University College School of Medicine, St 
George’s Healthcare, Guy’s and St Thomas’ Hospital, Great Ormond Street Hospital, Mid 
Yorkshire Hospitals, Norfolk & Norwich University Hospitals, Nottingham University 
Hospitals, University Hospital Southampton, Southend University Hospital, Newcastle upon 
Tyne Hospitals, Oxford University Hospitals, University Hospital of North Staffordshire, 
Northern General Hospital Sheffield, Salford Royal Manchester, Aberdeen Royal Infirmary, 
Plymouth Hospitals, Leeds General Infirmary, Cambridge University Hospitals, University 
Hospitals Birmingham, University Hospitals Bristol, Lothian Edinburgh, Liverpool (Aintree 
Hospitals, Alder Hey Children’s, Royal Liverpool Children's Hospitals, Liverpool Women’s), 
University Hospitals of Leicester, Belfast HSC, King’s College Foundation Trust Hospital, 
Royal Devon and Exeter, Imperial College Healthcare, Derby Hospitals, Cardiff University 
School of Medicine, The Ipswich Hospital, Medway Maritime Hospital, East and North 
Hertfordshire, North Bristol, Great Western Hospital Swindon, Barking Havering & Redbridge 
University Hospitals, Central Manchester University Hospitals, Countess of Chester NHS 
Foundation Trust, Lancashire Teaching Hospitals NHS Foundation Trust, University 
Hospitals Dorset NHS Foundation Trust, Sheffield Children’s NHS Foundation Trust, 
Ninewells Hospital and Medical School, The Walton Centre, The Christie NHS Trust, 

                                                                                                                    
 
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University 
Hospitals 
Coventry 
and 
Warwickshire and West Hertfordshire Hospitals NHS Trust). 
 
Analysis: 
At the start of this project all the genetic screening of patients was performed in our research 
laboratory at Bart’s. However, since that time, for the AIP gene the molecular genetics 
laboratory at the Royal Devon & Exeter Hospital, a CPA accredited NHS/Research 
laboratory, has set up a comprehensive service and we collaborate with them on the 
analysis of the samples. Most genetic testing of known or novel genes and areas will be 
performed at the CPA accredited molecular genetics laboratory in Exeter or at our research 
laboratories at Bart’s and Oxford. Additional analysis of anonymous samples may also be 
undertaken by a specialist laboratory (or laboratories), as required.  These sites may include 
our collaborators Dr Elaine Harper at Syntaxin, Oxford, Prof Eamonn Maher at the University 
of Birmingham and Cambridge, Prof Rainer Cramer at the University of Reading, Prof Eyal 
Gottlieb and Dr Simone Cardaci at the Beatson Institute Glasgow and the Institute of Cancer 
Research, London, Prof Christian Strasburger, at Charite University Berlin and Ingemar 
Pongratz, Karolinska Institutet, Stockholm, Sweden. Dr. Adrian Covaci, Toxicological Center, 
University of Antwerp, Charing Cross Hospital, Prof. Charles Swanton, The Francis Crick 
Institute in London, Dr Michael Themis, Brunel University and Prof. Ralf Kuppers, University 
of Duisburg-Essen. Craniopharyngiomas may be assessed by specialist pathologists 
Professor Teresa Ribalta Farres (Barcelona Childrens’ Hospital) and Associate Professor 
Gaetano Bulfamante (Universita Degli Studi Di Milano)  
 
 
Inclusion Criteria  
Patients with endocrine tumours 
Family members of patients with endocrine tumours 
Patients with other diseases serving as controls for endocrine patients 
Individuals who are asymptomatic but are at risk of carrying a genetic mutation 
Healthy volunteers serving as controls for endocrine patients 
Samples from autopsy with appropriate anonymization 
Samples from historical cases with appropriate anonymization 
 
All ages are included. Paediatric patients (age 6-15) have special Information sheets and 
Consent forms and parental agreement is also requested. Patients under the age of 6 will 
have parental agreement only. Next of kin will sign the patient consent forms on the behalf of 
the deceased patient. 
 
Exclusion Criteria  
Subjects who are not willing to sign the informed consent and do not fit the inclusion criteria.  
Patients that cannot understand the consent forms or PIS in English, unless a qualified 
translator is present 
Patients lacking capacity to consent 

                                                                                                                    
 
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8 
STUDY DESIGN / PLAN – STUDY VISITS  
Patients are contacted via their treating physicians (in or outpatient), via their family 
members or patients contact the researcher via patient website. 
 
• 
Inclusion and exclusion criteria assessed. 
• 
Patients meeting the inclusion and exclusion criteria are given information about the 
study and are given an appropriate information sheet about the study 
• 
Relevant patient contact details are taken 
• 
Patients are given opportunity to ask questions and raise any issues 
• 
Patient gives informed consent  
• 
Patient sample is taken (blood, saliva, tissue etc) 
• 
Patients notes, images and investigations are reviewed, patients’ symptoms 
recorded, using questionnaires/symptom scores as appropriate 
• 
Patients and their doctors are informed of their result, and if there is any risk to their 
relatives arises, possibility of contact to family members is discussed  
 
 
Schedule of Assessment (in Diagrammatic Format)  
 
 
Initial visit 
Intervention 
Follow up 
Assessment  
Screening 
endocrine 
patients 
Control 
patients 
Normal 
volunteers 
Family 
member 
of 
affected 
patient 
Treatment 
of 
endocrine 
patients 
Follow up 
visits  
History and / 
or physical 
x 
x 
x 
x 
x 
x 
Weight / 
height 
x 
x 
x 
x 
x 
x 
Imaging 
(MRI/CT/X-
ray) 
x 
 
 
If 
indicated 
x 
x 
ECG 
x 
x 
x 
x 
x 
 
Saliva 
x 
x 
x 
x 
 
x 
Urine 
x 
x 
x 
x 
x 
x 
Blood tests 
x 
x 
x 
x 
x 
x 
Biopsy / FNA 
x 
x 
x 
If 
indicated 
 
x (if 
recurrence) 
Fresh tissue 
samples 
 
x 
x 
If 
indicated 
x 
x (if 
recurrence) 
Fresh frozen 
samples 
 
x 
x 
 
x 
X (if 
recurrence) 
Adjacent 
normal tissue 
samples 
 
x 
 
 
x 
 
Hair samples 
x 
x 
x 
x 
 
 
Nail clippings 
x 
x 
x 
x 
 
 
 
 

                                                                                                                    
 
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Samples will be studied for DNA, RNA, 
protein content, hormone levels, plus tumour tissue will be processed to commence primary 
cell culture, extract RNA / DNA and next generation sequencing analysis. 
 
End of Study Definition  
This is an observational study which observes patients for the remainder of their lifespan to 
enable us to establish the natural history of these rare diseases.  Many of these tumours are 
known to recur or are associated with other tumour development, hence there is a need for 
long-term follow-up.  Patients will remain in the study indefinitely unless they withdraw. 
 
9 
STATISTICAL CONSIDERATIONS  
We have an established collaboration with Dr Jonathan Bestwick, a statistician at the 
Wolfson Institute. 
 
- Sample Size  
This is a nationwide observational study on endocrine tumours and their related novel 
diseases, where classical sample size calculations cannot be performed. We have 
setup a large, international patient cohort and plan to collect samples and patient 
outcome data for the next 30 years at least. 
 
- Method of Analysis  
- Descriptive demographic and treatment data will be analysed with group comparison 
tests (two-sample or multi-sample, parametric or nonparametric) and correlations will 
be calculated.  
Regular interim analysis will be performed throughout the duration of this research, and at 
the end of individual projects (PhD, post doc – i.e. every 2-4 years).   
 
 
10 
ETHICS  
Patients and suitable control subjects will be identified as outlined above and approached 
either in clinic or via their primary physician, to request that they enrol in the study.  Some 
patients contact us directly via the website or after receiving information regarding our study 
by other clinicians.  They are given information leaflets outlining what our study aims to 
achieve, and what we will do with the samples we take.  They will understand that they can 
refuse or change their mind at any time.  They will also be informed that they can access the 
results but will be made aware that these are long term studies and that results may take 
years.  We will explain that nothing we do will interfere with their diagnosis / staging or with 
the subsequent treatment that they may require.  Control patients will also be provided with 
information regarding our study, plus an outline of why we need healthy tissue for 
comparison and reassurance that they should not suffer any adverse outcome as a result of 
being included in this study.  Patients or family members detected as carrying oncogenic 
mutations will be referred to an appropriate genetic counselling service, and followed up as 
appropriate.  The same will be done for any family member unexpectedly diagnosed with a 
tumour during the study. 

                                                                                                                    
 
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11 
SAFETY CONSIDERATIONS: 
This is a well-established observational study and there have been no safety issues related 
to this study.  Any adverse events arising will be handled as detailed below. 
 
12 
DATA HANDLING AND RECORD KEEPING:  
- Confidentiality 
Information related to participants are kept confidential and managed in accordance 
with the Data Protection Act, NHS Caldecott Principles, The Research Governance 
Framework for Health and Social Care, and the conditions of Research Ethics 
Committee Approval. 
 
- Record Retention and Archiving 
Archiving of study data will follow Barts Health rules according to requirement of 
the Research Governance Framework and Trust Policy for the 20 years following 
data collection. 
 
- Anonymization of samples: 
All human tissue material, whether cellular or non-cellular, will be handled according 
to the requirements of current legislation.  Samples will be link-anonymised (if 
consent permits) or anonymised, with the link-file kept is a secure location with 
access restricted to authorised staff, in accordance with ethical approval.  All material 
transferred, stored or exported will only be with appropriate consent or ethical 
approval in anonymised form, with the identity of the donor withheld.  In the event of 
a finding of potential clinical significance to donors or their relatives this will be 
notified to the originating institution using the anonymised code.  In such an event, a 
decision will be made by the originating institution team as to whether the identity of 
the donor should be determined using the link file for notification through the ‘normal 
care’ or research team as appropriate. 
- The General Data Protection Regulation (GDPR) (Regulation (EU) 2016/679): 
All data will be handled in compliance with current legislation such as the Data 
Protection Act, in accordance with Ethical Approval, or with any subsequent legislation 
such as the proposed General Data Protection Regulations of the European Union or 
successor body as applicable to the UK in the event of future developments.  
 
 
13 
LABORATORIES (if applicable) 
Refer to Methods section in Methodology. 
 
- Central/Local Laboratories  
At the start of this project all the genetic screening of patients was performed in our research 
laboratory at Bart’s. However, since that time, for the AIP gene the molecular genetics 
laboratory at the Royal Devon & Exeter Hospital, a CPA accredited NHS/Research 
laboratory, has set up a comprehensive service and we collaborate with them on the 
analysis of the samples. Most genetic testing of known or novel genes and areas will be 
performed at the CPA accredited molecular genetics laboratory in Exeter or at our research 

                                                                                                                    
 
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laboratories 
at 
Bart’s 
and 
Oxford. 
Additional analysis of anonymous samples may also be undertaken by a specialist 
laboratory (or laboratories), as required.  These sites may include our collaborators Dr Elaine 
Harper at Syntaxin, Oxford, Prof Eamonn Maher at the University of Birmingham and 
Cambridge, Prof Rainer Cramer at the University of Reading, Prof Eyal Gottlieb and Dr 
Simone Cardaci at the Beatson Institute Glasgow and the Institute of Cancer Research, 
London, Prof Christian Strasburger, at Charite University Berlin and Ingemar Pongratz, 
Karolinska Institutet, Stockholm, Sweden.   Dr. Adrian Covaci, Toxicological Center, 
University of Antwerp, Charing Cross Hospital, Prof. Charles Swanton, The Francis Crick 
Institute in London, Dr Michael Themis, Brunel University and Prof. Ralf Kuppers, University 
of Duisburg-Essen. Craniopharyngiomas may be assessed by specialist pathologists 
Professor Teresa Ribalta Farres (Barcelona Childrens’ Hospital) and Associate Professor 
Gaetano Bulfamante (Universita Degli Studi Di Milano)   
 
 
- Lab Procedures  
 
Routine clinical care: DNA sequence determination, routine hormone level 
investigations, imaging studies, urinalysis, surgical intervention / biopsy 
 
 
Non-Routine clinical care: RNA expression determination, protein expression 
determination, circulating novel hormone level determination, in vitro tissue culture, 
next generation sequencing, DNA sequence determination, sample collection (serum, 
blood, hair, nail, urine, saliva). 
 
- Data Preparation and Collection 
- Sample labelling will be according to individually generated study codes. 
- We have an established set of tumour specific databases to record samples as they 
arrive / leave our facility via an in and out log.  
- Samples are kept according to nature of the sample (room temperature, -20 or -80 
freezers)  
- Samples are stored in dedicated cabinets and temperature monitored freezers  
 
14 
 PRODUCTS, DEVICES, TECHNIQUES AND TOOLS  
Devices 
N/A 
 
Techniques and interventions 
N/A 
 
Tools 
N/A 
 
Medicinal product  
N/A – This is an observational study and therefore any procedures we perform on these 
tissues will not impact the patient in any way.  
  

                                                                                                                    
 
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15 
SAFETY REPORTING  
Adverse Events (AE) 
We have established protocols for reporting adverse events should they arise.  Any clinical 
adverse event arising secondary to this study will be reported via the standard reporting 
system of the relevant trust, and also reported to the PI. 
 
Serious Adverse Event (SAE) 
As above, but in this case the R&D office will also be notified. 
 
Urgent Safety Measures 
N/A 
 
Annual Safety Reporting  
We perform an annual audit to review any safety and adverse events arising, and will alter 
protocols if necessary to minimise future risk.  If this is required R&D will be informed. 
 
Overview of the Safety Reporting responsibilities 
The CI/PI has the overall pharmacovigilance oversight responsibility. The CI/PI has a duty to 
ensure that safety monitoring and reporting is conducted in accordance with the sponsor’s 
requirements.  
 
The study coordinator and PI are responsible for safety reporting. 
 
16 
MONITORING & AUDITING 
The local HTA committee regularly monitors our activities and record keeping  
SOPs are kept updated for all activities. GCP training is up to date for all study personnel 
and all follow GCP rules.  
 
17 
TRIAL COMMITTEES 
The trial management committee consists of: 
Professor Sian Ellard, Professor Ashley Grossman and Professor Marta Korbonits 
 
18 
FINANCE AND FUNDING 
The study has received funding from MRC, Wellcome, BTLC, Pfizer, NIHR, The Royal 
Society, Mexican government grant scheme and we plan to apply for funding for research 
council and charity grants and investigator initiated pharmaceutical funding in the future. 
 
19 
INDEMNITY  
Queen Mary University London is the sponsor of this study and provided the necessary 
indemnity. 
 

                                                                                                                    
 
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20 
DISSEMINATION OF RESEARCH FINDINGS: 
Study results are disseminated in scientific literature (JCEM, NEJM, Clinical Endocrinology, 
Trends of Endocrinology and Metabolism, Journal of Endocrine Investigation, etc), via the 
media (BBC), via patient website (www.fipapatients.org), patient meetings and via talks on 
conferences (ENDO, ECE, BES, Pituitary meeting) and teaching courses organised in the 
UK and abroad. 
 
 

                                                                                                                    
 
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21 
REFERENCES 
1. 
Asa SL, Ezzat S. The pathogenesis of pituitary tumours. Nat Rev Cancer. 
2002;2(11):836-49. 
2. 
Hanahan D, Weinberg RA. The hallmarks of cancer. Cell. 2000;100(1):57-70. 
3. 
Hayward BE, Barlier A, Korbonits M, Grossman AB, Jacquet P, Enjalbert A, et al. 
Imprinting of the G(s)alpha gene GNAS1 in the pathogenesis of acromegaly. J Clin 
Invest. 2001;107(6):R31-6. 
4. 
Korbonits M, Bustin SA, Kojima M, Jordan S, Adams EF, Lowe DG, et al. The 
expression of the growth hormone secretagogue receptor ligand ghrelin in normal and 
abnormal human pituitary and other neuroendocrine tumors. J Clin Endocrinol Metab. 
2001;86(2):881-7. 
5. 
Korbonits M, Bustin SA, Grossman AB, editors. Ghrelin, GHS-R type 1a and 1b 
expression in gsp negative and positive pituitary tumors. 83rd Annual Meeting of the 
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