Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures (Cancer Growth and Progression, Volume 13)

Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures Cancer Growth and Pr...

Author: Boris R. Minev

77 downloads 1996 Views 10MB Size Report

This content was uploaded by our users and we assume good faith they have the permission to share this book. If you own the copyright to this book and it is wrongfully on our website, we offer a simple DMCA procedure to remove your content from our site. Start by pressing the button below!

Report copyright / DMCA form

DOWNLOAD PDF

Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures

Cancer Growth and Progression Volume 13 Founding Editor Hans E. Kaiser† , D. Sc. Series Editors Aejaz Nasir, M.D., M.Phil., FCAP Department of Interdisciplinary Oncology-Pathology, Moffit Cancer Center & Research Institute, Tampa, FL, U.S.A. Timothy J. Yeatman, M.D. Professor of Surgery, Executive Vice President Translational Research, President & Chief Scientific Officer M2Gen, Moffit Cancer Center & Research Institute, Tampa, FL, USA

For further volumes: http://www.springer.com/series/5721

Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures

Edited by Boris R. Minev Moores UCSD Cancer Center and UCSD Division of Neurosurgery, University of California San Diego (UCSD), La Jolla, CA, USA Genelux Corporation, San Diego Science Center, San Diego, CA 92109, USA

13

Editor Boris R. Minev Moores UCSD Cancer Center and UCSD Division of Neurosurgery University of California San Diego (UCSD) 3855 Health Sciences Drive 0820 92093-0820 La Jolla CA, USA and Genelux Corporation San Diego Science Center San Diego, CA 92109 USA [email protected]

ISBN 978-90-481-9703-3 e-ISBN 978-90-481-9704-0 DOI 10.1007/978-90-481-9704-0 Springer Dordrecht Heidelberg London New York © Springer Science+Business Media B.V. 2011 No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the Publisher, with the exception of any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Cover illustration: Tumor therapy with vaccinia virus. Mice were i.v. injected with a single dose (1 × 107 pfu per mice) of the light-emitting oncolytic vaccinia virus GLV-1h68 (row 2–4) or PBS control (row 1) 30 d after breast tumor cell implantation. Bright field photographs (left column), GFP fluorescence images (middle column), and immunohistochemical analyses of expression of GLV-1h68-encoded β-galactosidase (right column) in tumors were done 14 (row 2), 28 (row 1 and 3), and 56 d (row 4) after virus or PBS injection. Two weeks after virus injection, strong fluorescence of GFP was seen in tumors with a volume of ∼1400 mm3 . An additional 2 wk later, a much reduced GFP fluorescence was observed at tumor size of ∼480 mm3 in the same mouse. After 56 d, no GFP fluorescence was seen in the tumor which was ∼180 mm3 in size. β-galactosidase activity was detected concomitant with light emission and was completely eliminated as light emission was extinguished. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Dedicated to Professor Hans E. Kaiser, an unforgettable mentor, colleague and friend. Boris R. Minev

Contents

Part I

Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

1 Plant-Derived Natural Products as Anticancer Agents . . . . . . . . David G.I. Kingston

3

2 The Vinca Alkaloids . . . . . . . . . . . . . . . . . . . . . . . . . . . Nicole Coufal and Lauge Farnaes

25

3 Taxanes and Epothilones in Cancer Treatment . . . . . . . . . . . . Edward F. McClay

39

4 Alkylating Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laurent Gate and Kenneth D. Tew

61

5 Anthracyclines and Anthracenediones . . . . . . . . . . . . . . . . Nicole Coufal and Lauge Farnaes

87

6 Topoisomerase I Inhibitors – The Camptothecins . . . . . . . . . . Michael Newton, Gene Wetzstein, and Daniel Sullivan

103

7 Folate Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alex Ko

125

8 Platinum Complexes for the Treatment of Cancer . . . . . . . . . . David Roberts, Peter J. O’Dwyer, and Steven W. Johnson

145

9 Hormonal Therapy in Cancer . . . . . . . . . . . . . . . . . . . . . Soe T. Maunglay, Julia A. Cogburn, and Pamela N. Munster

165

10

Effects of Cancer Chemotherapy on Gonadal Function . . . . . . . Angela R. Bradbury and Richard L. Schilsky

11

Targeting the Tumor Microenvironment for Enhancing Chemotherapy in Hematologic Malignancies . . . . . . . . . . . . . Luis A. Crespo, Xinwei Zhang, and Jianguo Tao

Part II 12

191

215

Biological Therapy . . . . . . . . . . . . . . . . . . . . . . . . .

235

Cytokines in the Treatment of Cancer . . . . . . . . . . . . . . . . . Adrian Bot

237

vii

viii

Contents

13 Antibody-Based Therapies for Solid Tumors . . . . . . . . . . . . . Satish Shanbhag and Barbara Burtness

245

14 Cancer Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stephanie Schroter, Melanie Hayden, Wenxue Ma, Nellia Fleurov, Neha Rahan, and Boris R. Minev

257

15 Adoptive Immunotherapy of Cancer Using Autologous Lymphocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yoshiyuki Yamaguchi, Riki Okita, Akiko Emi, Katsuji Hironaka, Makoto Okawaki, Takuhiro Ikeda, Masahiro Ohara, Ichiro Nagamine, and Jun Hihara

285

16 Oncolytic Virotherapy of Cancer . . . . . . . . . . . . . . . . . . . Nanhai G. Chen and Aladar A. Szalay

295

Part III Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

317

17 Protein Kinase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . Daanish Hoda and Adil Daud

319

18 Inhibitors of Tumor Angiogenesis . . . . . . . . . . . . . . . . . . . Anaadriana Zakarija and William J. Gradishar

331

19 Transcatheter Management of Neoplasms . . . . . . . . . . . . . . Christos S. Georgiades and Jean-Francois Geschwind

341

20 Tumor Stem Cells: Therapeutic Implications of a Paradigm Shift in Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . Neil H. Riordan, Thomas E. Ichim, Famela Ramos, Samantha Halligan, Rosalia De Necochea-Campion, Grzegorz W. Basak, Steven F. Josephs, Boris R. Minev, and Ewa Carrier

349

Part IV Hyperthermia . . . . . . . . . . . . . . . . . . . . . . . . . . . .

363

21 Induced Hyperthermia in the Treatment of Cancer . . . . . . . . . Bert Hildebrandt, Johanna Gellermann, Hanno Riess, and Peter Wust

365

Part V

Supporting Measures . . . . . . . . . . . . . . . . . . . . . . . .

379

22 Hematologic Support of the Patient with Malignancy . . . . . . . . Thomas A. Lane

381

23 Current Status of Bone Marrow Transplantation for Treatment of Cancer . . . . . . . . . . . . . . . . . . . . . . . . Edward D. Ball, Asad Bashey, Ewa Carrier, Januario E. Castro, Peter Holman, and Thomas A. Lane 24 Pain Management in Cancer Patients . . . . . . . . . . . . . . . . . Hrachya Nersesyan, Jeffrey J. Mucksavage, Eljim Tesoro, and Konstantin V. Slavin

407

437

Contents

ix

25

Management of Nausea and Vomiting in Cancer Patients . . . . . . Rudolph M. Navari, Paula P. Province, and Steven D. Passik

453

26

Nutrition in the Management of the Cancer Patient . . . . . . . . . Cheryl L. Rock

473

27

Predictive Value of IFN-γ γ-Induced Indoleamine 2,3-Dioxygenase (IDO) Expression in Cancer Patients . . . . . . . . G. Brandacher, A. Amberger, K. Schroecksnadel, R. Margreiter, and Dietmar Fuchs

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

495

509

Contributors

A. Amberger Department of General and Transplant Surgery, Tyrolean Cancer Research Institute, Innsbruck Medical University, Innsbruck, Austria, [email protected] Edward D. Ball Department of Medicine and Moores UCSD Cancer Center, La Jolla, CA 92093-0960, USA, [email protected] Grzegorz W. Basak Department of Hematology, Oncology and Internal Diseases, Medical University of Warsaw, Warszawa, Poland, [email protected] Asad Bashey Department of Medicine and Moores UCSD Cancer Center, La Jolla, CA 92093-0960, USA, [email protected] Adrian Bot Scientific Management, MannKind Corporation, Valencia, CA 91354, USA, [email protected] Angela R. Bradbury Department of Medicine, Fox Chase Cancer Center, Philadelphia, PA 19111, USA, [email protected] G. Brandacher Department of General and Transplant Surgery, Tyrolean Cancer Research Institute, Innsbruck Medical University, Innsbruck, Austria, [email protected] Barbara Burtness Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111-2497, USA, [email protected] Ewa Carrier Moores UCSD Cancer Centre, San Diego, CA, USA, [email protected] Januario E. Castro Department of Medicine and Moores UCSD Cancer Center, La Jolla, CA 92093-0960, USA, [email protected] Nanhai G. Chen Genelux Corporation, San Diego Science Center, San Diego, CA, USA, [email protected] Julia A. Cogburn Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center, Experimental Therapeutics and Breast Medical Oncology, 12902 Magnolia Dr, Tampa, FL 33612, USA Nicole Coufal UCSD Department of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA, [email protected]

xi

xii

Luis A. Crespo Hematopathology and Laboratory Medicine, University of South Florida College of Medicine, H. Lee Moffitt Cancer Center and Research Institute, 12901 Magnolia Drive, Tampa, FL 33612, USA Adil Daud Department of Medicine, Division of Hematology Oncology, University of California, 1600 Divisadero Street, San Francisco, CA 94010, USA, [email protected], [email protected] Rosalia DeNecochea-Campion Moores UCSD Cancer Centre, San Diego, CA, USA, [email protected] Akiko Emi Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima 734-8553, Japan Lauge Farnaes UCSD Department of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA, [email protected] Nellia Fleurov Moores UCSD Cancer Center, La Jolla, CA 92093-0820, USA, [email protected] Dietmar Fuchs Department of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria, [email protected] Laurent Gate INRS, 54000 Nancy, France Johanna Gellermann Klinik für Strahlenheilkunde, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Humboldt-Universität, D-13344 Berlin, Germany, [email protected] Christos S. Georgiades Division of Vascular and Interventional Radiology, Department of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD 21287, USA, [email protected] Jean-Francois Geschwind Division of Vascular and Interventional Radiology, Department of Vascular and Interventional Radiology, The Johns Hopkins Hospital, MD, Baltimore 21287, USA William J. Gradishar Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Feinberg School of Medicine, 676 N. St. Clair, Suite 850, Chicago, IL 60611, USA, [email protected] Samantha Halligan Moores UCSD Cancer Centre, San Diego, CA, USA, [email protected] Melanie Hayden Moores UCSD Cancer Center, La Jolla, CA 92093-0820, USA, [email protected] Jun Hihara Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima 734-8553, Japan Bert Hildebrandt Medizinische Klinik für Hämatologie und Onkologie, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Humboldt-Universität, D-13344 Berlin, Germany, [email protected]

Contributors

Contributors

xiii

Katsuji Hironaka Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima 734-8553, Japan Daanish Hoda Division of Hematology Oncology, Department of Medicine, University of California, 1600 Divisadero Street, San Francisco, CA 94010, USA Peter Holman Department of Medicine and Moores UCSD Cancer Center, La Jolla, CA 92093-0960, USA, [email protected] Thomas E. Ichim Medistem Inc, San Diego, CA, USA, [email protected] Takuhiro Ikeda Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima 734-8553, Japan Steven W. Johnson Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA 19104, USA, [email protected] Steven F. Josephs Therinject LLC, San Diego, CA, USA, [email protected] David G.I. Kingston Department of Chemistry, M/C 0212, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA, [email protected] Alex Ko UCSD Department of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA, [email protected], [email protected] Thomas A. Lane UCSD Transfusion Services and Stem Cell Processing Lab, Moores UCSD Cancer Center, La Jolla, CA 92093-0960, USA, [email protected] Wenxue Ma Moores UCSD Cancer Center, La Jolla, CA 92093-0820, USA, [email protected] R. Margreiter Department of General and Transplant Surgery, Tyrolean Cancer Research Institute, Innsbruck Medical University, Innsbruck, Austria Soe T. Maunglay Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center, Experimental Therapeutics and Breast Medical Oncology, 12902 Magnolia Dr, Tampa, FL 33612, USA Edward F. McClay Melanoma Research Center, Pacific Oncology and Hematology Associates, San Diego, CA, USA, [email protected], [email protected] Boris R. Minev Moores UCSD Cancer Center and UCSD Division of Neurosurgery, La Jolla, CA 92093-0820, USA; Genelux Corporation, San Diego Science Center, San Diego, CA 92109, USA, [email protected] Jeffrey J. Mucksavage Department of Pharmacy Practice, University of Illinois at Chicago, 833 South Wood Street, Chicago, IL 60612, USA Pamela N. Munster Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center, Experimental Therapeutics and Breast Medical Oncology, 12902 Magnolia Dr, Tampa, FL 33612, USA, [email protected]

xiv

Ichiro Nagamine Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima 734-8553, Japan Rudolph M. Navari Department of Medicine, Indiana University School of medicine South Bend, South Bend, IN 46617, USA, [email protected] Hrachya Nersesyan Illinois Neurological Institute, OSF Saint Francis Medical Center, 530 N.E. Glen Oak Avenue, Peoria, IL 61637, USA, [email protected] Michael Newton Department of Clinical Pharmacy, West Virginia University School of Pharmacy and Mary Babb Randolph Cancer Center, Morgantown, WV 26506, USA Peter J. O’Dwyer Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA 19104, USA Masahiro Ohara Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima 734-8553, Japan Makoto Okawaki Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima 734-8553, Japan Riki Okita Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima 734-8553, Japan Steven D. Passik Sloan Kettering Cancer Center, Cornell University School of Medicine, New York, NY, USA Paula P. Province Walther Cancer Research Center, University of Notre Dame, South Bend, IN 46617, USA Famela Ramos Medistem Inc, San Diego, CA, USA, [email protected] Neha Rahan Moores UCSD Cancer Center, La Jolla, CA 92093-0820, USA, [email protected] Hanno Riess Medizinische Klinik für Hämatologie und Onkologie, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Humboldt-Universität, D-13344 Berlin, Germany Neil H. Riordan Medistem Inc, San Diego, CA, USA, [email protected] David Roberts Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA 19104, USA Cheryl L. Rock Department of Family and Preventive Medicine, and Cancer Prevention and Control Program, School of Medicine, University of California, San Diego, CA, USA, [email protected] Richard L. Schilsky Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA, [email protected]

Contributors

Contributors

xv

K. Schroecksnadel Department of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria Stephanie Schroter Moores UCSD Cancer Center, La Jolla, CA 92093-0820, USA, [email protected] Satish Shanbhag Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111-2497, USA, [email protected] Konstantin V. Slavin Section of Functional and Stereotactic Neurosurgery, Department of Neurosurgery, University of Illinois at Chicago, 912 South Wood Street, Chicago, IL 60612, USA, [email protected] Daniel Sullivan Experimental Therapeutics Program and Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA, [email protected] Aladar A. Szalay Genelux Corporation, San Diego Science Center, San Diego, CA 92109, USA; Rudolf Virchow Center for Experimental Biomedicine, Institute for Biochemistry and Institute for Molecular Infection Biology, University of Würzburg, Würzburg, Germany; Department of Radiation Oncology, Rebecca and John Moores Comprehensive Cancer Center, University of California, San Diego, CA, USA, [email protected] Jianguo Tao Hematopathology and Laboratory Medicine, University of South Florida College of Medicine, H. Lee Moffitt Cancer Center and Research Institute, 12901 Magnolia Drive, Tampa, FL 33612, USA, [email protected] Eljim Tesoro Department of Pharmacy Practice, University of Illinois at Chicago, 833 South Wood Street, Chicago, IL 60612, USA Kenneth D. Tew Department of Pharmacology, Medical University South Carolina, 173 Ashley Ave, Charleston, SC 29466, USA, [email protected] Gene Wetzstein Malignant Hematology Program and Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA Peter Wust Klinik für Strahlenheilkunde, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Humboldt-Universität, D-13344 Berlin, Germany Yoshiyuki Yamaguchi Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima 734-8553, Japan, [email protected] Anaadriana Zakarija Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Feinberg School of Medicine, 676 N. St. Clair, Suite 850, Chicago, IL 60611, USA, [email protected] Xinwei Zhang Hematopathology and Laboratory Medicine, University of South Florida College of Medicine, H. Lee Moffitt Cancer Center and Research Institute, 12901 Magnolia Drive, Tampa, FL 33612, USA

Part I

Chemotherapy

Chapter 1

Plant-Derived Natural Products as Anticancer Agents David G.I. Kingston

1.1 Introduction and Scope Natural products have proved to be an excellent source of lead compounds for anticancer drug discovery, and a recent survey by Newman et al. indicates that 40% of all the anticancer drugs developed before 2002 are natural products, while another 20% are synthetic compounds based on a natural product pharmacophore [1]. In addition to the three plant-derived natural products discussed in this chapter, several other natural products or modified natural products are in current clinical use as cancer chemotherapeutic agents. Many of these are microbial products, and are often referred to as antibiotics. The anthracycline antibiotics include daunorubicin, doxorubicin, and the newer epirubicin and idarubicin [2, 3]. The phenoxazinone chromopeptide antibiotic antinomycin D is clinically used for the treatment of Wilms’ Tumor in children and of rhabdomyosarcoma, Ewing’s Tumor, and Hodgkin’s disease [4]. The bleomycin group of glycosylated oligopeptide antibiotics is used in combination with other drugs for the treatment of testicular cancers, germ cell ovarian cancers, Hodgkin’s lymphomas, and some non-Hodgkin’s lymphomas [5]. The pyrroloindole antibiotic mitomycin C is used primarily in combination with other drugs, most commonly for the treatment of gastric and pancreatic carcinomas [6]. Several natural products with excellent anticancer activity have been isolated from marine organisms, and

one, ecteinascidin or YondelisTM , is in clinical use. In addition to their coverage in this volume, microbial and marine-derived anticancer agents in clinical use or in clinical trials are discussed in a recent book [7]. The plant kingdom has provided four current clinical agents or groups of related agents: the podophyllotoxin derivatives etoposide (VP16–213) and teniposide (VM26), the taxanes paclitaxel (TaxolTM ) and docetaxel (TaxotereTM ), the camptothecin analogs topotecan (HycamptinTM ) and irinotecan (CamptosarTM ), and the Vinca alkaloids vinblastine, vincristine, and the semisynthetic analog vinorelbine. The Vinca alkaloids are discussed in another chapter in this volume, and so this chapter covers the podophyllotoxin derivatives, the taxanes, and the camptothecin derivatives.

1.2 Podophyllotoxin Derivatives 1.2.1 Introduction The podophyllotoxin derivatives etoposide and teniposide are important anticancer drugs in their own right, but they are also important as examples of the development of a toxic natural product into clinically effective drugs with a different mechanism of action than the parent compound. The newer podophyllotoxin derivative etopophos is also included in this discussion.

1.2.2 History D.G.I. Kingston () Department of Chemistry, M/C 0212, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA e-mail: [email protected]

The dried roots and rhizomes of the North American plant Podophyllum peltatum L. (the American

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_1, © Springer Science+Business Media B.V. 2011

3

4

D.G.I. Kingston

mandrake or May apple) and of the related Indian species Podophyllum emodi Wallich have long been known to possess medicinal properties [8]. The major active substance in podophyllin, which is the resin product obtained by extraction of the dried roots and rhizomes with ethanol, was shown to be the lignan lactone podophyllotoxin (2.1), although a variety of other lignans and lignan glycosides have also been isolated from podophyllin. OH O O O O

OCH3

CH3O OCH3

2.1 Podophyllotoxin

Podophyllin was shown by Kaplan in 1942 to have curative effects on the benign tumor Condylomata acuminate [9], and this discovery served to increase interest in this substance. Podophyllin and its constituents were then studied by several investigators, including Jonathan Hartwell at the National Cancer Institute (NCI). These studies led indirectly to the establishment of the very successful NCI program in natural products drug discovery, and so in a real sense podophyllotoxin can be considered to be the “scientific grandfather” of later compounds such as paclitaxel, camptothecin, and a whole group of other compounds in advanced clinical and preclinical development. A review of the chemistry and pharmacology of podophyllin and its constituents summarizes developments to about 1957 [10]. Podophyllotoxin itself is a potent antimitotic agent, but it proved to be too toxic to be useful in the treatment of human neoplasms. A variety of podophyllotoxin derivatives have been isolated from natural sources or prepared by partial synthesis, however, and the two cyclic acetals of 4 -demethylepipodophyllotoxin β-D-glucopyranoside known as etoposide (VP16–213) and teniposide (VM26) gave promising results in both in vitro and in vivo screening trials and were selected for clinical trials. These trials have proved the efficacy of these compounds in treating certain tumors. The remainder of this section will thus be concerned with these two compounds and the newer derivative etopophos.

Information on various aspects of the podophyllotoxin class of compounds, including their use as anticancer agents, is contained in various reviews [11–15].

1.2.3 Chemistry The chemical structures of etoposide (2.2) (VP16–213) and teniposide (2.3) (VM26) are shown below. They differ from podophyllotoxin in having a 4 -hydroxyl group instead of a 4 -methoxyl group, in having the epi configuration at the 4-position, and in having a substituted glucose residue at the 4-position. They differ from each other only in the nature of the substituent on the glucose ring: etoposide is the cyclic acetal prepared from 4 -demethylepipodophyllotoxin β-Dglucopyranoside and acetaldehyde (as its dimethyl acetal), while teniposide is the cyclic acetal prepared when 2-thiophenecarboxaldehyde replaces acetaldehyde [16]. The two compounds are essentially insoluble in water, but are readily soluble in organic solvents such as chloroform.

R

O O HO

O OH

O

O O O O

CH3O

OCH3 OH

2.2 Etoposide R = CH3 2.3 Teniposide R = S

The chemistry and structure-activity relationships of etoposide have been reviewed [17, 18], and it is concluded that there is a great deal of room for additional chemical work on the molecule. The lack of a practical synthetic route to the parent basic aglycone may be a barrier to this work, however. The poor water solubility of etoposide and teniposide make them difficult to administer, and this

1

Plant-Derived Natural Products as Anticancer Agents

led to the development of the water-soluble etoposide phosphate etopophos (2.4) [19]. H3C

O O HO

5

is only weakly active in mouse lung carcinoma assays. This difference of response between species has also been observed with other antineoplastic agents.

O OH

1.2.5 Structure-Activity Studies and Mechanism of Action

O

O O O O

CH3O

OCH3 OPO3H2

2.4 Etopohos

1.2.4 Activity in In Vitro and In Vivo Assay Systems In vitro activity of etoposide and teniposide has been shown against a number of cell lines [8, 16, 20]. Etoposide was active in P-815 murine mastocytoma with an ED50 of 0.031 μg/ml, while teniposide had an ED50 of 0.0048 μg/ml in this system [16]. Human lymphoid cells exposed to etoposide at 1.0 μg/ml for 24 h have the major part of the population arrested with their DNA in the S part of the cell cycle [21]. Other results suggest that etoposide arrests cells in the late S or G2 phases of the cell cycle [20]. In animal studies etoposide is generally more active than teniposide; thus it give an increase in survival time in the L1210 mouse leukemia system of 167%, while teniposide gives a 121% increase in the same system [16]. In a comparative study of various dosage schedules in mice with L1210 leukemia, Dombernowsky and Wissen [22] concluded that etoposide was one of the most active drugs yet tested in the L1210 system. In a discussion of the results of in vitro and in vivo assays, Rose and Bradner [23] point out that etoposide shows a broad-spectrum activity, but there is no correlation in activity for specific histologic types of neoplasms between species. Thus although etoposide shows excellent activity in the L1210 and P-388 leukemia assays, it is not particularly active in human leukemias. On the other hand, etoposide shows good activity in certain types of human lung carcinomas, but

In the initial search for podophyllotoxin derivatives with useful anticancer activity, a large number of modified podophyllotoxins were prepared. Initial findings indicated that some podophyllotoxin derivatives such as podophyllinic acid ethylhydrazide (SP-1) did have some therapeutic activity, but the most active derivatives prepared were those of the type exemplified by etoposide and teniposide. Interestingly, the corresponding compounds in which the 4 -hydroxyl group is methylated (i.e., the epipodophyllotoxin derivatives) are much less active than the corresponding 4 -demethyl-epipodophyllotoxin derivatives. Of the many 4 -demethyl-epipdophyllotoxin β-Dglucopyranoside acetals prepared, etoposide showed the best activity in the L1210 in vivo system, while teniposide was one of the most active derivatives in the P-815 mouse mastocytoma cell assay. Changing the sugar moiety to galactose rather than glucose gave derivatives with lower activity [16]. Various analogs of etoposide modified in the lactone ring have also been prepared, but they were uniformly less active than the parent compound [24]. Interestingly, the modes of action of etoposide and teniposide differ markedly from that of the parent compound podophyllotoxin. Podophyllotoxin is a potent inhibitor of microtubule assembly in vitro, and competitively inhibits the binding of colchicines to microtubules [25, 38]. Because of this property, it arrests cells at mitosis by disrupting the equilibrium between tubulin polymer and tubulin dimer, thereby destroying the cytoskeletal framework from chromosome separation and arresting cell division at the mitotic stage of the cell cycle. Etoposide, teniposide, and etopophos, on the other hand, have a quite different mechanism of action. These compounds arrest cells in the late S and G2 phase of the cell cycle, and have no effect on tubulin assembly. Instead, they induce single strand breaks in DNA (etoposide) or in the DNA in L1210 cells (teniposide) [26–28]. In the case of teniposide, these breaks are predominantly double-stranded. These effects are

6

due to the ability of these compounds to inhibit DNA topoisomerase II (topo II) [29]. DNA topoisomerases are enzymes that allow DNA to coil and uncoil (i.e. change its topology), which is a necessary prelude to mitosis. DNA topoisomerase II mediates double-strand breaks by forming a complex with DNA, the so-called cleavable complex. Etoposide stabilizes this complex and inhibits the enzyme, thus leading to double-strand breaks and ultimately to cell death [30].

1.2.6 Pharmacology Etoposide and teniposide are only sparingly soluble in water, and are supplied for clinical use in nonaqueous formulations. Etoposide is supplied in 5 mL ampules at a concentration of 20 mg/mL, while the teniposide ampules contain 10 mg/mL in a total of 5 mL. Etoposide is also available for oral administration in 10 and 50 mg gelatin capsule formulations [36]. It is stable for at least 3 h in various aqueous solutions, and is stable for up to 72 h in aqueous dextrose or normal saline when its concentration does not exceed 0.25 mg/ml [33]. Dose schedules for etoposide are normally 300– 600 mg/m2 i.v. divided over 3 or 5 days and repeated every 3–4 weeks. For teniposide the schedule for adults is similar, but at a lower dose of 300 mg/m2 . The limiting toxicity in treatment with these drugs is myelosuppression, and hence a lower dose range is indicated for those patients whose bone marrow function has been compromised by prior radiation therapy or chemotherapy. For children, teniposide monotherapy is commonly used at a dose of 150–200 mg/m2 weekly or 100 mg/m2 twice weekly [36]. Studies on the clinical pharmacology of the drugs indicate that absorption from the lipophilic capsules is erratic, but that absorption from oral solution and hydrophilic gelatin capsules is much better. Plasma levels of unchanged drug have been monitored both by thin layer chromatography and high performance liquid chromatography (HPLC), and these studies have shown that etoposide has a shorter terminal half-life than teniposide Both drugs are reported to have activity against intracranial neoplasms, with most work having been done on teniposide. Only low levels of this drug have been found in the cerebrospinal fluid, however; typically these levels were 0.2–14.3% of the plasma levels found in the same patient [35].

D.G.I. Kingston

Excretion of both drugs is primarily in the urine, with approximately 50% of the administered radioactivity being recovered in the urine within 72 h of administration. Fecal excretion is variable, with amounts varying from 0 to 16% of the administered radioactivity being recovered in the feces of patients administered intravenous [3 H]etoposide. In the case of [3 H]teniposide, only 21% of the radioactivity recovered in the urine corresponded to unchanged drug, with the major metabolite being the ring-opened lactone 4 -demethyl-epipodophyllic acid-9-(4,6-O-ethylideneβ-D-glucopyranoside). In the case of [3 H]etoposide, 67% of the urinary radioactivity was in the form of unchanged drug, and the major metabolite has been shown to be the acid corresponding to the major metabolite of teniposide [31, 32]. The chemotherapy and pharmacology of the podophyllotoxin derivatives etoposide and teniposide have been discussed extensively in various reviews [33–39], and these reviews provide convenient sources of additional information on the subject. Reviews of the clinical pharmacology of etoposide in adults [40] and in children [41] have also appeared.

1.2.7 Clinical Single Agent Activity The composite response rates for etoposide and teniposide have been compiled by Issell [36], and a more recent review by Hande gives the single agent response rates for etoposide [42]. Etoposide is one of the most active single agents in small lung cancer with a composite single agent response rate of 44% in previously untreated patients, and a 13% response rate in previously treated patients [43]. Teniposide has been less thoroughly evaluated in this cancer, but preliminary results show a 28% response rate with 8% complete responses in one trial. For testicular cancer, response rates of up to 33% are reported with etoposide, and activity is retained even in patients refractory to front-line combination therapy [44]. Teniposide has not been adequately tested in this situation. Both etoposide and teniposide show activity against Hodgkin’s disease and other malignant lymphomas, with especially encouraging results in treatment of diffuse histocytic lymphoma with etoposide in patients who had become refractory to front-line combination chemotherapy.

1

Plant-Derived Natural Products as Anticancer Agents

Etoposide shows some activity against adult acute myelogenous leukemia, with a good response rate for patients with myelomonocytic and monocytic leukemia. Teniposide and etoposide are both useful in pediatric leukemia, with teniposide showing activity against refractory acute lymphoblastic leukemia and etoposide against acute monocytic leukemia. Etoposide and teniposide both have meaningful activity in pediatric refractory neuroblastoma, with responses in up to 50% of the patients evaluated. Teniposide appears to have some activity in brain tumors, with responses in up to 35% of the patients evaluated; responses were seen in patients who were progressing on nitrosoureas. Etoposide has some effect on breast cancer, with useful partial responses reported for 17% of heavily pretreated patients. Finally, etoposide has activity against Kaposi’s sarcoma associated with acquired immunodeficiency syndrome (AIDS); it is the most active single agent tested to date, with a response rate of 34% [45, 46]. Etopophos is essentially a prodrug form of etoposide, since it is converted to this compound by endogenous phosphatases; it thus has a similar pharmacological profile to etoposide [42]. It has improved water-solubility as compared with etoposide, and it also has a higher bioavailability than etoposide. It is has thus been preferred for clinical use since its approval by the FDA in 1996, although its higher cost may be a factor in some cases [42].

7

of multi-drug treatment protocols for non-Hodgkins lymphomas, refractory childhood leukemia, various lymphomas, and other types of cancer [13, 36, 47].

1.2.9 Toxicity The two dose-limiting toxic effects of etoposide and teniposide are myelosuppression and gastrointestinal disturbances, with the former being the more important since the latter effect is usually easily controlled. Other toxicities include alopecia, and less commonly peripheral neuropathy and acute toxicities such as fever, chills, hypertension, and brochospasm [36].

1.2.10 New Analogs in Development Several new analogs of podophyllotoxin are in development, and three have reached clinical trials. The derivative NK-611 (2.5) differs from etoposide only in having an dimethylamino group in place of the 2-OH group of glucose [49]. Clinical tests of NK-611 suggest that it has better bioavailability than etoposide, but evidence for cross-resistance between etoposide and NK-611 was found [15]. H3C

O O HO

O NMe2 O

1.2.8 Clinical Combination Therapy O

O

The drugs etoposide and teniposide are suitable candidates for combination therapy, since their toxicity is relatively low and they have unique modes of action. At this point, a number of combinations have been tested in experimental animals, but only a few are at the point where they are clinically useful. The most interesting situation to date is that of the combination of teniposide with cytarabine (ara C) in the treatment of refractory pediatric acute lymphoblastic leukemia. The drugs are reported to show a synergistic effect, and in one study 9 of 14 patients achieve complete remission after they had failed remission induction with standard therapy [13, 47, 48]. Etoposide is effective in combination with cisplatin for treatment of small cell lung cancer, non-small cell lung cancer, and refractory testicular cancer. It is also used as part

O O

CH3O

OCH3 OH

2.5 NK - 611

The derivative GL-331 (2.6) is a 4β-arylamino analog of etoposide in which the sugar moiety is replaced by a p-nitro anilino group. GL-331 is more active than etoposide in causing DNA double-strand breakage and G2-phase arrest [50], and it is also more potent against tumor cells both in vitro and in vivo. Initial results from Phase I clinical trials in non-small and small cell lung, colon, and head/neck cancers were encouraging, with

8

D.G.I. Kingston

minimal side effects. Phase II clinical evaluation in gastric cancer patients, however, showed no objective response [51]. NO2

HN O O O

is a standard agent in the treatment of small cell lung cancer, testicular cancer, and lymphomas, and it also has activity against monocytic or myelomonocytic leukemia, non-Hodgkin’s lymphomas, and hepatocellular carcinoma. Teniposide has a role in the treatment of Hodgkin’s disease, non-Hodgkin’s lymphomas, neuroblastoma, and childhood acute lymphoblastic leukemia. New analogs of etoposide have been developed and are at various stages of clinical trial [15], and prospects are good that improved analogs will contribute significantly to cancer chemotherapy.

O

CH3O

1.3 Paclitaxel

OCH3 OH

1.3.1 Introduction

2.6 GL - 331

The derivative TOP-53 (2.7) is an aminopodophyllotoxin derivative [52]. It was a more potent inhibitor of topoisomerase II than etoposide, and showed excellent activity against a mutant yeast type II enzyme highly resistant to etoposide. TOP-53 exhibited especially high activity against non-small cell lung cancer in both tumor cells and animal tumor models [53]. This compound is currently in phase I clinical trials. NMe2

N

O O O O

CH3O

OCH3

When the first edition of this book was published in 1989, paclitaxel (TaxolTM ) merited only three paragraphs of text, as an interesting compound in development. What a difference 15 years makes! Paclitaxel is now a widely used chemotherapeutic agent and it has been joined by its semisynthetic derivative docetaxel (TaxotereTM ). Several additional analogs are in development, with six currently in clinical trials. The diterpenoid paclitaxel (3.1) was first reported by Wani and Wall in 1971 [54], and emerged from being a laboratory curiosity in the 1970s and 1980s to a drug of major clinical importance in the 1990s. It is currently approved for the treatment of breast and ovarian cancers and for AIDS-related Kaposi’s sarcoma, and it is also used or under investigation for the treatment of a number of other cancers [55]. The combined annual sales of it and its semisynthetic analog docR [56]) (3.2) are well over $1 billion. etaxel (Taxotere

OH 2.7 TOP - 53

R2O

O

OH

O R1

1.2.11 Conclusion

NH

O

Ph OH

The modified podophyllotoxin derivatives etoposide and teniposide have demonstrated significant clinical activity in treatment of several tumors. Etoposide

O

O OH PhCOO

3.1 R1 = C6H5, R2 = Ac 3.2 R1 = Me3CO, R2 = H

OAc

1

Plant-Derived Natural Products as Anticancer Agents

1.3.2 History Taxol was discovered as a fruit of a systemic search by the National Cancer Institute (NCI) for naturally occurring anticancer agents. A sample of the bark of the western yew, Taxus brevifolia, was collected in 1962, and an extract of the bark was found to be cytotoxic to KB cells. The extract was assigned to Dr. Monroe Wall and his team at the Research Triangle Institute (RTI), and taxol (as it was then known) was isolated in 1967. The structure was not published until 1971, however, in part because of its complexity. Paclitaxel (3.1) is a complex diterpenoid with a phenylisoserine side chain, and its structure was finally solved by a combination of chemical degradations and x-ray crystallography [57]. The selection of T. brevifolia by the original collectors turns out in retrospect to have been providential. Had a different yew species been investigated, it is likely that fractionation would have led to the isolation of toxic taxine alkaloids as the cytotoxic constituents, and the smaller amounts of taxol present might have gone undetected [58]. The initial reaction to the discovery of paclitaxel was underwhelming. It has a very complex structure, and it was thus essentially inaccessible by synthesis, and it was only available in low yield from T. brevifolia. The supply of enough compound for clinical use was thus a major problem. In addition, it is very insoluble in water, so formulation was also clearly going to be a major problem. Small wonder then that the compound languished for several years before it was brought to clinical trial! Fortunately for clinicians and cancer patients, a few dedicated scientists, and especially Monroe Wall at RTI and Matthew Suffness at the NCI, believed in paclitaxel and continued to investigate it. Three key discoveries in the mid to late 1970s helped to move paclitaxel into clinical trials. The first was that it showed excellent activity against various human tumor xenografts in nude mice. This finding led to a decision by the NCI to move paclitaxel into preclinical development, and this led to the second important advance, which was the discovery of an effective formulation in a mixture of ethanol and Cremophor EL. The final discovery was made in 1979 by Susan Horwitz, who found that paclitaxel had a totally different mechanism of action from any previously known anticancer agent. Instead of preventing the assembly

9

of tubulin into microtubules, as was known for such compounds as the Vinca alkaloids and podophyllotoxin, paclitaxel promotes the assembly of tubulin into microtubules [59]. Taken together, these discoveries maintained interest in paclitaxel when toxicity was encountered in its clinical trials, and ultimately led to its successful development as a clinical agent. The history of paclitaxel’s early development has been documented in an interesting book [60].

1.3.3 Mechanism of Action As noted earlier, paclitaxel’s primary mechanism is as a tubulin-polymerization agent. This mechanism has been shown to result from promotion of the polymerization of tubulin heterodimers to microtubules. Paclitaxel binds to microtubules with a stoichiometry of approximately 1 mole of drug to 1 mole of tubulin dimer [59]. Although the drug stabilizes microtubules and also increases the total polymer mass at high concentrations [61], these concentrations are higher than those needed to inhibit microtubule functions [62]. The key feature of paclitaxel’s action from a clinical perspective is that it suppresses dynamic changes in microtubules at clinically relevant concentrations, leading to mitotic arrest [63]. It does this by interfering with the formation of the mitotic spindle, thus preventing the chromosomes from separating [64]. Further details of the tubulin-binding action of paclitaxel can be found in various reviews [65, 66]. The binding of paclitaxel to tubulin polymers and the associated interruption of the cell cycle is not the only biological effect produced by paclitaxel. Other effects at the cellular level include phosphorylation of and binding to Bcl-2, direct activation of signal transduction pathways, induction of the production and release of cytokines [67], and activation of transcription factors AP-1 or NF-κB. Probably the most important of these is paclitaxel’s ability to inactivate the antiapoptotic protein Bcl-2, which it does by inducing phosphorylation, which then leads to inactivation [68]. The phosphorylation of Bcl-2 may occur through activation of Raf-1 kinase, and it has been proposed that Raf-1 is activated following drug-induced disruptions of microtubules [69], but paclitaxel also binds directly to Bcl-2 [70]. These events have been

10

critically reviewed by Blagosklonny and Fojo [71], who conclude that all of paclitaxel’s effects occurring in vitro at clinically relevant concentrations are related to microtubule binding and cell-cycle arrest at G2/M. Although the clinical effects of paclitaxel may thus be traced to its microtubule binding activity, the actual cellular events resulting from this binding are rather complex. The situation has been aptly summarized as follows: “Depending on the phase of the cell cycle, taxanes can affect spindle formations, chromosome segregation, or completion of mitosis, thus activating the mitotic or the DNA-damage checkpoints and blocking cell-cycle progression. This complex scenario, with different cell cycle responses related to the specific microtubule function affected in each phase, is reflected in the variety of pathways described to result in apoptosis upon taxane treatment. . .” [72]. Although it is not relevant to paclitaxel’s use as a cancer chemotherapeutic agent, it should be noted that various analogs of the drug have been shown to have activity against other diseases, at least in vitro. Thus modified paclitaxels have shown activity against in vitro models of malaria [73, 74] and Alzheimers’ disease [75].

1.3.4 The Paclitaxel-Tubulin Interaction Since the most important biological effects of taxol can be attributed to its microtubule stabilization, the nature of its binding to microtubules becomes of great importance; this subject thus merits a separate discussion. Ideally the binding site of taxol on tubulin would be elucidated by x-ray crystallography, but because tubulin forms microtubules on attempted crystallization it has not proved possible to obtain an x-ray crystal structure of the protein. It has however proved possible to prepare stabilized crystalline sheets of “microtubules” in the presence of paclitaxel and zinc, and the structure of these sheets has been determined by electron crystallography at a resolution of 3.7 Å [76–78]. The location of the paclitaxel binding site on the tubulin molecule was shown to be on β-tubulin by photoaffinity labeling studies with azidobenzoyl paclitaxel derivatives, which photolabeled the N-terminal proton of β-tubulin [79] or amino acids 217–231 of β-tubulin [80], depending on the location of the azidobenzoyl group on paclitaxel. Some

D.G.I. Kingston

paclitaxel analogs do however label α-tubulin as well as (or instead of) β-tubulin [81, 82], leading to the suggestion that the drug most probably occupies a binding site located between α- and β-tubulin, but largely on β-tubulin. In the electron diffraction structure of the αβtubulin-taxol complex described above, taxol occupies a hydrophobic cleft on β-tubulin, and this binding converts it into a hydrophilic surface [83, 84]. This binding location is consistent with the photoaffinity results reported above showing labeling of β-tubulin by taxol; the labeling of α-tubulin is difficult to explain. Although these results show the general location of paclitaxel on tubulin, its actual binding conformation(s) cannot be discerned at the resolution obtained. Studies of the NMR spectra of paclitaxel in solution indicated the presence of three conformers; a nonpolar conformer [85–87] a polar form [88–90], and a third minor conformer, designated T-taxol, in which the C-2 benzoyl group bisects the angle between the C-3 phenyl and C-3 benzamido side chains [91]. Initial support for the T-taxol conformation as the binding conformation on tubulin was obtained by two studies using solid state NMR to probe the conformation of tubulin-bound drug [92, 93]; these results were also consistent with the unexpected activity of 2-mazidobaccatin III [94]. Final support for the T-taxol conformation came from synthesis of the constrained analog (3.3) [95]. This compound, which has a similar conformation to T-taxol, is about twentyfold more cytotoxic than paclitaxel to A2780 cells and has a critical concentration for tubulin polymerization over threefold lower than that of paclitaxel. It also fits the paclitaxel-binding pocket on β-tubulin, and it thus represents the best available model of the tubulin-bound conformation of paclitaxel.

AcO

O

OH

O HO

O

H

O

O

HO BzO N H

O O

3.3

1

Plant-Derived Natural Products as Anticancer Agents

11

Although the above discussion has focused on paclitaxel, much of the discussion applies to its sister drug docetaxel (3.2), although there are differences in the details of their effects. Nevertheless, both are potent anticancer drugs which promote the assembly of microtubules as their primary action relevant to cancer chemotherapy. It is worth noting that several other natural products with this mechanism have been identified over the last 10 years; these include the epothilones, discodermolide, eleutherobin, and laulimalide, among others, and the epothilione analog ixabepilone has been approved for clinical use. The importance of this class of microtubule-stabilizing agents has been recognized by several recent reviews [96–99].

1.3.5 Paclitaxel Analogs In the chemistry area virtually every position on the ring and on the side chain has been subjected to O

AcO O NH

Ph

O O

O

NH

Ph

O

Ph

H AcO HO OCOPh

O OH

O

AcO

OH

O

O

H AcO HO OCOPh

OH

O

AcO

OR

O

Ph

structural modifications. Space does not permit even a brief review of the synthetic and structure-activity relationship (SAR) work that has been carried out on paclitaxel, and reference is thus made to some reviews which discuss the work that has been done [100–106]. Suffice it to say that all the functional groups in the compound have been modified, in some cases in a combinatorial fashion, and that several improved analogs have been developed. A complete list of paclitaxel analogs in preclinical and clinical development as of late 2003 is provided in a review by Cragg and Newman of the NCI [107]. The six analogs DHA-paclitaxel (Taxoprexin, (3.4)) [108], 7hexanoylpaclitaxel (3.5) [108], the C-7 thioether (3.6) (BMS-184476) [109], the cyclopropyl derivative (3.7) (RPR-109881A) [110], the C-4 carbonate (3.8) (BMS188797) [111], and the 7,10-dimethyl ether (3.9) (TXD258) [112] are currently in Phase II clinical trial, while the four additional paclitaxel analogs ortataxel (3.10) [113], TL-00139 (3.13) [114], DJ-927 (3.14) [115], and BMS-275183 (3.15) are in Phase I clinical trial.

O

NH

O

HO

OH

3.7

3.4 R = COCH2(CH2CH=CH)6CH2CH3 3.5 R = CO(CH2)5CH3

O

H

O

Ph

OCOOCH3 OCOPh

3.8

3.6 R = OCH2SCH3 O CH3O

O O

NH

O

O

Ph

O NH

O O

OH

H AcO OH OCOPh

O

AcO

OCH3

O O

OH

O

3.9

H AcO O OCOPh O

O

O

AcO

O

NH

O

O

N

O OH F

H AcO OH OCOPh

3.13

O

NH

H

O OH

OH

OH

O

OCOOCH3 OCOPh

3.14

OH

H OH

OAc OCOPh 3.12

O

Ph

O O

O

3.10

O

O

NH

O

N

O

O

O

O

O

O

HO

OH

O

12

A further 23 paclitaxel analogs are in preclinical development; their structures are given in the review cited above. It thus seems clear that paclitaxel and docetaxel are simply the first examples of a whole new class of anticancer agents, and that more efficacious analogs will be available to the clinician within a few years’ time.

1.3.6 Mechanisms of Resistance There are two major mechanisms of acquired resistance to the taxane drugs. The first general mechanism involves tumors that contain mutated α- and β-tubulins. In some cases these tubulins have an impaired ability to assemble to microtubules, and in these cases the taxanes act to make the cells more normal [116]. In other cases the tubulins have mutated so that they are less susceptible to the taxanes; as one example, β-tubulin mutations were shown to be strong determinants of paclitaxel resistance in patients with non-small cell lung cancer [117]. The second general mechanism of resistance involves the well-known multi-drug resistant phenotype of tumor cells, which confers varying degrees of cross-resistance to structurally bulky natural products. Reversal of resistance to paclitaxel and docetaxel can be achieved with several classes of drugs, including the principal component of the vehicles used to formulate paclitaxel (Cremophor EL) and docetaxel (polysorbate 80) [118].

1.3.7 Formulation of Paclitaxel and Docetaxel Paclitaxel is very sparingly soluble in water, and it has a low oral bioavailability. It thus requires administration in a solubilizing formulation, and the current formulation consists of 30 mg of the drug in a 50/50 mixture of Cremophor EL (a polyethoxylated castor oil) and ethanol. As noted above this formulation has some benefits in assisting in the reversal of resistance by the MDR phenotype, but it also creates problems since it almost certainly is the cause of the hypersensitivity reactions associated with paclitaxel administration [119].

D.G.I. Kingston

Docetaxel is slightly more water-soluble than paclitaxel, and is administered with polysorbate 80 as its emulsifier. Many new formulations for the taxanes have been developed, and are summarized in a review [120]. Not included in this review is the announcement of the successful phase III trial of the albumin nanoparticlebased formulation of taxol ABI-007 [121]. This result shows that improved formulations can have a dramatic effect; the overall response rate for ABI-007 in patients with metastatic breast cancer was 33%, compared with 19% for taxol.

1.3.8 Paclitaxel Metabolism The human metabolism of paclitaxel has been studied by several researchers. Renal clearance contributes little to systemic clearance, and metabolism, biliary excretion, and tissue binding account for the bulk of the disposition of the administered doses of paclitaxel. Studies of the biliary metabolites of paclitaxel have shown that the major human metabolite is 6αhydroxypaclitaxel (3.15) [122]. This metabolite is significantly less active than paclitaxel, and so one fruitful goal of research has been the development of paclitaxel analogs which are resistant to this pathway of metabolic inactivation. Two other minor metabolites have also been identified, one hydroxylated on the para-position of the 3 -phenyl group (3.16) and the other hydroxylated on both the para-position of the 3 phenyl and on C-6 (3.17). The metabolism of paclitaxel in the rat has also been studied; in this case (3.16) is the major metabolite, and several metabolites that are not found in humans have also been identified. This subject has been reviewed [123, 124].

AcO

O

OH

O Ph

R2 NH

O O

O R1

OH

OH

AcO OCOPh

3.15 R1 = H, R2 = OH 3.16 R1 = OH, R2 = H 3.17 R1 = R2 = OH

1

Plant-Derived Natural Products as Anticancer Agents

1.3.9 Cancer Therapy with Paclitaxel and Docetaxel The use of taxol in cancer therapy has recently been reviewed [125], and several reviews have covered the use of taxol or docetaxel for the treatment of specific cancers [126–130]. This section will summarize the major results from these studies by cancer type.

1.3.9.1 Ovarian Cancer The initial report of the clinical activity of paclitaxel was made for ovarian cancer [131], and this continues to be an important indication for this drug. Paclitaxel is effective as a single agent [131, 132], but the preferred treatment is by combination therapy. The standard treatment for ovarian cancer prior to the advent of paclitaxel was cyclophosphamide-cisplatin, but paclitaxel-cisplatin has been shown to be more effective [133], and this now the standard of care for women with advanced ovarian cancer. The risks and benefits of taxanes in breast and ovarian cancer have been reviewed [134].

1.3.9.2 Breast Cancer Paclitaxel was first shown to have activity against breast cancer in 1991, and this finding immediately transformed it from “orphan drug” to “blockbuster” status. Both paclitaxel and docetaxel have shown excellent activity in treating advanced metastatic breast cancer [135], and their value in treating early stage breast cancer has also been demonstrated. One reviewer states “The evidence is now clear that taxanes added to standard adjuvant regimens . . . can improve outcomes for patients with breast cancer” [136]. A second systematic review of taxane versus non-taxane regimens for treatment of early breast cancer concludes “The results of this systematic review support the use of taxanes as adjuvant chemotherapy for women with early breast cancer and involved lymph nodes” [137]. In the studies summarized in this review, the 5-year relapse-free survival rate was 74% for the control (non-taxane) group versus 79% for the taxane-treated group [137].

13

1.3.9.3 Lung Cancer Docetaxel is the drug of choice for the treatment of advanced non-small cell lung cancer that is refractory to primary chemotherapy [138]. A study to compare the efficacy of three different treatment regimens (cisplatin and gemcitabine, cisplatin and docetaxel, or carboplatin and paclitaxel) found that the response rates and survival did not differ significantly between the regimens [135]. The combination of paclitaxel and carboplatin is also a standard treatment for patients with advanced non-small cell lung cancer [139].

1.3.9.4 AIDS-Related Kaposi’s Sarcoma Paclitaxel induces apoptosis in AIDS-related Kaposi’s sarcoma cells [140], and it has been approved for treatment of this disease.

1.3.10 Summary Paclitaxel and docetaxel may not be the wonder drugs they were thought to be in 1991, but they have nevertheless brought significant benefits to many cancer patients. The new analogs in clinical trials promise real improvements in efficacy over taxol and docetaxel, and improvements in drug delivery will also play a major role in improving treatment. Paclitaxel and its analogs can thus be expected to play an important role in cancer chemotherapy well into the 21st century.

1.4 Camptothecin and Analogs 1.4.1 Introduction The 1960s was a significant decade at the Research Triangle Institute, since both paclitaxel (TaxolTM ) and the alkaloid camptothecin (4.1) [141] were isolated there by Wani and Wall during this period. Ironically, the work on camptothecin had a higher priority at the time than work on paclitaxel, and this was a factor which contributed to delays in the structure elucidation of the latter. Camptothecin was obtained from

14

D.G.I. Kingston

extracts of Camptotheca acuminata Decne., 1873, and it showed good activity against L1210 leukemia. Since it had very low solubility in water, clinical studies were carried out on the water-soluble sodium salt (4.2). Unfortunately these trials revealed numerous problems and were suspended [142]. Interest in camptothecin revived when it was discovered that it had a previously unknown mechanism of action, namely the ability to inhibit topoisomerase I (topo I) [143]. This discovery led to the synthesis and evaluation of a large number of camptothecin analogs, and the two water-soluble analogs topotecan (Hycamtin) (4.3) and irinotecan (Camptosar) (4.4) have been approved for clinical use.

1.4.2 Mechanism of Action 1.4.2.1 Inhibition of Topoisomerase I As noted above, camptothecin acts by inhibiting the enzyme topoisomerase I, which it does by binding to the DNA-topoisomerase I covalent binary complex [3]. The topoisomerases I and II are enzymes that allow chromosomal DNA to undergo changes in topology (i.e. relaxation) prior to replication; any interference with this process would have obvious negative consequences for cell viability. This mechanism is thus consistent with the fact that camptothecin is capable of inhibiting DNA synthesis, leading to cell death dur-

ing the S-phase of the cell cycle [144]. Support for the inhibition of topo I as the target of camptothecin comes from studies showing that many camptothecinresistant cell lines have mutated variants of topo I [145], and that Saccharomyces cerevisiae cells in which the gene for topo I has been deleted (and which then overexpress topo II in compensation) are resistant to camptothecin [146]. It is noteworthy that camptothecin shows remarkable specificity in binding only to the cleavable complex formed between topo I and DNA; it does not bind to DNA alone or to topo I alone. Although topoisomerase I is an enzyme found in all cell types, its levels are elevated in tumors of the colon, ovary and the prostrate, and this is presumably a significant part of the reason for the effectiveness of the camptothecin analogs against the first two of these tumors [147]. Some cancer cells may be more susceptible to the camptothecins because of deficiencies in DNA repair capabilities, and dividing cell populations are also likely to be more susceptible to inhibition by topoisomerase poisons. 1.4.2.2 Other Biochemical Effects of Camptothecin Various other activities have been observed for the camptothecins. These include activation of the transcription factor NFκB [148], regulation of transcription [149], base mismatch nicking activity [150], and phosphorylation of SR proteins [151].

O

N

N

N

O

N OH O–Na+

O OH O

4.1

4.2

OH O

N

CH2NMe2 HO N

CH2CH3 N

O

O N

O

N

N

O

4.3

OH O

O

O

4.4

OH O

1

Plant-Derived Natural Products as Anticancer Agents

1.4.3 Mechanisms of Resistance Resistance to camptothecin analogs can take several forms in vitro. Topotecan is known to be susceptible to the classic multidrug resistance (MDR) phenotype, although several related compounds are apparently not susceptible [152]. The effect of this susceptibility is however less than for several other classes of anticancer drug such as the taxanes and the Vinca alkaloids, so the clinical significance of this finding is not clear [152]. Resistance may also result from decreased expression of topoisomerase I [153, 154], although clinical studies have not yet confirmed the significance of this finding [155]. Reduced or altered catalytic activity of topoisomerase I resulting from mutations has also been shown to cause resistance [156], while topoisomerase II is upregulated in human tumor cells after exposure to topotecan in vitro [157]. Further details on these and other possible mechanisms of resistance are given in an excellent recent review [158]. Although resistance to camptothecin and its analogs can take different forms, it is not yet clear which if any of these pathways contributes significantly to drug resistance in a clinical setting.

1.4.4 Camptothecin Supply As noted above, camptothecin was initially isolated from Camptotheca acuminata, but it has also been isolated from several other species; a full survey of the distribution of camptothecin and its metabolites is provided in a review [159]. In spite of the importance of camptothecin and its analogs as anticancer agents, the compounds are still obtained from the bark and seeds of C. acuminata and Nothapodytes foetida. Recent studies with hairy root cultures of C. acuminata and Ophiorrhiza pumila, however, offer the hope that plant tissue culture methods of production will prove feasible in the future, as is the case with paclitaxel [159].

15

syntheses have been reported by Ejima et al. [163], Comins et al. [164], Tagami et al. [165], Bennasar et al. [166], Ciufolini and Roschangar [167], Imura et al. [168], Fang et al. [169], Jew et al. [170], Blagg and Boger [171], and Curran et al. [172, 173]. The clinical drugs topotecan and irinotecan were both prepared initially by partial synthesis from naturally occurring precursors. Irinotecan (4) was prepared by Sawada et al. from 20(S)-camptothecin [174], with a photochemical rearrangement of an N-oxide derivative as the key step. Topotecan was synthesized by Kingsbury et al. in two steps from 20(S)-camptothecin [175], with a Mannich reaction on 10-hydroxycamptothecin furnishing the final product.

1.4.6 Medicinal Chemistry As has been the case with podophyllotoxin and paclitaxel described earlier, many analogs of camptothecin have been prepared and much is known about its SAR profile. This subject has recently been reviewed [176], and this discussion can thus be abbreviated. Studies of compounds modified on the quinoline ring system have shown that substitutions at C-11and C-12 normally result in a reduction of activity, while substitutions at C-7, C-9, and C-10 can lead to enhanced activity [176]. The E-ring lactone is important for activity, and almost all modifications to this ring have led to less active compounds; the homocamptothecins represent an important exception. Although the camptothecins are the only topo 1 inhibitors currently in clinical use, several compound classes are under investigation as sources of alternative inhibitors. These include the indolocarbazoles, indenoisoquinolines, benzacridines, and the benzimidazoles [177].

1.4.7 Camptothecin Analogs in Clinical Use

1.4.5 Synthetic Studies 1.4.7.1 Topotecan The synthesis of camptothecin has been achieved by several workers, following the first total synthesis in 1971 [160]; this work has been reviewed [161, 162], and thus will not be discussed in detail. Asymmetric

Topotecan (4.3) (Hycamtin) has a N,N-dimethylaminomethyl substituent at C-9; this basic functional group confers improved water solubility. Topotecan is

16

D.G.I. Kingston

presently utilized as second-line therapy for advanced ovarian cancer in patients who have failed to respond to treatment regimens that include platinum or paclitaxel. Recent results from a Phase III study, however, have shown that long-term survival of patients with advanced epithelial ovarian cancer was comparable for those on topotecan and those on paclitaxel [178]. Recurrent small-cell lung cancer is also an approved indication; it has been shown to increase the time to disease progression for patients previously treated with etoposide plus cisplatin [158]. It is usually administered as an intravenous infusion. Because topotecan binds relatively poorly to human plasma proteins, its half-life is much shorter than that of other camptothecin derivatives and thus drug accumulation is not apparent. The most common dose-limiting toxicity is neutropenia, although topotecan treatment can also be associated with some thrombocytopenia. Topotecan also has activity against hematological malignancies in addition to its action on ovarian and small-cell lung cancers. As is common for antitumor agents, combination regimens with many other agents including paclitaxel and cisplatin are under development [186]. 1.4.7.2 Irinotecan Irinotecan (4.4) (Camptosar) is a water-soluble prodrug of the 7-ethyl-10-hydroxycamptothecin ana-

log SN-38 (4.5). Carboxylesterase cleavage of the bispiperidine group at the 10-position affords the biologically active compound SN-38, which is three orders of magnitude more potent than irinotecan as an inhibitor of topoisomerase I in vitro. Irinotecan has been approved for the treatment of advanced colorectal cancer. It is approved both as first-line therapy (in combination with 5-fluorouracil) and as salvage treatment for 5-fluorouracil-resistent tumors. It is most commonly administered as an intravenous infusion [158]. One advantage of irinotecan over topotecan is that the biological half-life of the lactone form of SN-38 (4.5) exceeds that of topotecan. Since the lactone form binds preferentially to serum albumin, this results in the persistence in the plasma after drug administration of a relatively large percentage of the intact lactone form of both irinotecan and SN-38. The major mechanisms of elimination of SN-38 are glucuronidation and biliary excretion. Its principal dose-limiting toxicity is delayed diarrhea, with or without neutropenia, and it has been suggested that the risk of diarrhea is inversely related to the extent of glucuronidation [179]. Promising antitumor activity has also been observed against small-cell and nonsmall lung cancer, ovarian cancer, cervical cancer, and in recent clinical trials involving patients with malignant gliomas. Studies to evaluate additional irinotecan drug combinations with taxanes, anthracyclines, Vinca alkaloids, or alkylating agents are in progress.

N R HO

O

O

O

N

OH O OBut

OH O

4.8

NMe2

O

OH O

N

N O

4.11

OH O

O

N

N O

4.9

F

O

N

N

O

OH O

O

N

N

SiMe3

N

4.10

F O

O 4.6 R = NH2 4.7 R = NO2

N

N

O

N O

O

O N

N

N

4.5

NH2

N

OH O

F

N O

O 4.12

OH O

4.13 OH

O

1

Plant-Derived Natural Products as Anticancer Agents

1.4.8 Camptothecin Analogs in Clinical Trial or Preclinical Development The work summarized briefly above in Section 1.4.5 has led to the development of several camptothecin derivatives addition to topotecan and irinotecan.as clinical candidates. These are described briefly below. 9-Aminocamptothecin (IDEC-132) (4.6) was discovered by Monroe Wall and his group, and is being developed by the National Cancer Institute. Initial clinical trials using intravenous infusion gave disappointing results, but a solid oral dosage form was developed by incorporating the drug into poly(ethylene)glycol1000. Testing of the conjugate in cancer patients yielded bioavailabilities of 49% [180], and phase II studies using this formulation have been initiated. 9-Nitrocamptothecin (Rubitecan) (4.7) was developed for oral administration; it is metabolically converted 9-aminocamptothecin into in vivo, and is thus likely to share many of the characteristics of this compound. It is in phase II clinical trials [181]. Lurotecan (4.8) is more cytotoxic than topotecan [182], but initial clinical studies failed to show any clear advantage over topotecan. A liposomal formulation of the drug known as OSI-211 did however give encouraging results, and responses were observed in a phase I trial in patients with solid malignancies [183]. Exactecan (4.9) is a potent water soluble analog that is active in vitro against tumors resistant to topotecan and irinotecan [184]; it is currently in phase II clinical trials. Gimatecan (4.10) has shown excellent cytotoxicity, and it is currently in phase I clinical trials [185]. CKD-602 (4.11) has better water solubility and lower toxicity than camptothecin, and is more potent against several cell lines [181]. It is in phase II clinical trials, where responses have been seen in patients with stomach and ovarian cancer [181]. Karenitecin (BNP-1350) (4.12) is a lipophilic compound that is more cytotoxic than camptothecin both in vitro and in vivo. It has enhanced oral bioavailability. Its lactone ring is also more stable than those of most other analogs, which could be clinically advantageous. Having completed phase I clinical trials for pancreatic and colorectal cancer, it is currently in phase II clinical trials [181]. Diflomotecan (BN-80915) (4.13) is the only homocamptothecin analog in clinical trials; the extra

17

carbon in the lactone ring gives it enhanced stability. Diflomotecan showed strong antiproliferative activity towards a panel of tumor cell lines, including MDR cell lines, and was also active at low doses in several human tumor xenografts. It is currently undergoing phase I clinical trials in Europe [181, 186–188].

1.4.9 Conclusions The major importance of camptothecin and its analogs is that they represent a new class of antineoplastic agents with a previously unknown mechanism of action. They are thus of considerable interest, and studies continue to offer meaningful insights into the drug nearly 40 years after Wani and Wall first reported its structure. The most promising of the current analogs is irinotecan, which is the only new cytotoxic drug to be approved for colorectal cancer in decades, and it is presently the drug of choice for this disease in combination with fluoropyrimidines. The biochemical basis of camptothecin activity is now well understood, and recent advances in the synthesis of camptothecin and its analogs allow construction of new analogs on a scale not possible previously. Novel analogs are now being reported that optimize and exploit important structural features and further expand the therapeutic potential of camptothecin. Another exciting aspect of the camptothecin analogs is that they have the potential of synergistic interactions with cell cycle inhibitors such as UCN-01 (7-hydroxystaurosporine). Thus UCN-01 selectively enhances the antiproliferative activity of camptothecin in p53-deficient cells [189], and it has been suggested that inhibitors of the enzyme checkpoint kinase 2 could be used in association with the camptothecins to increase the effectiveness of the latter drugs [190]. In addition to their intrinsic value, the camptothecin analogs have opened up the whole area of inhibitors of topoisomerase I as drug targets, and the next generation of topoisomerase I inhibitors is now beginning to enter clinical trials. These compounds lack the unstable lactone ring of camptothecin, and it will be interesting to see if any of them prove to be more clinically efficacious than topotecan or irinotecan. Whatever the outcome of these investigations, camptothecin retains its importance as the progenitor of a new class of anticancer agents.

18 Acknowledgements The author’s work on paclitaxel mentioned in Section 1.3 was supported by the National Cancer Institute (grants CA-55131 and CA-69571), and this support is gratefully acknowledged. The author is also grateful to Dr. S. M. Hecht (University of Virginia) for advice and assistance in the preparation of Section 1.4.

References 1. Newman DJ, Cragg GM (2007) Natural products as sources of new drugs over the last 25 years. J Nat Prod 70:461–477 2. Arcamone F, Cassinelli G. (1998) Biosynthetic anthracyclines. Curr Med Chem 5:391–419 3. Arcamone F, Animati F, Capranico G, Lombardi P, Pratesi G, Manzini S et al (1997) New developments in antitumor anthracyclines. Pharmacol Ther 76:117–124 4. Farber S, D’Angio G, Evans A, Mitus A. (2002) Part III. Clinical significance: clinical studies of actinomycin D with special reference to Wilms’ tumor in children. J Urol 168:2560–2562 5. Sikic BI, Rozenciveig M, Carter SK (eds) (1985) Bleomycin chemotherapy. Academic, Orlando, FL 6. Crooke ST, Bradner WT (1976) Mitomycin C: a review. Cancer Treat Rev 3:121–139 7. Cragg GM, Kingston DGI, Newman DJ (eds) (2005) Antitumor agents from natural sources. Taylor and Francis, London 8. Kelly MG, Hartwell JL (1954) The biological effects and the chemical composition of podophyllin. A Review. J Natl Cancer Inst 14:967–1010 9. Kaplan IW (1942) Condylomata acuminate. New Orleans Med Surg J 94:388–395 10. Hartwell JL, Schrecker AW (1958) The chemistry of Podophyllum. Fortschr Chem Org Naturst 15:83–166 11. Bohlin L, Rosén B (1996) Podophyllotoxin derivatives: drug discovery and development, Drug Discovery Today 8:343–351 12. Damayanthi Y, Lown JW (1998) Podophyllotoxins: current status and recent developments. Curr Med Chem 5:205–252 13. Gordaliza M, Castro MA, Miguel Del Corral JM, San Feliciano A (2000) Antitumor properties of podophyllotoxin and related compounds. Curr Pharm Design 6: 1811–1839 14. Jardine I (1980) Podophyllotoxins. In: Cassady JM, Douros JD (eds) Anticancer agents based on natural product models. Academic, New York, pp 319–351 15. Lee K-H, Xiao Z (2005) The podophyllotoxins and analogs. In: Cragg GM, Kingston DGI, Newman DJ (eds) Anticancer agents from natural products. CRC, New York 16. Keller-Juslén C, Kuhn M, Von Warburg A, Stahelin H (1971) Synthesis and antimitotic activity of glycosidic lignan derivatives related to podophyllin. J Med Chem 14:936–940 17. Doyle TW (1984) The chemistry of etoposide. In: Issell BF, Muggia FM, Carter SK (eds) Etoposide (VP16). Current status and new developments. Academic, New York, pp 15–32

D.G.I. Kingston 18. Meresse P, Dechaux E, Monneret C, Bertounesque E (2004) Etoposide: discovery and medicinal chemistry. Curr Med Chem 11:2443–2466 19. Saulnier MG, Langley DR, Kadow JF, Senter PD, Knipe JO, Jay O et al (1994) Synthesis of etoposide phosphate, BMY-40481: a water-soluble clinically active prodrug of etoposide. Bioorg Med Chem Lett 4:2567–2572 20. Grieder A, Maurer R, Stahelin H (1974) Effect of an epipodophyllotoxin derivative (VP16–213) on macromolecular synthesis and mitosis in mastocytoma cells in vitro. Cancer Res 34:1788–1793 21. Krishan A, Paika K, Frei E III (1975) Cytofluorometric studies on the action of podophyllotoxin and epipodophyllotoxins (VM26:VP16–213) on the cell cycle traverse of human lymphoblasts. J. Cell Biol 66: 521–530 22. Dombernowsky P, Nissen NI (1973) Schedule dependency of the anti-leukaemic activity of the podophyllotoxin derivative VP16–213 (NSC 141540) in L1210 Leukaemia. Acta Path Microbial Scand 81:715–724 23. Rose WC, Bradner WT (1984) In vivo experimental antitumor activity of etoposide. In: Issell BF, Muggia FM, Carter SK (eds) Etoposide (VP-16). Current status and new developments. Academic, New York, pp 33–47 24. Jardine I, Strife RJ, Kozlowski J (1982) Synthesis, 470-MHz H-NMR spectra, and activity of delactonized derivatives of the anticancer drug etoposide. J Med Chem 25:1077–1081 25. Cortese F, Bhattacharyya B, Wolff J (1977) Podophyllotoxin as a probe for the colchicine binding site of tubulin. J Biol Chem 252:1134–1140 26. Wozniak AJ, Ross WE (1983) DNA damage as a basis for 4-demethylepipodophyllotoxicity. Cancer Res 43: 120–124 27. Loike JB, Horwitz SB, Grollman AP (1976) Effect of podophyllotoxin and VP-16 on microtubule assembly in vitro and nucleoside transport in HeLa cells. Biochemistry 15:5435–5442 28. Roberts D, Hilliard S, Peck C (1980) Sedimentation of DNA from L1210 cells after treatment with 4 -demethylepipodophyllotoxin-9-(4,6-O-2-thenylideneβ-D-glucopyramoside) of 1-β-D-arabinofuranosylcytosine or both drugs. Cancer Res 40:4225–4231 29. Ross W, Rowe T, Glisson B, Yalowich J, Liu L (1984) Role of topoisomerase II in mediating epipodophyllotoxin-induced DNA cleavage. Cancer Res 44:5857–5860 30. Berger JM, Wang JC (1996) Recent developments in DNA topoisomerase II structure and mechanism. Curr Opin Struct Biol 6:84–90 31. Allen LM, Marcks C, Creaven PJ (1976) 4 -Demethyl-epipodophyllic acid-9-(4,6-O-ethylideneβ-D-glucopyranoside), major urinary metabolite of VP-16–213 in man. Proc Am Assoc Cancer Res 17:6–6 32. Strife RJ, Jardine I, Colvin M (1980) Analysis of the anticancer drugs VP16–213 and VM26 and their metabolites by high performance liquid chromatography. J Chromatogr 182:211–220 33. Canetta R, Hilgard P, Florentine S, Bendogni P, Lenaz L (1982) Current development of podophyllotoxins. Cancer Chemother Pharmacol 7:93–98

1

Plant-Derived Natural Products as Anticancer Agents 34. Cavalli F. (1982) VP16–213 (Etoposide). A critical review of its activity. Cancer Chemother Pharmacol 7:81–85 35. Creaven PJ (1982) The clinical pharmacology of VM26 and VP16–213. A brief overview. Cancer Chemother Pharmacol 7:133–140 36. Issell BF (1982) The podophyllotoxin derivatives VP16– 213 and VM26. Cancer Chemother Pharmacol 7:73–80 37. Issell BF, Muggia FM, Carter SK (eds) (1984) Etoposide (VP-16). Current status and new developments. Academic, New York 38. Loike JD (1982) VP16–213 and podophyllotoxin. A study on the relationship between chemical structure and biological activity. Cancer Chemother Pharmacol 7: 103–111 39. Macbeth FR (1982) VM26: phase I and II studies. Cancer Chemother Pharmacol 7:87–91 40. Creaven PJ (1984) The clinical pharmacology of etoposide (VP-16) in adults. In: Issell BF, Muggia FM, Carter SK (eds) Etoposide (VP16). Current status and new developments. Academic, New York, pp 103–115 41. Evans WF, Sinkule JA, Hutson PR, Hayeo FA, Rivera G (1984) The clinical pharmacology of etoposide (VP16– 213) in children with cancer. In: Issell BF, Muggia FM, Carter SK (eds) Etoposide (VP16). Current status and new developments. Academic, New York, pp 117–125 42. Hande KR (1998) Etoposide: four decades of development of a topoisomerase II inhibitor. Eur J Cancer 34: 1514–1521 43. Johnson DH, Hainsworth JD, Hande KR, Grfeco FA (1991) Current status of etoposide in the management of small cell lung cancer. Cancer 67:231–244 44. Vogelzang NJ, Raghavan D, Kennedy BJ (1982) VP-16– 214 (Etoposide). The mandrakie root from Issyk-Kul. Am J Med 72:136–144 45. Laubenstein LJ, Krigel RL, Odajnyk CM, Hymes KB, Friedman-Kien A, Wernz JC et al (1984) Treatment of epidemic Kaposi’s sarcoma with etoposide or a combination of doxorubicin, bleomycin, and vinblastine. J Clin Oncol 2:1115–1120 46. Fleming RA, Miller AA, Stewart CF (1989) Etoposide: an update. Clin Pharmacy 8:274–292 47. Ayres DC, Loike JD (1990) Lignans. Chemical, biological and clinical properties. University Press, Cambridge, p 113 48. Rivera G, Dahl GV, Bowman WP, Avery TL, Wood A, Aur RJ (1980) VM26 and cytosine arabinoside combination chemotherapy for initial induction failures in childhood lymphocytic leukemia. Cancer 46:1727–1730 49. Saito H, Yoshikawa H, Nishimura Y, Kondo S, Takeuchi T, Umezawa H (1986) Studies on lignan lactone antitumor agents. II. Synthesis of N-alkylamino- and 2,6-dideoxy2-aminoglycosidic lignan variants related to podophyllotoxin. Chem Pharm Bull 34:3741–3746 50. Wang ZQ, Kuo YH, Schnur D, Bowen JP, Liu SY, Han FS (1990) Antitumor agents 113. New 4β-arylamino derivatives of 4 -O-demethylepipodophyllotoxin and related compounds as potent inhibitors of human DNA topoisomerase II. J Med Chem 33:2660–2666 51. Liu JM, Chen LT, Chao YL, Anna FY, Wu CW, Liu TS, Shiah HS, Chang JY, Chen JD, Wu HW, Lin WC, Lan C, Whang-Peng, J (2002) Phase II and pharmacokinetic

19

52.

53.

54.

55.

56.

57.

58.

59. 60.

61.

62.

63.

64.

65.

66. 67.

68.

study of GL331 in previously treated Chinese gastric cancer patients, Cancer Chemother Pharmacol 49:425–428 Terada T, Fujimoto K, Nomura M, Yamashita J, Wierzba K, Yamazaki R (1993) Antitumor agents 3. Synthesis and biological activity of 4β-alkyl derivatives containing hydroxyl, amino, and amido groups of 4 -O-demethyl-4deoxypodophyllotoxin as antitumor agents. J Med Chem 36:1689–1699 Byl JAW, Cline SD, Utsugi T, Kounai T, Yamada Y, Osheroff N (2001) DNA topoisomerase II as the target for the anticancer drug TOP-53: mechanistic basis for drug action, Biochemistry 40:712–718 Wani MC, Taylor HL, Wall ME, Coggon P, McPhail AT (1971) Plant antitumor agents. VI. The isolation and structure of taxol, a novel antileukemic and antitumor agent from Taxus brevifolia. J Am Chem Soc 93:2325–2327 Brown DT (2003) Preclinical and clinical studies of the taxanes. In: Itokawa H, Lee K.-H. (eds) Taxus: the genus taxus. Taylor and Francis, London, pp 387–435 Guénard D, Gueritte-Voegelein F, Potier P (1993) Taxol and taxotere: discovery, chemistry, and structure-activity relationships. Acc Chem Res 26:160–167 Wani MC, Taylor HL, Wall ME, Coggon P, McPhail AT (1971) Plant antitumor agents. VI. The isolation and structure of taxol, a novel antileukemic and antitumor agent from Taxus brevifolia. J Am Chem Soc 93:2325–2327 Itokawa H (2003) Introduction. In: Itokawa H, Lee K-H (eds) Taxus: the genus taxus. Taylor and Francis, London, p1 Schiff PB, Fant J, Horwitz SB (1979) Promotion of microtubule assembly in vitro by taxol. Nature 277:665–667 Goodman J, Walsh V (2001) The story of taxol; nature and politics in the pursuit of an anticancer drug. University Press, Cambridge, pp 1–282 Schiff PB, Horwitz SB (1980) Taxol stabilizes microtubules in mouse fibroblast cells. Proc Natl Acad Sci USA 77:1561–1565 Jordan MA, Wilson L (1998) Microtubules and actin filaments: dynamic targets for cancer chemotherapy. Curr Opin Cell Biol 10:123–130 Jordan MA, Toso RJ, Thrower D, Wilson L (1993) Mechanism of mitotic block and inhibition of cell proliferation by taxol at low concentrations, Proc Natl Acad Sci 90:9552–9556 Long BH, Fairchild CR (1994) Paclitaxel inhibits progression of mitotic cells to G1 phase by interference with spindle formation without affecting other microtubule functions during anaphase and telephase. Cancer Res 54:4355–4361 Horwitz SB, Lothstein L, Manfredi JJ, Mellado W. Parness J, Roy SN et al (1986) Taxol: mechanisms of action and resistance. Ann NY Acad Sci 466:733–744 Horwitz SB (1992) Mechanism of action of taxol. Trends Pharmacol Sci 13:134–136 Carboni JM, Singh C, Tepper MA (1993) Taxol and lipopolysaccharide activation of a murine macrophage cell line and induction of similar tyrosine phosphoproteins. J Natl Cancer Inst Monogr 15:95–101 Haldar S, Chintapalli J, Croce CM (1996) Paclitaxel Induces Bcl-2 phosphorylation and death of prostate cancer cells. Cancer Res 56:1253–1255

20 69. Blagosklonny MV, Giannakakou P, El-Deiry WS, Kingston DGI, Higgs PI, Neckers L et al (1997) Raf-1/bcl-2 phosphorylation: a step from microtubule damage to cell death. Cancer Res 57:130–135 70. Rodi DJ, Janes RW, Sanganee HJ, Holton RA, Wallace BA, Makowski L (1999) Screening of a library of phagedisplayed peptides identifies human bcl-2 as a taxolbinding protein. J Mol Biol 285:197–203 71. Blagosklonny MV, Fojo T (1999) Molecular effects of paclitaxel: myths and reality (a critical review). Int J Cancer 83:151–156 72. Abal M, Andreu JM, Barasoain I (2003) Taxanes: microtubule and centrosome targets, and cell cycle dependent mechanisms of action. Curr Cancer Drug Targets 3: 193–203 73. Schrevel J, Sinou V, Grellier P, Frappier F, Guenard D, Potier P (1994) Interactions between docetaxel (Taxotere) and Plasmodium falciparum-infected erythrocytes. Proc Natl Acad Sci USA 91:8472–6476 74. Pouvelle B, Farley PJ, Long CA, Taraschi TF (1994) Taxol arrests the development of blood-stage Plasmodium falciparum in vitro and Plasmodium chabaudi adami in malaria-infected mice. J Clin Invest 94:413–417 75. Michaelis ML, Ranciat N, Chen Y, Bechtel M, Ragan R, Hepperle M et al (1998) Protection against β-amyloid toxicity in primary neurons by paclitaxel (taxol). J Neurochem 70:1623–1627 76. Nogales E, Wolf SG, Downing KH (1997) Visualizing the secondary structure of tubulin: three-dimensional map at 4 Å. J Struct Biol 118:119–127 77. Nogales E, Wolf SG, Downing KH (1998) Structure of the αβ tubulin dimer by electron crystallography. Nature 391:199–203 78. Nogales E, Whittaker M, Milligan RA, Downing KH (1999) High-resolution model of the microtubule. Cell 96:79–88 79. Rao S, Krauss NE, Heerding JM, Swindell CS, Ringel I, Orr GA et al (1994) 3 -(p-azidobenzamido)taxol photolabels the N-terminal 31 amino acids of β-tubulin. J Biol Chem 269:3132–3134 80. Rao S, Orr GA, Chaudhary AG, Kingston DGI, Horwitz SB (1995) Characterization of the taxol binding site on the microtubule. J Biol Chem 270:20235–20238 81. Dasgupta D, Park H, Harriman GCB, Georg GI, Himes RH (1994) Synthesis of a photoaffinity taxol analogue and its use in labeling tubulin. J Med Chem 37:2976–2980 82. Loeb C, Combeau C, Ehret-Sabatier L, BretonGilet A, Faucher D, Rousseau B et al (1997) [3H](azidophenyl)ureido taxoid photolabels peptide amino acids 281–304 of β-tubulin. Biochemistry 36:3820–3825 83. Snyder JP, Nettles JH, Cornett B, Downing KH, Nogales E. (2001) The binding conformation of taxol in beta tubulin: a model based on the electron crystallographic density. Proc Natl Acad Sci USA 98:5312–5316 84. Lowe J, Li H, Downing KH, Nogales E (2001) Refined structure of β-tubulin at 3.5 a resolution. J Mol Biol 313:1045–1057 85. Dubois J, Guenard D, Gueritte-Voegelein F, Guedira N, Potier P, Gillet B et al (1993) Conformation of taxotere and analogues determined by nmr spectroscopy and molecular modeling studies. Tetrahedron 49:6533–6544

D.G.I. Kingston 86. Williams HJ, Scott AI, Dieden RA, Swindell CS, Chirlian LE, Francl MM et al (1993) NMR and molecular modeling study of the conformations of taxol and of its side chain methylester in aqueous and non-aqueous solution. Tetrahedron 49:6545–6560 87. Cachau RE, Gussio R, Beutler JA, Chmurny GN, Hilton BD, Muschick GM et al (1994) Solution structure of taxol determined using a novel feedback-scaling procedure for non-restrained molecular dynamics. Supercomputer Applications High Performance Computing 8:24–34 88. Vander Velde DG, Georg GI, Grunewald GL, Gunn CW, Mitscher LA (1993) “Hydrophobic collapse” of taxol and taxotere solution conformations in mixtures of water and organic solvent. J Am Chem Soc 115:11650–11651 89. Paloma LG, Guy RK, Wrasidlo W, Nicolaou KC (1994) Conformation of a water-soluble derivative of taxol in water by 2D-NMR spectroscopy. Chem Biol 1: 107–112 90. Ojima I, Kuduk SD, Chakravarty S, Ourevitch M, Begue J-P (1997) A novel approach to the study of solution structures and dynamic behavior of paclitaxel and docetaxel using fluorine-containing analogs as probes. J Am Chem Soc 119:5519–5527 91. Snyder JP, Nevins N, Cicero DO, Jansen J (2000) The conformations of taxol in chloroform. J Am Chem Soc 122:724–725 92. Ojima I, Inoue T, Chakravarty S (1999) Enantiopure fluorine-containing taxoids: potent anticancer agents and versatile probes for biomedical problems. J Fluorine Chem 97:3–10 93. Li Y, Poliks B, Cegelski L, Poliks M, Gryczynski Z, Piszczek G et al (2000) Conformation of microtubulebound paclitaxel determined by fluorescence spectroscopy and REDOR NMR. Biochemistry 39:281–291 94. He L, Jagtap PG, Kingston DGI, Shen H.-J Orr GA, Horwitz SB (2000) A common pharmacophore for taxol and the epothilones based on the biological activity of a taxane molecule lacking a C-13 side chain. Biochemistry 39:3972–3978 95. Ganesh T, Guza RC, Bane S, Ravindra R, Shanker N, Lakdawala AS et al (2004) The bioactive Taxol conformation of β-tubulin: experimental evidence from highly active constrained analogs. Proc Natl Acad Sci USA 101:10006–10011 96. Borzilleri RM, Bite GD (2009) Case History: Discovery of ixabepilone (IxempraTM ), a first-in-class epothilone analog for treatment of metastatic breast cancer. Ann Rep Med Chem 301–322 97. Altmann K-H (2001) Microtubule-stabilizing agents: a growing class of important anticancer drugs. Curr Opin Chem Biol 5:424–431 98. Myles DC (2002) Emerging microtubule stabilizing agents for cancer chemotherapy. Ann Rep Med Chem 37:125–132 99. Jimenez-Barbero J, Amat-Guerri F, Snyder JP (2002) The solid state, solution and tubulin-bound conformations of agents that promote microtubule stabilization. Curr Med Chem-Anti-Cancer Agents 2:91–122 100. Georg GI, Harriman GCB, Vander Velde DG, Boge TC, Cheruvallath ZS, Datta A et al (1995) Medicinal chemistry of paclitaxel. In: Georg GI, Chen, TT, Ojima I, Vyas DM (eds) Taxane anticancer agents: basic science and current

1

Plant-Derived Natural Products as Anticancer Agents

101. 102.

103.

104. 105.

106.

107.

108.

109.

110. 111.

112.

113.

114.

115.

116.

117.

118.

status. American Chemical Society, Washington, DC, pp 217–232 Nicolaou KC, Dai W-M, Guy RK (1994) Chemistry and biology of taxol. Angew Chem Int Ed Engl 33:15–44 Vyas DM, Kadow JF (1995) Paclitaxel: a unique tubulin interacting anticancer agent. In: Ellis GP, Luscombe DK (eds) Progress in medicinal chemistry. Elsevier Science B.V., Amsterdam, pp 289–337 Guénard D, Gueritte-Voegelein F, Lavelle F (1995) Taxoids: a new class of antimitotic compounds. Curr Pharm Design 1:95–112 Kingston DGI (2001) Taxol, a molecule for all seasons. Chem Commun 867–880 Kingston DGI, Jagtap PG, Yuan H, Samala L (2002) The chemistry of taxol and related taxoids. Prog Chem Org Nat Prod 84:53–225 Wang X, Itokawa H, Lee K-H (2003) Structure-activity relationships of taxoids. In: Itokawa H, Lee K-H (eds) Taxus: the genus taxus. Taylor and Francis, London, pp 298–386 Cragg GM, Newman DJ (2004) A tale of two tumor targets: topoisomerase I and tubulin. The Wall and Wani contribution to cancer chemotherapy. J Nat Prod 67:232–244 Ali S, Ahmad, I, Peters A, Masters G, Minchey S, Janoff A et al (2001) Hydrolyzable hydrophobic taxanes: synthesis and anti-cancer activities. Anti-Cancer Drugs 12:117–128 Altstadt TJ, Fairchild CR, Golik J, Johston KA, Kadow JF, Lee FY et al (2001) Synthesis and antitumor activity of novel C-7 paclitaxel ethers: discovery of BMS-184476. J Med Chem 44:4577–4583 Ojima I, Geney R (2003) 109881(Aventis). Curr Opin Invest Drugs 4:737–740 Chen S-H (2002) Discovery of a novel C-4 modified 2nd generation paclitaxel analog BMS-188797. Frontiers Biotechnol Pharmaceut 3:157–171 Cisternino S, Bourasset F, Archimbaud Y, Semiond D, Sanderink G, Scherrmann J-M (2003) Nonlinear accumulation in the brain of the new taxoid TXD258 following saturation of P-glycoprotein at the blood-brain barrier in mice and rats. Br J Pharmacol 138:1367–1375 Ojima I, Geney R, Ungureanu IM, Li D (2002) Medicinal chemistry and chemical biology of new generation taxane antitumor agents. Life 53:269–274 Sampath D, Discafani CM, Loganzo F, Beyer C, Liu H, Xingzhi T et al (2003) MAC-321:a novel taxane with greater efficacy than paclitaxel and docetaxel in vitro and in vivo. Mole Cancer Ther 2:873–874 Shionoya M, Jimbo T, Kitagawa M, Soga T, Tohgo A (2003) DJ-927:a novel oral taxane, overcomes Pglycoprotein-mediated multidrug resistance in vitro and in vivo. Cancer Sci 94:459–466 Cabral F, Wible L, Brenner S, Brinkley BR (1983) Taxolrequiring mutant of Chinese hamster ovary cells with impaired mitotic spindle assembly. J Cell Biol 97:30–39 Monzo M, Rosell R, Sanchez JJ, Lee JS, O’Brate A, Gonzalez-Larriba JL et al (1999) Paclitaxel resistance in nonsmall-cell lung cancer associated with beta-tubulin gene mutations. J Clin Oncol 17:1786–1793 Webster L, Linsenmeyer M, Millward M, Morton C, Bishop J, Woodcock D (1993) Measurement of cremophor EL following taxol: plasma levels sufficient to reverse

21

119. 120.

121. 122.

123.

124.

125. 126. 127.

128.

129.

130.

131.

132.

133.

134.

135. 136. 137.

drug exclusion mediated by the multi-drug phenotype. J Natl Cancer Inst 85:1685–1690 Liebmann J, Cook JA, Mitchell JB (1993) Cremophor EL, solvent for paclitaxel, and toxicity. Lancet 342:1428 Lin S, Ojima I (2000) Recent strategies in the development of taxane anticancer drugs. Exp Opin Ther Patents 10:1–21 Garber K. (2004) Improved paclitaxel formulation hints at new chemotherapy approach. J Nat Cancer Inst 96:90–91 Harris JW, Katki A, Anderson LW, Chmurny GN, Paukstelis JV, Collins JM (1994) Isolation, structural determination, and biological activity of 6a-hydroxytaxol, the principal human metabolite of taxol. J Med Chem 37:706–709 Rowinsky EK, Wright M, Monsarrat B, Lesser GJ, Donehower RC (1993) Taxol: pharmacology, metabolism and clinical implications. Cancer Surv 17 (Pharmacokinetics Cancer Chemother), 283–304 Vuilhorgne M, Gaillard C, Sanderink GJ, Royer I, Monsarrat B, Dubois J et al (1995) Metabolism of taxoid drugs. In: Georg GI, Chen TT, Ojima I, Vyas DM (eds) Taxane anticancer agents: basic science and current status. American Chemical Society, Washington, DC, pp 98–110 Mekhail T, Markman M (2002) Paclitaxel in cancer therapy. Exp Opin Pharmacother 3:755–766 Levin M (2001) The role of taxanes in breast cancer treatment. Drugs Today 37:57–65 Rowinsky EK (1997) The development and clinical utility of the taxane class of antimicrotubule chemotherapy agents. Ann Rev Med 48:353–374 Kris MG, Manegold C (2001) Docetaxel (taxotere) in the treatment of non-small cell lung cancer: an international update. Sem Oncol 28:1–3 Michaud LB, Valero V, Hortobagyi G (2000) Risks and benefits of taxanes in breast and ovarian cancer. Drug Safety 23:401–428 Calderoni A, Cerny T. (2001) Taxanes in lung cancer: a review with focus on the European experience. Critical Rev Oncol/Hematol 38:105–127 McGuire WP, Rowinsky EK, Rosenshein NB, Grumbine FC, Ettinger DS, Armstrong DK (1989) Taxol: a unique antineoplastic agent with significant activity in advanced ovarian epithelial neoplasms. Ann Intern Med 111: 273–279 Eisenhauer EA, Vermorken JB (1998) The taxoids: comparative clinical pharmacology and therapeutic potential. Drugs 55:5–30 Piccart MJ, Bertelsen K, James K, Cassidy J, Mangioni C, Simonsen E et al (2000) Randomized intergroup trial of cisplatin-paclitaxel versus cisplatin-cyclophosphamide in women with advanced epithelial ovarian cancer: threeyear results. J Natl Cancer Inst 92:699–708 Michaud LB, Valero V, Hortobagyi G (2000) Risks and benefits of taxanes in breast and ovarian cancer. Drug Safety 23:401–428 Mekhail T, Markman M (2002) Paclitaxel in cancer therapy. Exp Opin Pharmacother 3:755–766 Hudis C (2003) The use of taxanes in early breast cancer. EJC Suppl 1:1–10 Nowak AK, Wilcken NRC, Stockler MR, Hamilton A, Ghersi D (2004) Systematic revierw of taxane-containing

22

138.

139. 140.

141.

142.

143.

144.

145.

146.

147.

148.

149.

150.

151.

152.

153.

D.G.I. Kingston versus non-taxane-containing regimens for adjuvant and neoadjuvant treatment of early breast cancer. Lancet Oncol 5:372–380 Rowinsky EK (1997) The development and clinical utility of the taxane class of antimicrotubule chemotherapy agents. Ann Rev Med 48:353–374 Ramalingam S, Belani CP (2004) Paclitaxel for non-small cell lung cancer. Exp Opin Pharmacother 5:1771–1780 Cai J, Zheng T, Masood R, Smith DL, Hinton DR, Kim CN et al (2000) Paclitaxel induces apoptosis in AIDSrelated Kaposi’s Sarcoma cells. Saracoma 4:37–45 Wall ME, Wani MC, Cook CE, Palmer KH, McPhail AT, Sim GA (1966) Plant antitumor agents. I. The isolation and structure of camptothecin, a novel alkaloidal leukemia and tumor inhibitor from Camptotheca acuminate. J Am Chem Soc 88:3888–3890 Moertel CG, Schutt AJ, Reitmemeier RJ, Hahn RG (1972) Phase II study of camptothecin (NSC-100880) in the treatment of advanced gastrointestinal cancer. Cancer Chemother Rep 56:95–101 Hsiang Y.-H Hertzberg, R, Hecht S, Liu F (1985) Camptothecin induces protein-linked DNA breaks via mammalian DNA topoisomerase I. J Biol Chem 260:14873–14878 Gallo RC, Whang-Peng J, Adamson RH (1971) Studies on the antitumor activity, mechanism of action, and cell cycle effects of camptothecin. J Natl Cancer Inst 46: 789–795 Pommier Y, Pourquier P, Urasaki Y, Wu J, Laco GS (1999) Topoisomerase I inhibitors: selectivity and cellular resistance. Drug Resistance Updates 2:307–318 Nitiss J, Wang JC (1988) DNA topoisomerase-targeting antitumor drugs can be studied in yeast. Proc Natl Acad Sci USA 85:7501–7505 Husain I, Mohler JL, Seigler HF, Bestermann JM (1994) Elevation of topoisomerase I messenger RNA, protein, and catalytic activity in human tumors: demonstration of tumor-type specificity and implications for cancer chemotherapy. Cancer Res 54:539–546 Siddoo-Atwal C, Haas AL, Rosin MP (1996) Elevation of interferon beta-inducible proteins in ataxia telangiectasia cells. Cancer Res 56:443–447 Kretzschmar M, Meisterernst M, Roeder RG (1993) Identification of human DNA topoisomerase I as a cofactor for activator-dependent transcription by RNA polymerase II. Proc Natl Acad Sci USA 90:11508–11512 Yeh YC, Liu HF, Ellis CA, Lu AL (1994) Mammalian topoisomerase I has base mismatch nicking activity. J Biol Chem 269:15498–15504 Rossi F, Labourier E, Forne T, Divita G, Derancourt J, Riou JF et al (1996) Specific phosphorylation of SR proteins by mammalian DNA topoisomerase I. Nature 381:80–82 Hoki Y, Fujimori A, Pommier Y. (1997) Differential cytotoxicity of clinically important camptothecin derivatives in P-glycoprotein-overexpressing cell lines. Cancer Chemother Pharmacol 40:433–438 Sugimoto Y, Tsukahara S, Oh-Hara T, Isoe T, Tsuruo T (1990) Decreased expression of DNA topoisomerase I in camptothecin-resistant cell lines as determined by monoclonal antibody. Cancer Res 50:6925–6930

154. Eng WK, McCabe FL, Tan KB, Mattern MR, Hofmann GA, Woessner RD et al (1990) Development of stable camptothecin-resistant subline of P388 leukemia with reduced topoisomerase I content. Mol Pharmacol 38:471–480 155. Kaufmann SH, Gore SD, Letendre L, Svingen PA, Kottke T, Buckwalter CA et al (1996) Factors affecting topotecan sensitivity in human leukemia samples. Ann NY Acad Sci 803:128–142 156. Rubin E, Pantazis P, Bharti A, Toppmeyer D, Giovanella B, Kufe D (1994) Identification of amutant human topoisomerase I with intact catalytic activity and resistance to 9-nitrocanmptothecin. J Biol Chem 269:2433–2439 157. Woessner RD, Eng WK, Hofmann GA, Rieman DJ, McCabe FL, Hertzberg RP et al (1992) Camptothecin hyper-resistant P388 cells: drug-dependent reduction in topoisomerase I content. Oncol Res 4:481–488 158. Garcia-Carbonero R, Supko JG (2002) Current perspectives on the clinical experience, pharmacology, and continued development of the camptothecins. Clin Cancer Res 8:641–661 159. Lorence A, Nessler CL (2004) Camptothecin, over four decades of surprising findings. Phytochemistry 65: 2735–2749 160. Stork G, Schultz AG (1971) The total synthesis of dlcamptothecin. J Am Chem Soc 93:4074–4075 161. Jew S-S, Kim G, Kim H-J, Roh E-Y, Park H (1996) Synthesis and antitumor activity of camptothotecin analogues. Korean J Med Chem 6:263–282 162. Thomas CJ, Rahier NJ, Hecht SM (2004) Camptothecin: current perspectives. Bioorg Med Chem 12:1585–1604 163. Ejima A, Teresawa H, Sugimori M, Tagawa H (1990) Antitumour agents. Part 2. Asymmetric synthesis of (S)camptothecin. J Chem Soc Perkin Trans 1:27–31 164. Comins DL, Nolan JM (2001) A practical six-step synthesis of (S)-camptothecin. Org Lett 3:4255–4257 165. Tagami K, Nakazawa N, Sano S, Nagao Y (2000) Asymmetric synthesis of (+)-camptothecin and (+)-7-ethyl-10-methoxycamptothecin. Heterocycles 53:771–776 166. Bennasar M.-L Zulaica E, Juan C, Alonso Y, Bosch J (2002) Addition of ester enolates to N-alkyl-2fluoropyridinium salts: total synthesis of (±)-20deoxycamptothecin and (+)-camptothecin. J Org Chem 67:7465–7474 167. Ciufolini MA, Roschangar F. (2000) Practical synthesis of (20 S)-(+)-camptothecin: the progenitor of a promising group of anticancer agents. Targets Heterocyclic Systems 4:25–55 168. Imura A, Itoh M, Miyadera A (1998) Enantioselective synthesis of 20(S)-camptothecin using an enzymecatalyzed resolution. Tetrahedron: Asymmetry 9: 2285–2291 169. Fang FG, Xie S, Lowery MW (1994) Catalytic enantioselective synthesis of 20(S)-camptothecin: a practical application of the sharpless asymmetric dihydroxylation reaction. J Org Chem 59:6142–6143 170. Jew S-S, Ok K, Kim H, Kim MG, Kim JM, Hah JM et al (1995) Enantioselective synthesis of 20(S)-camptothecin using sharpless catalytic asymmetric dihydroxylation. Tetrahedron: Asymmetry 6:1245–1248

1

Plant-Derived Natural Products as Anticancer Agents

171. Blagg BSJ, Boger DL (2002) Total synthesis of (+)camptothecin. Tetrahedron 58:6343–6349 172. Curran DP, Josien H, Bom D, Gabarda AE, Du W (2000) The cascade radical annulation approach to new analogues of camptothecins. Combinatorial synthesis of silatecans and homosilatecans. Ann NY Acad Sci 922:112–121 173. Yabu K, Masumoto S, Kanai M, Curran DP, Shibasaki M (2002) Studies toward practical synthesis of (20S)camptothecin family through catalytic enantioselective cyanosilylation of ketones: improved catalyst efficiency by ligand-tuning. Tetrahedron Lett 43:2923–2926 174. Sawada, S, Okajima S, Aiyama R, Nokata K, Furuta T, Yokokura T et al (1991) Synthesis and antitumor activity of 20(S)-camptothecin derivatives: carbamate-linked, water-soluble derivatives of 7-ethyl-10hydroxycamptothecin. Chem Pharm Bull 39:1446–1454 175. Kingsbury WD, Boehm JC, Jakas DR, Holden KG, Hecht SM, Gallagher G et al (1991) Synthesis of water-soluble (aminoalkyl)camptothecin analogs: inhibition of topoisomerase I and antitumor activity. J Med Chem 34:98–107 176. Thomas CJ, Rahier NJ, Hecht SM (2004) Camptothecin: current perspectives. Bioorg Med Chem 12:1585–1604 177. Meng L, Liao Z, Pommier Y (2003) Non-camptothecin DNA topoisomerase I inhibitors in cancer therapy. Curr Top Med Chem 3:305–320 178. Ten Bokkel Huinink W, Lane SR, Ross GA (2004) Longterm survival in a phase III, randomized study of topotecan versus paclitaxel in advanced epithelial ovarian carcinoma. Ann Oncol 15:100–103 179. Abigerges D, Chabot GG, Armand JP, Herait P, Gouyette A, Gandia G (1995) Phase I and pharmacologic studies of the camptothecin analog irinotecan administered every 3 weeks in cancer patients. J Clin Oncol 13:210–221 180. Sparreboom A, de Jonge MJ, Punt CJ, Nooter K, Loos WJ, Porro MG et al (1998) Pharmacokinetics and bioavailability of oral 9-aminocamptothecin capsules in adult patients with solid tumors. Clin Cancer Res 4:1915–1919 181. Kim D-K, Lee N (2002) Recent advances in topoisomerase I-targeting agents, camptothecin analogues. Mini Rev Med Chem 2:611–619

23 182. Luzzio MJ, Besterman JM, Emerson DL, Evans MG, Lackey K, Leitner PL et al (1995) Synthesis and antitumor activity of novel water soluble derivatives of camptothecin as specific inhibitors of topoisomerase I. J Med Chem 38:395–401 183. MacKenzie MJ, Hirte HW, Siu LL, Gelmon K, Ptaszynski M, Fisher B, Eisenhauer E (2004) A phase I study of OSI211 and cisplatin as intravenous infusions given on days 1:2 and 3 every 3 weeks in patients with solid cancers. Ann Oncol 15:665–670 184. van Hattum AH, Pinedo HM, Schluper HMM, Erkelens CAM, Tohgo A, Boven E (2002) The activity profile of the hexacyclic camptothecin derivative DX-8951f in experimental human colon cancer and ovarian cancer. Biochem Pharm 64:1267–1277 185. Dallavalle S, Ferrari A, Biasotti B, Merlini L, Penco S, Gallo G et al (2002) Novel 7-oxyiminomethyl derivatives of camptothecin with potent in vitro and in vivo antitumor activity. J Med Chem 44:3264–3274 186. Ulukan H, Swaan PW (2002) Camptothecins. A review of their chemotherapeutic potential. Drugs 62: 2039–2057 187. Dallavalle S, Merfini, L, Penco S, Zunino F (2002) Perspectives in camptothecin development. Exp Opin Ther Patents 12:837–844 188. Bailly C (2003) Homocamptothecins: potent topoisomerase I inhibitors and promising anticancer drugs, Critical Rev Oncol/Hematol 45:91–108 189. Shao R-G, Cao C-X, Shimizu T, O’Connor P, Kohn KW, Pommier Y (1997) Abrogation of an S-phase checkpoint and potentiation of camptothecin cytotoxicity by 7-hydroxystaurosporine (UCN-O1) in human cancer cell lines, possibly influenced by p53 function. Cancer Res 57:4029–4035 190. Pommier Y. (2004) Camptothecins and topoisomerase I: a foot in the door. Targeting the genome beyond topoisomerase I with camptothecins and novel anticancer drugs: importance of DNA replication, repair, and cell cycle checkpoints. Curr Med Chem Anticancer Agents 4:429–434

Chapter 2

The Vinca Alkaloids Nicole Coufal and Lauge Farnaes

2.1 Introduction The periwinkle plant, Cantharanthus roseus G. Don (Vinca rosea Linn.) is endemic to the island of Madagascar, and has long been ascribed a wide assortment of medicinal properties ranging from the treatment of diabetes to wound healing. Of the over fifty alkaloids present in minute quantities within the plant, only two (vincristine and vinblastine) have been isolated, synthesized, and are widely used as chemotherapeutic agents [1, 2]. The antitumor activity of the vinca alkaloids was identified by two independent groups both investigating extracts of Vinca rosea for hypoglycemic activity in the late 1950s [2, 3]. Numerous other natural alkaloids were also investigated but not pursued due to severe toxicity [4]. Now the vinca alkaloids have become part of the standard of care for more than 30 years. A number of semisynthetic derivates have since been identified and tested. Two of these, vindesine and vinorelbine, are currently used in clinical practice. A third, vinflunine, is presently in phase III clinical trials [5, 6]. These compounds are commonly administered as sulfate salts to enhance solubility and increase stability. All members of this family of molecules enact their cytotoxic activity primarily by binding to tubulin and inhibiting polymerization or extension of microtubules. Microtubules are crucial for a wide range of cellular activities, including mitotic spindles formation necessary for cell division. The naturally occurring

vinca alkaloids have been used in the treatment of a wide range of malignancies, most prominently hematological cancers such as leukemia and lymphoma, but also testicular cancer. The semi-synthetics have exhibited clinical activity against lung, ovarian, and breast malignancies.

2.2 Chemistry The vinca alkaloids are bulky molecules with closely related structures (Fig. 2.1), containing both an indole nucleus (catharanthine portion) and a dihydroindole nucleus (vindoline portion) connected by a carbon– carbon ring with variable substituents attachment to the rings. Vincristine differs from vinblastine, vindesine, and vinorelbine as it has an acetaldehyde group at the nitrogen atom at position one (see vincristine in Fig. 2.1 for numbering) in the vindoline nucleus instead of a methyl group. Vincristine, vinblastine, and vinorelbine all have a methyl ester moiety attached to carbon 3 in the vindoline nucleus while vindesine has an amide attached at this same site. Vincristine, vinblastine, and vinorelbine are all acetylated at carbon 4 while vindesine has a hydroxyl group. Vinorelbine also has a different structure in the catharanthine portion of the molecule with the 11-membered ring being replaced with a 10-membered ring by the elimination of carbon 7 .

2.3 Mechanism of Action N. Coufal () UCSD Department of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA e-mail: [email protected]

The vinca alkaloids interact with tubulin thereby disrupting the mitotic spindle apparatus [7–9]. Tubulin is usually present as a heterodimer of α-tubulin and

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_2, © Springer Science+Business Media B.V. 2011

25

26

N. Coufal and L. Farnaes 7'

N

N

N

N N H O

H 1

O O

3

N

O

O

H O

O

O

Vinblastine N

N

N

N H O O

O

OH O

O

O

Vincristine

N H O

O

N O

OH O

O

O

4

N H O

N O

OH OH NH2

Vindesine

N H O

H O O

N O

O

OH O

Vinorelbine

Fig. 2.1 The structure of the vinca alkaloids

β-tubulin each with a molecular weight of 55 kDa. The heterodimers polymerize to form microtubules which are involved in mitosis and meiosis through the formation of the spindle apparatus which separates the chromosomes. In addition microtubules are involved in cell shape, axonal transport, and secretion [10]. The biological function of microtubules is determined largely by their polymerization dynamics [11]. The two main types of dynamic behavior are “dynamic instability” and “treadmilling.” The assembly and disassembly of the microtubule polymers are regulated by the binding of tubulin and guanosine 5-triphoshpate (GTP) [12]. All microtubules have a plus end of the microtubule that polymerizes faster and thereby grows faster than the opposing minus end. Dynamic instability is characterized by changes in the length of the microtubule structure, primarily at the plus end whereas treadmilling is characterized by the movement of cellular components along a tubule that is maintained at constant length, with equal addition at the minus end and subtraction at the plus end. It has been suggested that treadmilling might be particularly important in mitosis [13]. In mitosis the microtubules form the spindle apparatus which aligns the chromosomes along the metaphase plate and then pulls the chromosomes apart during the mitotic process.

All the vinca alkaloids bind to tubulin with high affinity and inhibit further polymerization. Since microtubules are in a constant dynamic state of polymerization and depolymerization the inhibition of polymerization by the vinca alkaloids functions to create a state of net depolymerization. The interaction of the vinca alkaloids with the microtubules of the spindle apparatus disrupts the spindle apparatus and leads to metaphase arrest. Vinorelbine, vincristine, and vinblastine have all been shown to possess roughly equal tubulin binding constants [8] and cause metaphase block at roughly the same concentrations. It has been suggested that the differences in the relative potencies of the vinca alkaloids may not be due to their binding efficiencies but rather to differences in their intracellular retention times or the stability of the drug-tubulin complexes [14]. In addition, vincristine is a much more potent inhibitor of axonal microtubule formation [15]. While the disruption of the mitotic process is the key feature of the vinca alkaloids the final effect of this metaphase arrest is the death of the cell through activation of apoptotic pathways [16, 17]. In vitro experiments with these agents have shown that exposure can lead to apoptosis through both p53-dependent and p53-independent pathways [18–20]. Tumor cells that have been exposed to the agents show characteristic morphological and molecular changes that are

2

The Vinca Alkaloids

associated with the induction of apoptosis in a dose and time dependent fashion. Since the drugs attempt to induce apoptosis by halting the cell in mitosis, cytotoxicity is strongly dependent on the duration of exposure. A number of other cellular effects beyond microtubule inhibition have also been reported for the vinca alkaloids. These include inhibition of amino acid metabolism [21], calmodulin-dependent Ca2+ ATPase activity [22], nucleic acid synthesis [4]. In order to achieve these other effects though the concentrations of the drugs had to be at much higher levels than are achieved in vivo.

2.4 Clinical Use The vinca alkaloids are broad acting mitotic inhibitors used in the treatment of numerous malignancies [23]. They have been used for both curative and palliative aims in the treatment of a variety of tumors, most often Hodgkin’s disease, acute lymphocytic leukaemia, testicular cancer, breast carcinoma, ovarian cancer, and non-small-cell lung cancer (NSCLC). Other malignancies treated with vinca alkaloids include Wilms’ tumor, Ewing’s sarcoma, neuroblastomas, hepatoblastoma, and rhabdomyosarcoma. Vincristine is part of a front-line therapy for the treatment of acute lymphocytic leukaemia. It is also commonly used in pediatric oncology owing to the higher level of sensitivity of pediatric malignancies and the better tolerance of therapeutic doses in children. Vincristine is also a standard treatment for non Hodgkin’s lymphoma as part of the chemotherapy regimen CHOP (Cytoxan, Hydroxyrubicin (Adriamycin), Oncovin (Vincristine), Prednisone) [24] and as a treatment of Hodgkin’s lymphoma as part of MOPP or COPP. Vincristine is also generally used in the treatment of multiple myeloma as a bolus or daily infusion in combination with doxorubicin and dexamethasone [25]. Vinblastine is used in combination with other agents as a front-line therapy for the treatment of Hodgkin’s disease and testicular cancer. It is also approved for use as a single agent or in combination with cisplatin for the treatment of NSCLC and advanced breast cancer [26, 27]. Vindesine is used in combination with other agents, such as mytomycin C and/or platinating agents in the treatment of

27

NSCLC [28]. Vinorelbine is the only vinca which can be administered orally, and resistance to vinorelbine develops more slowly and is less cross-resistant with resistance to vincristine and vinblastine. Vinflunine is currently being investigated for use in the treatment of metastatic breast cancer and NSCLC trials [5, 6]. The vinca alkaloids are routinely administered by direct intravenous injection. They are extreme vesicants (see Section 2.8) so are often administered as a rapid bolus. Vinorelbine can be administered orally. The single dose cap for vincristine is 2.0 (mg/m2 ) due to substantial neurotoxicity reported at higher doses. However, significant interpatient variability exist, and some patients can tolerate much higher doses with limited toxicity [29, 30]. For vinblastine, initial dose recommendations are 2.5 and 3.7 mg/m2 for children and adults, respectively, with gradual dose escalation based on hematologic tolerance. Vinesine has been evaluated for weekly and biweekly administrations, and is most commonly administered at 2–4 mg/m2 every 7–14 days [27]. Additionally, prolonged infusion schedules have been evaluated to increase the critical threshold concentration of vincristine, vinblastine, and vindesine, and all indicate an increased dose can be administered safely without major toxicity for 1–2 days (vindesine) or up to 5 days (vincristine) [27]. However, there is little evidence that prolonged infusions are more effective than bolus schedules. Vinorelbine is most commonly administered at a dose of 30 mg/m2 weekly or biweekly. It can be administered as a slow infusion or bolus, although evidence indicates decreased local venous toxicity with a bolus [31].

2.5 Mechanisms of Resistance Resistance to the vinca alkaloids develops rapidly and can occur through alterations in numerous cell pathways. For chemotherapeutic agents, resistance is commonly due to decreased drug accumulation and retention within target tumor cells. The most widely documented mechanism of vinca alkaloid efflux is by members of the ATP-binding cassette (ABC) transporter family, a huge gene family of transmembrane transporters which efflux large endobiotic and xenobiotic compounds from cells in an ATP dependent fashion. Resistance via multidrug resistance channels

28

(MDR) can be innate or acquired. These transporters not only confer resistance to the vinca alkaloids, but also to a variety of other well known pharmacologic agents such as taxanes, anthracyclines, epipodophyllotoxins, dactinomycin and colchicine [32]. The two most investigated members of this family in regards to vinca alkaloid resistance are the permeability glycoprotein (P-gp)/MDR1 endcoded gene product (ABC subfamily B1;ABCB1) and the multidrug resistance protein MRP (ABC subfamily C2; ABCB1) [33–37]. Although these two transport systems have the same end result, they appear to utilize slightly different mechanisms. For instance, P-gp vesicles have been shown to directly transport vinca alkaloids, whereas MRP vesicles transport in a glutathione dependent fashion [34]. MDR1 is a 170-kD P-gp transmembrane pump that regulates efflux of large amphipathic hyrdophic substances in an energy dependent fashion. Drug resistance is proportional to the amount of channel present in the cell membrane [36]. Innate resistance is offered by tissues which constitutively express a high amount of the channel, such as endothelium and epithelial tissue, especially renal epithelium and colonic endothelium [38]. This channel is highly expressed in tumors arising from constitutively expressing tissues (kidney and colon cancer). Secondarily tumors can overexpress MDR1 or related ABC transporters as a result of treatment with vinca alkaloids, a phenomenon which has been observed in post-treatment leukemia, lymphoma, and multiple myeloma. MRP is a 190-kD transmembrane protein with a 15% homology to MDR1 which has been shown to mediate vinca alkaloid resistance as well as resistance to other chemotherapeutic agents such as methotrexate [32, 39–41]. Although many other ABC transporters have been characterized and implicated in vinca alkaloid resistance, their role is even less apparent than that of MDR1 and MRP. One important feature of MDR1 and MRP resistance is that is reversible in specific conditions, such as after treatment with calcium channel blockers, detergents, progesterone or estrogenic antagonists, antibiotics, antihypertensives, antimalarials, antiarrhythmics, and immunosuppressives [32]. All of these agents bind directly to the channel and inhibit efflux, thereby increasing intracellular concentrations of chemotherapeutic agents. To date the usefulness of this observation has been limited as these agents also act to enhance drug uptake into normal cells,

N. Coufal and L. Farnaes

thereby decreasing biliary elimination and decreasing drug clearance, ultimately lead to enhanced toxicity [42–44]. In addition, MDR1 has been shown to respond to environmental stress by producing multiple alternative proteins, which could explain the unsatisfactory outcomes from pharmacologic modulations efforts thus far [32]. Other mechanisms of resistance to the vinca alkaloids have also been identified, although primarily in preclinical models. Each of these represents a different modification in the mechanism of vinca alkaloid action or of downstream signaling to allow the tumor cell to escape programmed cell death. For instance, changes in tubulin expression or tubulin binding [45] can lead to resistance. Resistant tumors have been found to contain mutations which lead to amino acid substitutions or posttranslational modifications such as acetylation or phosphorylation and thereby change the structure of tubulin [46, 47]. Although the mechanism of resistance in these cases is not entirely clear, it is thought to be as a result of hyper-stabilization of tubulin rather than a change in the drug binding affinity of the vinca alkaloids [48]. In addition, changes in heat shock response [49] or alterations in apoptotic signaling allowing cells to escape apoptosis [50, 51]. Typically apoptosis in response to the vinca alkaloids is initiated through a lengthy set of signaling pathways comprising c-jun and stress-activated protein kinase activation [19]. Therefore, overexpression of anti-apoptotic genes such as Bcl-2 and Bcl-XL has been shown to afford resistance to a wide assortment of chemotherapeutic agents including vincristine and vinblastine [52, 53].

2.6 Pharmacokinetics Pharmacokinetic data on the vinca alkaloids has been hampered by a lack of sensitive, specific, and reliable detection methods in the past. Since the vinca alkaloids are given in such minute amounts it had been necessary to trace them with radioactively labeled drugs. This was a difficult process as the vinca alkaloids can be somewhat unstable and rapidly form degradation products which can be separated by highpressure liquid chromatography (HPLC) [54]. In an effort to further understand the distribution of the vinca alkaloid, radioimmuno assay and enzyme-linked immunosorbent assay (ELISA) have been developed that can observe the vinca alkaloids in the picomolar

2

The Vinca Alkaloids

29

concentraton range [27]. These assays were originally performed with polyclonal antisera which were hampered by reactions with possible metabolites but in the interim monoclonal antibodies were raised which have allowed for more precise tracking of the vinca alkaloids in vivo. The vinca alkaloids are most commonly given intravenously by bolus injection or brief infusion and their pharmacokinetic profile most closely fits a three compartment model [27]. Characteristics of the vinca alkaloids include large volumes of distribution, high clearance rates, long terminal half lives (T1/2 ), significant hepatic metabolism, and biliary/fecal metabolism. With a normal adult dose peak plasma concentrations of 100–500 nmol are maintained for only a few minutes with concentrations of 1–2 nmol persisting for longer durations [55, 56]. There can be a significant variation in the pharmacokinetics of these drugs in different patients. This may be due to variations in protein or tissue binding, hepatic metabolism and/or biliary clearance [57]. Although prolonged infusion schedules may help to avoid excessively toxic peak concentration levels and increase the duration of drug exposure, there is no evidence that prolonged infusion schedules are more effective than bolus schedules [58]. Vincristine, vinblastine, and vindesine are only given by an intravenous route but vinorelbine can be given both by intravenous and oral routes. Oral absorption of vinorelbine is rapid with maximal drug concentrations achieved in 1–2 h with an absolute Table 2.1 Properties of the vinca alkaloids Vincristine

bioavailability of approximately 27% with a range of 10–60% [58] when given in soft gelatin capsules. The oral clearance of vinorelbine approaches hepatic flow (0.8 L/H/Kg) suggesting a significant first-pass effect. Due to the large first pass effect, oral doses may need to be up to three times larger than intravenous doses to achieve the same effect. In addition the bioavailability of oral vinorelbine may be lowered slightly by food [59] (Table 2.2). The vinca alkaloids all bind strongly to plasma proteins including albumin, lipoproteins, and α1-acid glycoprotein [61]. The primary binding protein for the vinca alkaloids is α1-acid glycoprotein with an approximately 10 fold higher affinity for these compounds than for albumin [62, 63]. At drug concentrations similar to those achieved in vivo protein binding of vincristine and vinblastine is 99% suggesting that the total binding sights for the vinca alkaloids are saturatable [64]. In addition to the binding of vinca alkaloids to serum proteins the vinca alkaloids also rapidly bind to platelets and lymphocytes after intravenous infusion [61, 65]. Platelet bound drug accounts for approximately 80% of the blood bound drug. The distribution of the drug into platelets and lymphocytes is 1/2 h for vinorelbine, 1 h for vinblastine, and 3 h for vincristine [61, 65]. Since the binding of the drug to platelets is a reversible process and the release of vincristine is much slower than it is vinblastine or vinorelbine this may explain the differences in their respective T1/2 (see Table 2.1).

Vinblastine

Vindesine

Vinorelbine

Mechanism of action

Low concentrations inhibit changes in microtubule length (treadmilling and dynamic instability) whereas high concentrations inhibit polymerization of tubulin Standard Dose (mg/m2 ) 1–1.4 every 3 weeks 6–8 every week 3–4 every 1–2 weeks 15–30 every 1–2 weeks Route of administration Intravenous Intravenous Intravenous Intravenous, oral Metabolism Predominantly P450 Predominantly P450 Predominantly P450 Predominantly P450 IIIA IIIA IIIA IIIA Elimination Biliary/Fecal Biliary/Fecal Biliary/Fecal Biliary/Fecal Terminal half-life (h) (T1/2 ) 95 (range 19–155) 25 (range 7–47) 24 (range 12–42) 33 (range 14–44) Principal toxicity Peripheral Neuropathy Neutropenia Neutropenia Neutropenia Table 2.2 Disposition of vinca alkaloids by bolus injection in patients with normal organ function [60] Volume of Elimination Fecal Clearance distribution (l/kg) half-life (h) Clearance (l/h/kg) (%)

Renal Clearance (%)

Vincristine Vinblastine Vindesine Vinorelbine

4–13.5 5.5–34 4–19 3.3–24.6

7.2 (3.1–11.0) 24.7 (17.3–35.1) 8.6 (6.8–10.5) 54.3 (44.7–75.6)

45.1 (8.2–144) 25.6 (19.6–29.2) 23.6 (19.0–34.8) 41.2 (31.2–62.4)

0.16 (0.1–0.3) 0.79 (0.7–0.9) 0.22 (0.1–0.3) 0.95 (0.8–1.3)

69 25–41 ND 40–58

30

Animal studies using radiolabeled drugs show that, following intravenous administration the vinca alkaloids are rapidly and widely distributed throughout the body [66–70]. After treatment with radiolabeled vincristine, vinblastine, or vindesine radioactivity is concentrated in the spleen, liver, kidney, lymph nodes, and thymus. Moderate levels are found in lungs, heart, and skeletal muscle. Brain and fat contain low levels. Not all of these studies were able to clearly distinguish between drug and degradation products. Vinorelbine also accumulates in the spleen, liver, kidney, and to very high levels in the lungs. Tracing the distribution of radioactively labeled vinorelbine in patients shows that the concentration of drug in the lungs may be up to 300 times greater than that in the serum and 3.4–13.8 fold higher than the lung concentration that is achieved by vincristine or vindesine [71]. This higher concentration of vinorelbine in the lungs is a primary reason for its preferential use in the treatment of non-small cell lung cancer. In addition, vinblastine is more actively sequestered in tissue than is vincristine as demonstrated by a retention of 73% of radioactivity in the body six days post-treatment [72]. The vinca alkaloids have poor penetration into the central nervous system (CNS). Although these drugs have a high lipophilicity their extensive lymphocyte, platelet and protein binding prevents them from penetrating the blood brain barrier (BBB). Additionally, since the vinca alkaloids are substrates for permeability glycoprotein (P-gp) and this protein is an active part of the blood brain barrier, any vinca alkaloid that does pentrate the BBB is actively removed. It has been found that mice that lack P-gp have a 22 fold higher accumulation of the vinca alkaloids when compared to mice that express wild-type P-gp [73]. Accumulation and uptake of the vinca alkaloids shows a direct correlation to their respective lipophilicities. Since vinorelbine is the most lipophilic of the vinca alkaloids it also exhibits the most liver uptake of the vinca alkaloids [74]. In vitro experiments using freshly isolated hepatocytes have shown that vincristine, vinblastine, vindesine, and vinorelbine are almost totally converted to water soluble metabolites which are then excreted into the extracellular fluid [56, 70, 75]. The nature of the metabolites that have been identified so far suggest that the vinca alkaloids are metabolized by the hepatic cytochrome P-450 mixed function oxidase CYP3A [26, 54, 56, 76–78]. The importance of CYP3A

N. Coufal and L. Farnaes

in the metabolism of the drug is the observation of increased clearance of the drug when used in conjunction with drugs that induce CYP3A, such as phenytoin and carbamazepine and the incidence of increased toxicity with CYP3A inhibitors such as itraconazole [77, 79]. It also appears that the individual vinca alkaloids inhibit the biotransformation of one another indicating a common metabolic pathway that is saturable. Although few of the metabolites of the vinca alkaloids have been actively studied, low levels of deacetylated vinblastine and vinorelbine have been detected in the feces, urine and tissues of animals [80, 81]. In human patients only deacetylated vinorelbine has been observed in a very small amount in the urine. It appears though that the deacetylated metabolite of vinorelbine is equipotent to the parent compound [81]. The vinca alkaloids are primarily eliminated by the hepatobiliary system. There is some variation in the percentages of metabolites that are excreted in the feces or the urine between the various vinca alkaloids but roughly between 33 and 80% excreted in the feces with up to 40% consisting of metabolites and 12 and 30% excreted in the urine most of which is unmetabolized [26, 56, 67, 69, 72, 76, 81–84]. Vincristine is rapidly excreted into the bile with an initial bile to plasma concentration ratio of 100:1 which declines to 20:1 by 72 h post treatment [67]. As a result of compounds being eliminated through the hepatobiliary system extra care must be exercised in patients with compromised liver function such as liver metastases or cirrhosis of the liver.

2.7 Doses and Schedules The vinca alkaloids are most commonly administered by direct intravenous injection. Only experienced oncology personnel should administer these agents as extravasation causes severe soft tissue injury.

2.7.1 Vincristine Vincristine may be given to pediatric patients weighing less than 10 kg (body surface area <1 m2 ) at 0.05– 0.065 mg/kg weekly. In children weighing more than 10 kg (body surface area ≥ 1 m2 ) a bolus injection dose

2

The Vinca Alkaloids

of 1.5–2.0 mg/m2 may be given weekly. For adults the common dose is 1.4 mg/m2 weekly. There have been efforts to create a prolonged infusion scheme as a result of some evidence that the duration of exposure above a critical concentration is important for cytotoxicity [27, 85]. A restriction of the absolute single dose of 2.0 mg/m2 has been adopted due to early reports of substantial neurotoxicity at higher doses. There is some evidence now that this cap should be reconsidered [86]. The setting of a cap for the maximum dose is further complicated by the large amount of interpatient variability in the tolerance of and metabolism of these compounds. Vincristine dosage modification should be based on the appearance of toxicity such as the appearance of peripheral or autonomic neuropathy [87]. The dosage should not be reduced for mild peripheral neuropathy especially if it is being used in a curative setting. If there are more serious toxic effects associated with serious neurotoxicity such as sensory changes, motor or cranial nerve changes or ileus then the dosage should be modified until there is an adequate reduction of symptoms of toxicity. In palliative settings it may be advisable to reduce dosage or select an alternative agent for moderate toxicity. Due to the hepatobiliary elimination of vincristine a 50% dose reduction is indicated for patients with plasma total bilirubin levels of 1.5–3.0 mg/dl and a 75% dose reduction for patients with a serum total bilirubin >3.0 mg/ml. There is no dosage reduction indicated for renal dysfunction [88, 89].

2.7.2 Vinblastine Vinblastine may be given to pediatric patients on a weekly schedule starting at 2.5 mg/m2 followed by dose escalation of 1.25 mg/m2 each week based on hematological tolerance of the drug. It is not recommended to administer a dose higher than 12.5 mg in pediatric patients although most patients have myelosuppression before this dose level is reached. Adults may be given a weekly schedule starting at 3.7 mg/m2 followed by dose escalation of 1.8 mg/m2 each week based on hematological tolerance of the drug. It is not recommended to use a dose higher than 18.5 mg in adult patients although most patients have myelosuppression at submaximal doses regardless. Vinblastine is also commonly used as a bolus

31

injection of 6 mg/m2 in cyclic combination chemotherapy regimens. Because leukopenia occurring with the administration of vinblastine can vary widely with identical doses, vinblastine should not be administered more than once per week. Although there are no specific guidelines for dose reduction in patients with compromised liver function it would most likely be necessary to significantly reduce the dosage of the drugs due to the hepatic role in the clearing of these drugs.

2.7.3 Vindesine Vindesine is most commonly given as an intravenous bolus of 2–4 mg/m2 weekly to biweekly which is associated with antitumor activity and a tolerable toxicity prolfile [27]. Intermittent or continuous schedules usually infuse 1–2 mg/m2 per day for 1–2 days or 1.2 mg/m2 for 5 days every 3–4 weeks [27, 56]. As with the other vinca alkaloids a dose reduction is warranted if the patient has hepatic dysfunction.

2.7.4 Vinorelbine Vinorelbine is commonly given intravenously at dose of 30 mg/m2 as an injection using the sidearm port of a running infusion. Alternatively vinorelbine may be given as a slow bolus injection followed by flushing with 0.9% sodium chloride or a short infusion over 20 min. It appears that the shorter infusions are associated with a decrease in local venous toxicity [31]. Patients with hepatic dysfunction should be given a lower dose [90]. Dosage reductions for hepatic dysfunction include a 50% reduction in patients with serum total bilirubin between 1.5 and 3.0 mg/dl and a 75% reduction in patients with serum total bilirubin >3.0 mg/dl. As with the other vinca alkaoids dosage reductions are not indicated in patients with renal insufficiency.

2.8 Toxicity Despite the structural and pharmacologic resemblance between vinca alkaloid family members, a broad range of adverse reactions have been noted, and

32

there are striking differences in the severity and incidence of adverse reactions for each. There is no precise explanation for these side-effects, however the affinity for tubulin and the cellular uptake rate is likely the culprit. The predominant toxicity for vincristine is neurotoxicity, whereas myelosuppresion is most frequent with vinblastine, vinesine, and vinorelbine. However, peripheral neurotoxicity and myelosuppresion can be associated with any vinca alkaloid as a result of prolonged treatment, unintentional high-dose treatment, or in highly susceptible patients (e.g., individuals with hepatic dysfunction or the elderly). The ability of the vinca alkaloids to bind tightly to microtubules present in peripheral nerves, which are essential for axonal transport and secretory functions makes neurotoxicity unavoidable. Axonal degeneration and decreased axonal transport result, and can be measured as diminished amplitude of sensory and motor nerve action potentials and prolonged distal latencies [26, 91]. Despite being highly lipophilic, the large size and significant platelet and protein binding activity of these agents prevents them from crossing the blood-brain barrier. Additionally, MDR1 is highly expressed in brain capillary endothelium, resulting in drug efflux [92]. As a result, neural toxicity is primarily as a result of peripheral nerve damage, and central nervous system toxicity is rare [2]. There are numerous reports of seizures after administration, but due to low CNS penetration, are unlikely to be directly due to vinca alkaloid administration. They are more likely a result of intracranial metastasis, infection, or as a result of hyponatremia secondary to inappropriate antidiuretic hormone secretion which can be caused by vincristine [93]. Neurotoxicity as a result of vinca alkaloid treatment is characterized by peripheral, symmetric mixed sensory, motor, and autonomic polyneuropathy [26, 94, 95]. Neurotoxicity occurs as a welldocumented progression in most patients, usually beginning with asymptomatic Achilles tendon reflex loss [93], followed by paresthesias in the hands and feet. This is followed by neuritic pain, and can progress to foot drop, wrist drop, muscle pain, weakness, ataxia, and paralysis. Deficits are symmetrical and may persist for weeks or months after therapy is discontinued [93]. Rarely the cranial nerves are affected, resulting in dipolopia, hoarseness, and facial palsies. Severe jaw pain has been reported shortly

N. Coufal and L. Farnaes

after administration, but does not usually persist [93]. Autonomic neuropathies are common, ranging from constipation, bloating, and abdominal pain to paralytic ileus in the more severe cases. Paralytic ileus, intestinal necrosis, and perforation have lead to several deaths as a consequence of vinca alkaloid treatment [93, 96]. Gastrointestinal effects are generally most severe with vincristine [2, 58]. Autonomic neurotoxicity secondary to vincristine may produce bladder atony and resulting polyuria, dysuria, and urinary retention [97]. Cardiovascular autonomic neurotoxicities have also been reported, most frequently hypertension and hypotension, but also rarely cardiac ischemia and massive myocardial infarctions when vinca alkaloids are combined with cisplatin and bleomycin [98, 99]. Frequently mild autonomic neuropathies precede more severe peripheral neuropathies. Attempts to reverse or prevent neurotoxicity have been largely unsuccessful, as a result supportive care and dose adjustments are the primary treatments [94, 100]. There has been limited success with folinic acid (not folic acid) which has been shown to protect against an otherwise lethal dose of vincristine in animal models, and used in several overdose patients [88, 89]. Also shown to have some efficacy is gluatmic acid and a mixture of gangliosides to reduce neurotoxicity [101, 102]. Patients should be routinely treated with dietary bulk, stool softeners, and laxatives to prevent severe constipation. All the vinca alkaloids have been shown to act directly on the hypothalamus, posterior pituitary, or neurohypophyseal tract (where the blood-brain barrier is the least robust) and can cause syndrome of inappropriate antidiuretic hormone secretion (SIADH). Patients who are already receiving extensive hydration are particularly susceptible to hyponatremia as a result of SIADH and can result in generalized seizures [2, 27]. Usually elevated plasma ADH levels return to normal within two to three days. Hyponatremia should be treated with fluid restriction, as SIADH would be treated from other causes. Bone marrow suppression is a common side effect of the vinca alkaloids. Leukopenia is common, peaking 5–10 days after drug administration. Extent and duration of leucopenia is dose dependent. White cell count returns to normal within 1–2 weeks, and myelosuppression is not typically cumulative. Thrombocytopenia and anemia are less common and severe, unless used in combination with radiation or

2

The Vinca Alkaloids

other agents. Leukopenia is least pronounced with vincristine, and is therefore the agent of choice if bone marrow suppression is dose-limiting. Vincristine, vinblastine, and vindesine are strong vesicants, and extreme caution should be taken in their administration to avert leakage into surrounding tissues. They should never be administered intramuscularly, subcutaneously, or intraperitoneally. Inadvertent intrathecal injection, which has occurred in clinical accidents, induces severe myeloencephalopathy including ascending motor and sensory neuropathies and rapid death [103]. It is recommended that these agents be administered as a bolus whenever possible to minimize risk of extravasation. Injection site reactions include erythema, pain, and venous discoloration. There is a risk of phlebitis if veins are not flushed after administration. If extravasation is suspected, treatment should cease, and aspiration of any residual drug attempted [104]. Extravasation has been successfully treated with corticosteroids to limit tissue damage [104]. Immediate surgical consultation to consider early debridement should be considered. Dosage modifications should be based on toxicity, although mild toxicity is acceptable in a curative setting. Severe toxicities, such as ileus and sensory, motor, and cranial nerve deficits indicate a need for dose modification. In palliative situations, modifying doses or increasing dosing intervals may be justified even with moderate neurotoxicity. Due to their hepatic clearance, vinca alkaloid dose modifications should be considered for patients with low hepatic function [100]. A 75% dose reduction is recommended for patients with serum total bilirubin levels < 3.0 mg/dL, and a 50% dose reduction for patients with plasma total bilirubin of 1.5–3.0 mg/dL [88, 89]. Dose reductions is not indicated for patients with renal dysfunction [88, 89]. Lastly, dose reductions should be considered with elderly patients, who often exhibit reduced hepatic function.

2.9 Drug Interactions Pharmacokinetic interactions have not been extensively studied. Those pharmaceuticals which are known to interact with the vinca alkaloids are primarily those which utilize the same elimination pathway, liver cytochrome P450 3A (CYP3A) metabolism. This includes drugs such as quinine, cyclosporine, and

33

nifedipine which are also substrates for CYP3A, and have been shown to inhibit vinca alkaloid metabolism in vitro [75]. Nifedipine has been shown to decrease patient’s plasma clearance of vincristine by 69% [105]. Administration of vinca alkaloids in combination with drugs which actively inhibit CYP3A, such as erythromycin and itraconazole, can lead to severe toxicity. There are several medications where administration concomitantly with vinca alkaloids can lead to excessive toxicity. For instance, the use of mitomycin C in combination with vinca alkaloids is associated with pulmonary toxicity [106, 107]. These reactions are usually either acute bronchospasm or subacute reversible cough and dyspnea 1 h after treatment. Furthermore, treatment with vinblastine in combination with either erythromycin or cyclopsorin leads to greater than predicted vincristine toxicity [108, 109]. Similarly, vincristine associated toxicity is much higher with concomitant etoposide treatment (another substrate for CYP3A) [110]. Lastly, the large degree of variability within and between individuals in vincristine pharamcokinetics has been ascribed to unpredictable CYP3A induction secondary to corticosteroid therapy [111]. Pharmaceuticals which upregulate liver enzymes may increase vinca alkaloid metabolism (e.g., phenytoin and phenobarbitol) and decrease their efficacy [112, 113]. Conversely, treatment with vinca alkaloids has precipitated seizures associated with subtherapeutic plasma phenytoin concentrations, likely as a result of CYP3A induction [86, 114]. Reduced phenytoin levels have been documented 24 h–10 days post treatment with vinblastine and vincristine.

References 1. Cutts JH, Beer CT, Noble RL (1960) Biological properties of Vincaleukoblastine, an alkaloid in Vinca rosea Linn, with reference to its antitumor action. Cancer Res 20:1023–1031 2. Johnson IS, Armstrong JG, Gorman M, Burnett JP Jr (1963) The Vinca alkaloids: a new class of oncolytic agents. Cancer Res 23:1390–1427 3. Beer CT, Gallagher TF (1955) Excretion of estrogen metabolites by humans. I. The fate of small doses of estrone and estradiol-17beta. J Biol Chem 214(1):335–349 4. Creasey W (1975) Vinca alkaloids and colchicine. In: Sartorelli AC, Johns DG (eds) Antineoplastic and

34

N. Coufal and L. Farnaes

5.

6.

7.

8.

9.

10. 11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

immunosuppressive agents part II, vol 38. Springer, Berlin, pp 232–256 Bennouna J, Breton JL, Tourani JM, Ottensmeier C, O’Brien M, Kosmidis P et al (2006) Vinflunine – an active chemotherapy for treatment of advanced non-smallcell lung cancer previously treated with a platinumbased regimen: results of a phase II study. Br J Cancer 94(10):1383–1388 Campone M, Cortes-Funes H, Vorobiof D, Martin M, Slabber CF, Ciruelos E et al (2006) Vinflunine: a new active drug for second-line treatment of advanced breast cancer. Results of a phase II and pharmacokinetic study in patients progressing after first-line anthracycline/taxanebased chemotherapy. Br J Cancer 95(9):1161–1166 Na GC, Timasheff SN (1982) In vitro vinblastineinduced tubulin paracrystals. J Biol Chem 257(17): 10387–10391 Lobert S, Vulevic B, Correia JJ (1996) Interaction of vinca alkaloids with tubulin: a comparison of vinblastine, vincristine, and vinorelbine. Biochemistry 35(21):6806–6814 Himes RH (1991) Interactions of the catharanthus (Vinca) alkaloids with tubulin and microtubules. Pharmacol Ther 51(2):257–267 Luduena RF, Shooter EM, Wilson L (1977) Structure of the tubulin dimer. J Biol Chem 252(20):7006–7014 Waterman-Storer CM, Salmon ED (1997) Microtubule dynamics: treadmilling comes around again. Curr Biol 7(6):R369–R372 Mitchison TJ (1993) Localization of an exchangeable GTP binding site at the plus end of microtubules. Science 261(5124):1044–1047 Chen W, Zhang D (2004) Kinetochore fibre dynamics outside the context of the spindle during anaphase. Nat Cell Biol 6(3):227–231 Singer WD, Himes RH (1992) Cellular uptake and tubulin binding properties of four Vinca alkaloids. Biochem Pharmacol 43(3):545–551 Binet S, Chaineau E, Fellous A, Lataste H, Krikorian A, Couzinier JP et al (1990) Immunofluorescence study of the action of navelbine, vincristine and vinblastine on mitotic and axonal microtubules. Int J Cancer 46(2):262–266 Tsukidate K, Yamamoto K, Snyder JW, Farber JL (1993) Microtubule antagonists activate programmed cell death (apoptosis) in cultured rat hepatocytes. Am J Pathol 143(3):918–925 Harmon BV, Takano YS, Winterford CM, Potten CS (1992) Cell death induced by vincristine in the intestinal crypts of mice and in a human Burkitt’s lymphoma cell line. Cell Prolif 25(6):523–536 Li G, Tang L, Zhou X, Tron V, Ho V (1998) Chemotherapy-induced apoptosis in melanoma cells is p53 dependent. Melanoma Res 8(1):17–23 Yu K, Ravera CP, Chen YN, McMahon G (1997) Regulation of Myc-dependent apoptosis by p53, c-Jun N-terminal kinases/stress-activated protein kinases, and Mdm-2. Cell Growth Differ 8(7):731–742 Fan S, Cherney B, Reinhold W, Rucker K, O’Connor PM (1998) Disruption of p53 function in immortalized human cells does not affect survival or apoptosis after taxol or vincristine treatment. Clin Cancer Res 4(4):1047–1054

21. Cline MJ (1968) Effect of vincristine on synthesis of ribonucleic acid and protein in leukaemic leucocytes. Br J Haematol 14(1):21–29 22. Watanabe K, West WL (1982) Calmodulin, activated cyclic nucleotide phosphodiesterase, microtubules, and vinca alkaloids. Fed Proc 41(7):2292–2299 23. Chabner BA (1992) Mitotic inhibitors. Cancer Chemother Biol Response Modif 13:69–74 24. Nachman J (1990) Therapy for childhood non-Hodgkin’s lymphomas, nonlymphoblastic type. Review of recent studies and current recommendations. Am J Pediatr Hematol Oncol 12(3):359–366 25. Dimopoulos MA, Pouli A, Zervas K, Grigoraki V, Symeonidis A, Repoussis P et al (2003) Prospective randomized comparison of vincristine, doxorubicin and dexamethasone (VAD) administered as intravenous bolus injection and VAD with liposomal doxorubicin as first-line treatment in multiple myeloma. Ann Oncol 14(7):1039–1044 26. Joel S (1996) The comparative clinical pharmacology of vincristine and vindesine: does vindesine offer any advantage in clinical use? Cancer Treat Rev 21(6):513–525 27. Rowinsky EK, Donehower RC (1991) The clinical pharmacology and use of antimicrotubule agents in cancer chemotherapeutics. Pharmacol Ther 52(1):35–84 28. Dancey J, Steward WP (1995) The role of vindesine in oncology –recommendations after 10 years’ experience. Anticancer Drugs 6(5):625–636 29. Costa G, Hreshchyshyn MM, Holland JF (1962) Initial clinical studies with vincristine. Cancer Chemother Rep 24:39–44 30. Peltier AC, Russell JW (2002) Recent advances in druginduced neuropathies. Curr Opin Neurol 15(5):633–638 31. Zeffren J, Yagoda A, Kelsen D, Winn R (1984) Phase I-II trial of a 5-day continuous infusion of vinblastine sulfate. Anticancer Res 4(6):411–413 32. Cornwell MM, Tsuruo T, Gottesman MM, Pastan I (1987) ATP-binding properties of P glycoprotein from multidrugresistant KB cells. Faseb J 1(1):51–54 33. Inaba M, Fujikura R, Sakurai Y (1981) Active efflux common to vincristine and daunorubicin in vincristine-resistant P388 leukemia. Biochem Pharmacol 30(13):1863–1865 34. Lautier D, Canitrot Y, Deeley RG, Cole SP (1996) Multidrug resistance mediated by the multidrug resistance protein (MRP) gene. Biochem Pharmacol 52(7):967–977 35. Lockhart AC, Tirona RG, Kim RB (2003) Pharmacogenetics of ATP-binding cassette transporters in cancer and chemotherapy. Mol Cancer Ther 2(7):685–698 36. Nooter K, Westerman AM, Flens MJ, Zaman GJ, Scheper RJ, van Wingerden KE et al (1995) Expression of the multidrug resistance-associated protein (MRP) gene in human cancers. Clin Cancer Res 1(11):1301–1310 37. Sikic BI, Fisher GA, Lum BL, Halsey J, BeketicOreskovic L, Chen G (1997) Modulation and prevention of multidrug resistance by inhibitors of P-glycoprotein. Cancer Chemother Pharmacol 40 Suppl:S13–S19 38. Greenberger LM, Williams SS, Horwitz SB (1987) Biosynthesis of heterogeneous forms of multidrug resistance-associated glycoproteins. J Biol Chem 262(28):13685–13689

2

The Vinca Alkaloids 39. Hipfner DR, Mao Q, Qiu W, Leslie EM, Gao M, Deeley RG et al (1999) Monoclonal antibodies that inhibit the transport function of the 190-kDa multidrug resistance protein MRP. Localization of their epitopes to the nucleotide-binding domains of the protein. J Biol Chem 274(22):15420–15426 40. Zaman GJ, Flens MJ, van Leusden MR, de Haas M, Mulder HS, Lankelma J et al (1994) The human multidrug resistance-associated protein MRP is a plasma membrane drug-efflux pump. Proc Natl Acad Sci USA 91(19):8822–8826 41. Kruh GD, Gaughan KT, Godwin A, Chan A (1995) Expression pattern of MRP in human tissues and adult solid tumor cell lines. J Natl Cancer Inst 87(16):1256–1258 42. Bertrand Y, Capdeville R, Balduck N, Philippe N (1992) Cyclosporin A used to reverse drug resistance increases vincristine neurotoxicity. Am J Hematol 40(2): 158–159 43. List AF, Kopecky KJ, Willman CL, Head DR, Persons DL, Slovak ML et al (2001) Benefit of cyclosporine modulation of drug resistance in patients with poor-risk acute myeloid leukemia: a Southwest Oncology Group study. Blood 98(12):3212–3220 44. Pinkerton CR (1996) Multidrug resistance reversal in childhood malignancies – potential for a real step forward? Eur J Cancer 32A(4):641–644 45. Geyp M, Ireland CM, Pittman SM (1996) Resistance to apoptotic cell death in a drug resistant T cell leukaemia cell line. Leukemia 10(3):447–455 46. Amos LA, Baker TS (1979) The three-dimensional structure of tubulin protofilaments. Nature 279(5714): 607–612 47. Rai SS, Wolff J (1998) Localization of critical histidyl residues required for vinblastine-induced tubulin polymerization and for microtubule assembly. J Biol Chem 273(47):31131–31137 48. Hari M, Wang Y, Veeraraghavan S, Cabral F (2003) Mutations in alpha- and beta-tubulin that stabilize microtubules and confer resistance to colcemid and vinblastine. Mol Cancer Ther 2(7):597–605 49. Lee WC, Lin KY, Chen KD, Lai YK (1992) Induction of HSP70 is associated with vincristine resistance in heat-shocked 9L rat brain tumour cells. Br J Cancer 66(4):653–659 50. Jia L, Allen PD, Macey MG, Grahn MF, Newland AC, Kelsey SM (1997) Mitochondrial electron transport chain activity, but not ATP synthesis, is required for druginduced apoptosis in human leukaemic cells: a possible novel mechanism of regulating drug resistance. Br J Haematol 98(3):686–698 51. Srivastava RK, Srivastava AR, Korsmeyer SJ, Nesterova M, Cho-Chung YS, Longo DL (1998) Involvement of microtubules in the regulation of Bcl2 phosphorylation and apoptosis through cyclic AMP-dependent protein kinase. Mol Cell Biol 18(6):3509–3517 52. Simonian PL, Grillot DA, Nunez G (1997) Bcl-2 and BclXL can differentially block chemotherapy-induced cell death. Blood 90(3):1208–1216 53. Zhang J, Alter N, Reed JC, Borner C, Obeid LM, Hannun YA (1996) Bcl-2 interrupts the ceramide-mediated

35

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.

69.

pathway of cell death. Proc Natl Acad Sci USA 93(11): 5325–5328 Sethi VS, Thimmaiah KN (1985) Structural studies on the degradation products of vincristine dihydrogen sulfate. Cancer Res 45(11 Pt 1):5386–5389 Nelson RL, Dyke RW, Root MA (1980) Comparative pharmacokinetics of vindesine, vincristine and vinblastine in patients with cancer. Cancer Treat Rev 7(Suppl 1): 17–24 Rahmani R, Bruno R, Iliadis A, Favre R, Just S, Barbet J et al (1987) Clinical pharmacokinetics of the antitumor drug navelbine (5 -noranhydrovinblastine). Cancer Res 47(21):5796–5799 Beck WT, Mueller TJ, Tanzer LR (1979) Altered surface membrane glycoproteins in Vinca alkaloid-resistant human leukemic lymphoblasts. Cancer Res 39(6 Pt 1): 2070–2076 Rowinsky EK, Noe DA, Trump DL, Winer EP, Lucas VS, Wargin WA et al (1994) Pharmacokinetic, bioavailability, and feasibility study of oral vinorelbine in patients with solid tumors. J Clin Oncol 12(9):1754–1763 Bugat R, Variol P, Roche H, Fumoleau P, Robinet G, Senac I (2002) The effects of food on the pharmacokinetic profile of oral vinorelbine. Cancer Chemother Pharmacol 50(4):285–290 van Tellingen O, Sips JH, Beijnen JH, Bult A, Nooijen WJ (1992) Pharmacology, bio-analysis and pharmacokinetics of the vinca alkaloids and semi-synthetic derivatives (review). Anticancer Res 12(5):1699–1715 Urien S, Bree F, Breillout F, Bastian G, Krikorian A, Tillement JP (1993) Vinorelbine high-affinity binding to human platelets and lymphocytes: distribution in human blood. Cancer Chemother Pharmacol 32(3):231–234 Fitos I, Visy J, Simonyi M (1991) Binding of vinca alkaloid analogues to human serum albumin and to alpha 1-acid glycoprotein. Biochem Pharmacol 41(3): 377–383 Steele WH, Haughton DJ, Barber HE (1982) Binding of vinblastine to recrystallized human alpha 1-acid glycoprotein. Cancer Chemother Pharmacol 10(1):40–42 Steele WH, King DJ, Barber HE, Hawksworth GM, Dawson AA, Petrie JC (1983) The protein binding of vinblastine in the serum of normal subjects and patients with Hodgkin’s disease. Eur J Clin Pharmacol 24(5): 683–687 Gout PW, Wijcik LL, Beer CT (1978) Differences between vinblastine and vincristine in distribution in the blood of rats and binding by platelets and malignant cells. Eur J Cancer 14(11):1167–1178 El Dareer SM, White VM, Chen FP, Mellet LB, Hill DL (1977) Distribution and metabolism of vincristine in mice, rats, dogs, and monkeys. Cancer Treat Rep 61(7):1269–1277 Castle MC, Margileth DA, Oliverio VT (1976) Distribution and excretion of (3H)vincristine in the rat and the dog. Cancer Res 36(10):3684–3689 Culp HW, Daniels WD, McMahon RE (1977) Disposition and tissue levels of [3H]vindesine in rats. Cancer Res 37(9):3053–3056 Rahmani R, Zhou XJ, Placidi M, Martin M, Cano JP (1990) In vivo and in vitro pharmacokinetics and

36

70.

71.

72.

73.

74.

75.

76.

77.

78.

79.

80.

81.

82.

83.

84.

85.

N. Coufal and L. Farnaes metabolism of vincaalkaloids in rat. I. Vindesine (4deacetyl-vinblastine 3-carboxyamide). Eur J Drug Metab Pharmacokinet 15(1):49–55 Zhou XJ, Martin M, Placidi M, Cano JP, Rahmani R. (1990) In vivo and in vitro pharmacokinetics and metabolism of vincaalkaloids in rat. II. Vinblastine and vincristine. Eur J Drug Metab Pharmacokinet 15(4):323–332 Leveque D, Quoix E, Dumont P, Massard G, Hentz JG, Charloux A et al (1993) Pulmonary distribution of vinorelbine in patients with non-small-cell lung cancer. Cancer Chemother Pharmacol 33(2):176–178 Owellen RJ, Root MA, Hains FO (1977) Pharmacokinetics of vindesine and vincristine in humans. Cancer Res 37(8 Pt 1):2603–2607 van Asperen J, Schinkel AH, Beijnen JH, Nooijen WJ, Borst P, van Tellingen O. (1996) Altered pharmacokinetics of vinblastine in Mdr1a P-glycoprotein-deficient Mice. J Natl Cancer Inst 88(14):994–999 Zhou XJ, Placidi M, Rahmani R (1994) Uptake and metabolism of vinca alkaloids by freshly isolated human hepatocytes in suspension. Anticancer Res 14(3A):1017–1022 Zhou-Pan XR, Seree E, Zhou XJ, Placidi M, Maurel P, Barra Y et al (1993) Involvement of human liver cytochrome P450 3A in vinblastine metabolism: drug interactions. Cancer Res 53(21):5121–5126 Gidding CE, Kellie SJ, Kamps WA, de Graaf SS (1999) Vincristine revisited. Crit Rev Oncol Hematol 29(3):267–287 Villikka K, Kivisto KT, Maenpaa H, Joensuu H, Neuvonen PJ (1999) Cytochrome P450-inducing antiepileptics increase the clearance of vincristine in patients with brain tumors. Clin Pharmacol Ther 66(6):589–593 Yao D, Ding S, Burchell B, Wolf CR, Friedberg T (2000) Detoxication of vinca alkaloids by human P450 CYP3A4mediated metabolism: implications for the development of drug resistance. J Pharmacol Exp Ther 294(1): 387–395 Gillies J, Hung KA, Fitzsimons E, Soutar R (1998) Severe vincristine toxicity in combination with itraconazole. Clin Lab Haematol 20(2):123–124 Owellen RJ, Hartke CA, Hains FO (1977) Pharmacokinetics and metabolism of vinblastine in humans. Cancer Res 37(8 Pt 1):2597–2602 Jehl F, Quoix E, Leveque D, Pauli G, Breillout F, Krikorian A et al (1991) Pharmacokinetic and preliminary metabolic fate of navelbine in humans as determined by high performance liquid chromatography. Cancer Res 51(8):2073–2076 Budman DR (1997) Vinorelbine (Navelbine): a third-generation vinca alkaloid. Cancer Invest 15(5): 475–490 Bender RA, Castle MC, Margileth DA, Oliverio VT (1977) The pharmacokinetics of [3H]-vincristine in man. Clin Pharmacol Ther 22(4):430–435 Krikorian A, Rahmani R, Bromet M, Bore P, Cano JP (1989) Pharmacokinetics and metabolism of Navelbine. Semin Oncol 16(2 Suppl 4):21–25 Van den Berg HW, Desai ZR, Wilson R, Kennedy G, Bridges JM, Shanks RG (1982) The pharmacokinetics

86.

87.

88.

89.

90.

91.

92.

93. 94. 95.

96. 97. 98.

99.

100.

101.

102.

103.

104.

of vincristine in man: reduced drug clearance associated with raised serum alkaline phosphatase and doselimited elimination. Cancer Chemother Pharmacol 8(2): 215–219 Bollini P, Riva R, Albani F, Ida N, Cacciari L, Bollini C et al (1983) Decreased phenytoin level during antineoplastic therapy: a case report. Epilepsia 24(1):75–78 Chabner B, Longo DL (2006) Cancer chemotherapy and biotherapy: principles and practice, 4th edn. Lippincott Williams and Wilkins, Philadelphia Jackson DV Jr, McMahan RA, Pope EK, Case LD, Cooper MR, Kaplon MK et al (1986) Clinical trial of folinic acid to reduce vincristine neurotoxicity. Cancer Chemother Pharmacol 17(3):281–284 Jackson DV Jr, Richards F 2nd, Spurr CL, Long TR, Rardin DA, Albertson DA et al (1984) Hepatic intra-arterial infusion of vincristine. Cancer Chemother Pharmacol 13(2):120–122 Robieux I, Sorio R, Borsatti E, Cannizzaro R, Vitali V, Aita P et al (1996) Pharmacokinetics of vinorelbine in patients with liver metastases. Clin Pharmacol Ther 59(1):32–40 Bradley WG, Lassman LP, Pearce GW, Walton JN (1970) The neuromyopathy of vincristine in man. Clinical, electrophysiological and pathological studies. J Neurol Sci 10(2):107–131 Tatsuta T, Naito M, Oh-hara T, Sugawara I, Tsuruo T (1992) Functional involvement of P-glycoprotein in blood-brain barrier. J Biol Chem 267(28):20383–20391 Kaplan RS, Wiernik PH (1982) Neurotoxicity of antineoplastic drugs. Semin Oncol 9(1):103–130 Quasthoff S, Hartung HP (2002) Chemotherapy-induced peripheral neuropathy. J Neurol 249(1):9–17 Legha SS (1986) Vincristine neurotoxicity. Pathophysiology and management. Med Toxicol 1(6):421–427 Sharma RK (1988) Vincristine and gastrointestinal transit. Gastroenterology 95(5):1435–1436 Gottlieb RJ, Cuttner J (1971) Vincristine-induced bladder atony. Cancer 28(3):674–675 Hirvonen HE, Salmi TT, Heinonen E, Antila KJ, Valimaki IA (1989) Vincristine treatment of acute lymphoblastic leukemia induces transient autonomic cardioneuropathy. Cancer 64(4):801–805 Subar M, Muggia FM (1986) Apparent myocardial ischemia associated with vinblastine administration. Cancer Treat Rep 70(5):690–691 Desai ZR, Van den Berg HW, Bridges JM, Shanks RG (1982) Can severe vincristine neurotoxicity be prevented? Cancer Chemother Pharmacol 8(2):211–214 Boyle FM, Wheeler HR, Shenfield GM (1996) Glutamate ameliorates experimental vincristine neuropathy. J Pharmacol Exp Ther 279(1):410–415 Hellmann K, Hutchinson GE, Henry K (1987) Reduction of vincristine toxicity by Cronassial. Cancer Chemother Pharmacol 20(1):21–25 Slyter H, Liwnicz B, Herrick MK, Mason R (1980) Fatal myeloencephalopathy caused by intrathecal vincristine. Neurology 30(8):867–871 Bellone JD (1981) Treatment of vincristine extravasation. JAMA 245(4):343

2

The Vinca Alkaloids

105. Fedeli L, Colozza M, Boschetti E, Sabalich I, Aristei C, Guerciolini R et al (1989) Pharmacokinetics of vincristine in cancer patients treated with nifedipine. Cancer 64(9):1805–1811 106. Ballen KK, Weiss ST (1988) Fatal acute respiratory failure following vinblastine and mitomycin administration for breast cancer. Am J Med Sci 295(6):558–560 107. Hohneker JA (1994) A summary of vinorelbine (Navelbine) safety data from North American clinical trials. Semin Oncol 21(5 Suppl 10):42–46; discussion 46–47 108. Samuels BL, Mick R, Vogelzang NJ, Williams SF, Schilsky RL, Safa AR et al (1993) Modulation of vinblastine resistance with cyclosporine: a phase I study. Clin Pharmacol Ther 54(4):421–429 109. Tobe SW, Siu LL, Jamal SA, Skorecki KL, Murphy GF, Warner E. (1995) Vinblastine and erythromycin: an unrecognized serious drug interaction. Cancer Chemother Pharmacol 35(3):188–190

37 110. Thant M, Hawley RJ, Smith MT, Cohen MH, Minna JD, Bunn PA et al (1982) Possible enhancement of vincristine neuropathy by VP-16. Cancer 49(5):859–864 111. Sathiapalan RK, El-Solh H (2001) Enhanced vincristine neurotoxicity from drug interactions: case report and review of literature. Pediatr Hematol Oncol 18(8):543–546 112. Crom WR, de Graaf SS, Synold T, Uges DR, Bloemhof H, Rivera G et al (1994) Pharmacokinetics of vincristine in children and adolescents with acute lymphocytic leukemia. J Pediatr 125(4):642–649 113. Chan JD (1998) Pharmacokinetic drug interactions of vinca alkaloids: summary of case reports. Pharmacotherapy 18(6):1304–1307 114. Jarosinski PF, Moscow JA, Alexander MS, Lesko LJ, Balis FM, Poplack DG (1988) Altered phenytoin clearance during intensive chemotherapy for acute lymphoblastic leukemia. J Pediatr 112(6): 996–999

Chapter 3

Taxanes and Epothilones in Cancer Treatment Edward F. McClay

There is no subject so old that something new cannot be said about it. Dostoyevsky, A Diary of a Writer (1876), 3, July–August

3.1 Introduction The discovery of compounds that bind and inhibit the function of microtubules dates back many centuries. The first compound to be used medicinally in humans, ultimately identified to have anti-microtubule properties, was colchicine. Colchicine, extracted from the plant Colchicum autumnale, was first administered to humans with gout in the sixth century A.D. [1]. After it was identified that colchicine blocked cells in metaphase, the compound became an important tool in the study of the cell cycle and mitosis [2]. The vinca alkaloids represent the first class of antimicrotubule agents to enter the field of chemotherapy [3]. They act to depolymerize the microtubule and block the cell cycle at the metaphase/anaphase junction in mitosis. Since the identification of the vinca alkaloids, there have been other anti-microtubule compounds added to the list of active chemotherapeutic agents including estramustine and the taxanes. Similar to the vinca alkaloids, the taxanes arrest cells in metaphase, however, their mechanism of action was to stabilize the microtubule and therefore they represented a new class of anticancer agents. The taxanes have been identified as amongst the most active

E.F. McClay () Melanoma Research Center, Pacific Oncology and Hematology Associates, San Diego, CA, USA e-mail: [email protected]

chemotherapeutic agents with a broad spectrum of activity against a variety of different tumors. More recently, the discovery of the epothilones has extended our armamentarium of potentially useful agents.

3.2 Microtubules Microtubules are ubiquitous in eukaryotic cells and are vital to the performance of many important cellular functions, including the maintenance of cell shape, intracellular transport, secretion, neurotransmission. Additionally, they participate in the development of the mitotic spindle, a function critically important in cell division [4, 5]. Microtubules are composed of molecules of the protein, tubulin and exist in dynamic equilibrium due to their ability to polymerize and de-polymerize as required by cellular needs. Tubulin exists as a dimmer composed of α and ß proteins, each having a molecular mass close to 50 kd, forming a tightly packed globular subunit [5, 6]. Several isoforms of both α and β tubulin exist in human cells [7, 8]. As tubulin molecules are assembled into microtubules, one α-tubulin subunit combines stoichiometrically with a β-tubulin molecule forming a protofilament. Microtubules consist of 13 protofilaments aligned in a side by side structure around a central core [9]. Each of the protofilaments is aligned with the same polarity where there is one end of the molecule

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_3, © Springer Science+Business Media B.V. 2011

39

40

exhibiting rapid growth while the other end is growing more slowly. Both the α- and β-tubulin molecules may undergo posttranslational modification including acetylation and detyrosylation [10]. These modifications only occur on microtubule polymers and not on individual tubulin proteins which likely account for the different functions of microtubules. In some cases the microtubule is modified in a specific region, providing a binding site for microtubuleassociated proteins. The binding of such proteins can stabilize the microtubule against disassembly and can also mediate or modulate interactions with other cellular components [11]. Microtubules are incredibly dynamic polymers, constantly undergoing modification of their structure, exhibiting a plus and a minus end. While both ends alternately grow or shorten, net growth occurs at the plus end and net shortening occurs at the minus end. Soluble tubulin binds GTP in a reversible fashion at a site on the β subunit. GTP is subsequently hydrolyzed very quickly to GDP and Pi [12]. The irreversible hydrolysis of GTP provides energy for two distinct microtubule behaviors, treadmilling and dynamic instability [13]. Treadmilling is characterized by net growth at the plus end and net shortening at the minus end occurring simultaneously. This process allows the plus end of the microtubule to probe the cytoplasm during prometaphase, forming a link with the kinetochore of the chromosome [14]. The ends of the microtubule switching stochastically between episodes of slow steady growth and rapid shortening characterize dynamic instability. Both of these functions play an important role in many microtubule-dependent cell functions. These activities appear to be critically important during mitosis and are essential for proper spindle assembly and function [13]. By modifying the activity of each of these functions, the cell can control a variety of specific activities. Modification of microtubules by proteins can also suppress these functions and likely plays a role in stabilizing the microtubule against de-polymerization, thus allowing the cell to organize its cytoplasm. Given their importance to the normal homeostasis of the cell, microtubules represent an important target for anticancer compounds.

E.F. McClay

3.3 Taxanes 3.3.1 Background The development of the taxane family of chemotherapeutic agents has had a profound effect on the treatment of patients with a variety of malignancies. Interest in the first of these compounds, paclitaxel (Taxol), began in the 1960s when a crude extract of the bark from the Pacific yew tree, Taxus brevifolia, demonstrated significant anti-tumor activity in the screening program of the National Cancer Institute. In 1971, Wani and co-workers identified Taxol as the active agent in the bark extract [15]. Initially, there was not much enthusiasm for further development of this compound because the Pacific yew was a relatively scarce, slow-growing tree found in the old growth forests of the Pacific Northwest. Additionally, the compound did not appear to be significantly more active than other compounds being tested at the same time [16]. It wasn’t until 1979 that Schiff et al. identified the unique activity of this compound [17]. Unlike the vinca alkaloids that act to inhibit tubulin assembly into microtubules, the taxanes stabilize the structure of the microtubule, preventing disassembly [18]. This discovery heralded a new class of anticancer agents, the taxoids, and resulted in significant interest in the further development of these agents. In 1986, docetaxel was semi synthetically produced at the Institut de Chimie des Substances Naturalles (Gif sur Yvette, France) through a collaborative effort between the Centre National de la Recherche Scientifique and Rhône-Poulenc Rorer [19]. Whereas Taxol was derived form the bark of the Taxus brevifolia, docetaxel was synthesizes from a noncytotoxic precursor from the needles of the Taxus baccata, a European yew [19]. In this process, 10-deacetyl baccatin III was esterified with a chemically synthesized side chain. As a result of the unique chemical structure of the taxanes, significant problems were encountered in their production and development. Developing a formulation, that would allow the delivery of these compounds intravenously, required the use of surfactant solvents. Paclitaxel required a formulation that was a

3

Taxanes and Epothilones in Cancer Treatment

combination of 50% ethanol and 50% polyoxylethyR while lated castor oil surfactant (Cremophor-EL) docetaxel was formulated in a mixture of ethanol and polysorbate 80 initially and later changed to polysorbate 80 alone. In the case of paclitaxel, the addition of these agents results in an increase in measurable side effects, primarily in the form of hypersensitivity reactions (HSR), that in come cases can be life threatening. AbraxaneTM (nanoparticle albumin-bound paclitaxel, nab-paclitaxel), the most recently approved form of the taxane compounds, is an albumin-coated formulation of paclitaxel. In order to eliminate the need for the solvents required to increase the solubility of the parent paclitaxel molecule, investigators at Abraxis Bioscience Inc. coated the molecule with nanoparticles of albumin. While the molecular activity of the nabpaclitaxel molecule is the same as that for paclitaxel, the resultant 130 nm nab-molecule is better tolerated, can be administered at higher doses and can be given to a higher cumulative dose with less toxicity.

3.3.2 Mechanism of Action As a class of compounds, the taxanes exert their anti-tumor activity primarily through binding to the β subunit of tubulin causing the stabilization of the polymerized microtubule [20]. Paclitaxel binds to the N-terminal 31 amino acids of the β tubulin subunit in the microtubule but does not bind to tubulin dimers [21]. The actual site appears to be on the inside of the microtubule surface and it is likely that paclitaxel gains access to this area through small pores in the surface lattice of the microtubule [22]. This binding of paclitaxel to the microtubule results in the bundling of microtubules and the formation of a large number of mitotic spindle asters [23]. Additionally, paclitaxel alters the structure of microtubules. Microtubules formed in the presence of paclitaxel frequently have only 12 protofilaments instead of the 13 found in normal microtubules [24]. Microtubules formed in the presence of paclitaxel are extremely stable and therefore dysfunctional. Of all of the microtubule structures, paclitaxel exerts its greatest influence on the mitotic spindle. The

41

stabilization of the mitotic spindle results in cell cycle arrest at the G2 /M phase. This produces a sustained mitotic block at the metaphase-anaphase boundary, resulting in inhibition of mitosis. Paclitaxel can cause this disruption of the cell cycle at concentrations much less than those required to increase microtubule mass. A small ratio of bound paclitaxel molecules to total tubulin in a microtubule is sufficient to produce a high degree of stability [25]. Paclitaxel has activities in addition to effects on microtubules. Paclitaxel as been shown to inhibit the transition from G0 to S in human fibroblasts, delay the passage of sensitive leukemia cells through nonmitotic phases of the cell cycle, inhibit many functions of human neutrophils and decrease the production of tumor necrosis factor-α receptors and release [26–29]. Exposure of human tumor cells to paclitaxel results in the phosphorylation of bcl-2 resulting in the induction of apoptosis [30]. Finally paclitaxel has demonstrated anti-angiogenesis properties. At concentrations lower than those required for tumor cell cytotoxicity, paclitaxel inhibits the proliferation of vascular endothelial cells [31]. In contrast to paclitaxel, docetaxel exerts its greatest influence on the microtubules of the centrosome. Interfering with the organization of centrosomes results in inhibition of the cell cycle in the S/G2 /M phases [3]. While paclitaxel has essentially no activity against cells in S phase, docetaxel has been shown to be extremely cytotoxic to S-phase cells [32]. Docetaxel has a higher binding affinity for β-tubulin (1.9 vs. 1.0) than paclitaxel and inhibits microtubule depolymerization at a drug concentration that is half (0.2 vs. 0.4 μM) of that required for paclitaxel [20]. Unlike paclitaxel, docetaxel does not alter the number of protofilaments incorporated into microtubules [24]. Finally, docetaxel has been shown to induce Bcl-2 phosphorylation and apoptotic cell death at concentrations that are 100-fold less than those required by paclitaxel [30]. Other studies have demonstrated that docetaxel is taken up by tumor cells in higher concentrations and is effluxed from the cell at a slower rate leading to higher retention times for docetaxel [33]. The latter has been proposed as at least part of the reason for incomplete cross-resistance between the compounds. Since the early work of McGuire et al and Mastrangelo et al. demonstrating that pre-treatment

42

with certain chemotherapeutic agents enhances immunologic response to vaccinations, other compounds have been tested to determine if they have similar properties [34–36]. More recently, several investigators have begun to evaluate the effect of taxanes on immunologic response. In an animal model using HER-2/neu tolerized mice, Machiels et al. demonstrated that pre-treatment of the animals with paclitaxel actually enhanced rather than depleted T-cell precursors [37]. Pre-treatment with paclitaxel 1 day prior to vaccination resulted in a delay in tumor growth related at least in part to an increase in antigen-specific T cells. More recently, Arlen et al. demonstrated that pretreatment of patients with metastatic prostate cancer with docetaxel enhanced immunologic response to a prostate cancer specific vaccine [38]. In this study, patients with androgen-independent prostate cancer were prospectively randomized to receive either vaccine alone or vaccine following pre-treatment with docetaxel. The vaccine consisted of a vaccinia virus expressing a prostate specific antigen gene admixed with the B7.1 costimulatory gene. Of interest, patients were treated with dexamethasone along with docetaxel raising the concern that this might inhibit the ability of the patient to mount an appropriate immunologic response. Despite the inclusion of dexamethasone, the median progression free survival for patients treated with docetaxel plus vaccine was 6.1 months vs. 3.7 months for the vaccine alone arm. The molecular targets for nab-paclitaxel are the same as paclitaxel. Entry into the cell appears to be enhanced for this molecule.

3.3.2.1 Mechanism of Resistance Several mechanisms of resistance to taxanes have been proposed and demonstrated to be important over time. One of the earliest proposed mechanisms is related to the presence in some tumors, of α and β-tubulin isoforms with impaired ability to polymerize into microtubules [39]. Giannakakou et al reported that a paclitaxel resistant human ovarian cancer cell line contained mutant β-tubulin that exhibited impaired paclitaxel driven polymerization [40]. In contrast, Ranganathan et al. demonstrated that estramustine induced resistance resulted in the over-expression of Class III

E.F. McClay

β-tubulin [41]. The expression of the isoform was associated with resistance to taxanes. In general, one of the most commonly cited mechanisms of resistance to the anti-microtubule agents is the expression of the MDR phenotype, which is mediated by the presence of the 170-kd Pgp efflux pump, encoded by the msr1 gene [3, 42, 43]. Horowitz et al. was amongst the first to demonstrate paclitaxel susceptibility to this very common mechanism of resistance [44], Antimicrotubule agents are substrates for this energy dependent pump. Other mechanisms of resistance have also been proposed. Masuda el al reported a link between impairment of the mitotic spindle checkpoint and resistance to anti-microtubule agents [45]. The mitotic spindle checkpoint is activated by the presence of unattached kinetochores resulting in arrest of the cell cycle at prometaphase [46]. Activation of this checkpoint prevents abnormal chromosome segregation because of the lack of bipolar attachment of kinetochores to the mitotic spindle. Several human cancer cell lines with abnormal mitotic spindle checkpoint activity, demonstrated impaired sensitivity to anti-microtubule agents including the taxanes. As mentioned earlier, several different proteins, termed microtubule-binding proteins (MAP), have been associated with normal or abnormal microtubule function. Recently, the MAP-Tau protein has been shown to be an important predictor of paclitaxel sensitivity in patients with breast cancer [47, 48]. This observation, first made by Rouzier et al., was further investigated by Wagner et al. Gene expression profiling using Affymetrix chips, was examined in 82 patients who underwent pre-operative treatment with paclitaxel, 5-FU, doxorubicin and cyclophosphamide [48]. Tau mRNA expression was statistically significantly lower in patients who experience a pathologic complete response when compared to patients who only achieved a partial or no response. Resistance in cells with higher levels of MAP-Tau appears to be related to the fact that MAP-Tau binds to both the inner an outer surface of microtubules and binds to the same pocket on the inner surface that also binds paclitaxel [49]. Ramanathan et al have shown that nitric oxide (NO) is also an important mediator of paclitaxel cytotoxicity [50]. Agents with antioxidant activity interfered with paclitaxel cytotoxicity while inhibitors of antioxidants increased paclitaxel cytotoxicity. These authors also introduced an important concept related to cellular

3

Taxanes and Epothilones in Cancer Treatment

antioxidant capacity. This study demonstrated that resistance to paclitaxel is related to the total antioxidant properties of the cell rather than the level of any one antioxidant moiety. Thus, combining paclitaxel with agents that inhibit antioxidants may prove to be an important component of increasing the activity of paclitaxel. Mutation of the p53 tumor suppressor gene has been identified as one of the most ubiquitous genetic mutations found in cancer cells and has been linked to drug resistance. Van Poznak et al. retrospectively evaluated breast cancer tumor tissue from 144 patients treated with single agent paclitaxel to determine if there was any relationship between the expression of a variety of biomarkers, including p53, and response [51]. This study found no correlation between the expression of p53 and response to paclitaxel. In contrast, Schmidt et al prospectively examined tumor tissue from thirtythree patients scheduled to be treated with paclitaxel [52]. No patient with p53 mutation responded while 10 of 22 patients without mutation exhibited clinical response. The role of Her-2/neu expression and response to taxanes has also been investigated. Her-2/neu is a receptor tyrosine kinase that triggers a cascade of events that ultimately results in an increase in cell proliferation [53]. Her-2/neu is over expressed in 20–30% of breast cancers and is associated with aggressive disease and poorer survival [53, 54] Gandour-Edwards et al. found that Her-2/neu was over expressed in 71% of patients with advanced urothelial malignancies [55]. In this small study of 39 patients, elevated Her2/neu expression was associated with a non-significant increase in the response over those patients low expression. Conversely, several studies have associated elevated Her-2/neu expression with resistance to paclitaxel. Yu et al transfected Her-2/neu into MDA-MB435 human breast cancer cells and increased resistance to paclitaxel [56]. Similarly, Perez-Soler transplanted human non-small cell lung cancer cells into nude mice and tested for response to paclitaxel [57]. None of the responding animals expressed Her-2/neu while 48% of the non-responders expressed the protein, Witters et al, transfected Her-2/neu into the human breast cancer cell line MCF-7 and tested for a differential response to paclitaxel vs. docetaxel [58]. Expression of Her-2/neu significantly reduced the effectiveness of paclitaxel, while there was essentially no effect of expression on the cytotoxicity of docetaxel.

43

Glutathione (GST) and its related enzymes, the glutathione S transferases are part of a major detoxification route employed by cells to metabolize xenobiotics and endogenous products of reactive oxygen species (ROS) [59]. These compounds have been shown to be an important component in metabolizing anticancer agents. Over-expression of GST’s has been associated with drug resistance in many different cancers and is a major obstacle to successful chemotherapeutic intervention in patients. Over-expression of GST is typically isozyme specific and GSTP1–1 is amongst the most frequently reported form associated with resistance in malignant tumors and cell lines resistant to anthracyclines [60]. To determine the role of this protein in the clinical response of patient with metastatic breast cancer, Arai et al. examined GSTP1 expression in clinical specimens [61]. The study included 62 patients who underwent treatment with either paclitaxel or docetaxel, correlating their clinical response with GSTP1 expression. The authors demonstrated a statistically significant difference in response in this group of patients. Those patients with absent GSTP1 exhibited a significantly higher reduction in tumor than those with GSTP1 expression. Recently, there has been increased interest in ROS and their effect on cancer initiation, progression and resistance to anti-cancer modalities [62]. Reactive oxygen species include the super anion radical (O2 − ), singlet oxygen (1 O2 ), hydrogen peroxide (H2 O2 ) and the highly reactive hydroxyl radical (OH). These species exist in all aerobic cells and are usually in balance with biochemical antioxidants. Oxidative stress occurs, when this critical balance is disrupted because of excess reactive oxygen species, depletion of antioxidants or both. Cancer cells are usually in a state of oxidative stress and therefore typically have elevated levels of ROS. Several chemotherapeutic agents have been associated with the generation of increased levels of ROS in treated cancer cells, including the taxanes [63–65]. Alexandre has recently shown that treatment of human breast cancer cells with the anti-microtubule agents paclitaxel, docetaxel and vincristine results in an increase in extracellular O2 − and H2 O 2 [65]. This increase in ROS resulted in lethal damage to non-paclitaxel treated bystander breast cancer cells. The generation of the ROS was mediated by membrane bound NADPH oxidase. Furthermore, the same author demonstrated that co-treatment of BALB/c mice implanted with CT26 human cancer cells with

44

paclitaxel and mangafodipir, a superoxide dismutase mimic, resulted in an enhanced growth inhibitory effect on the malignant tumors [64]. Modulation of ROS through the use of taxanes and other like-acting compounds may prove to be an important pathway to take advantage of in the fight against cancer.

3.3.3 Pharmacology There are substantial differences in the pharmacokinetic and the pharmacodynamic profiles of the three taxanes currently used clinically. These differences are responsible for the varied delivery schedules employed for the three agents. All of the taxanes are administered intravenously, however their infusion times are different. Early in the development of paclitaxel, prolonged infusion times (6–24 h) were employed because of hypersensitivity reactions [66]. However, when patients were premedicated for these reactions, it was demonstrated that there was no difference in the occurrence of hypersensitivity reactions between the 3 and 24 h infusion times, thus allowing a shorter infusion times to be explored [67]. The taxanes are extensively metabolized in the liver by the cytochrome P-450 system. This leads to biliary excretion as the main route of elimination. It is also the reason that the dose of taxanes must be lowered in patients with elevated liver enzymes. The major fraction of metabolized taxanes is excreted in the feces as either parent drug or as hydorxylated metabolites [20]. The known metabolites of taxanes are either inactive of less active than the parent compound. Renal excretion of the taxanes is <6%. Paclitaxel, in part due to the formulation in R exhibits non-linear pharmacokiCremophor-EL, netics [68, 69]. The entrapment of paclitaxel in Cremophor micelles acts to keep the paclitaxel in the plasma compartment [70]. This causes problems in the clinic as dose escalations or reductions of paclitaxel, especially with shorter infusion schedules, result in a disproportionate increase or decrease in the area under the time-concentration curve (AUC) and the peak plasma concentration (Cmax ). Thus, a small reduction in the dose can have a significant effect on the clinical response, as well as the toxicity experienced by patients. Interestingly, neutropenia was not related to either the AUC or Cmax of paclitaxel but

E.F. McClay

correlated significantly with the time that the plasma concentration of paclitaxel was >0.05 μM. Docetaxel, in contrast, exhibits linear pharmacokinetics, and is typically administered over 1 h. Adjustments in the dose either up or down results in a proportional change in the AUC as well as the Cmax . Population pharmacokinetic studies demonstrated that the clearance of docetaxel is significantly lower with increasing age, less body surface area and decreased liver function [71]. While the action of nab-paclitaxel on microtubules is essentially the same as paclitaxel, the compound is quite a bit different from a pharmacologic perspective. Nab-paclitaxel is formulated by high-pressure homogenization of paclitaxel in the presence of human serum albumin [72]. Nab-paclitaxel is much more solR paclitaxel. uble in normal saline than Cremophor-El The solubility of nab-paclitaxel is 2–10 mg/ml compared to 0.3–1.2 mg/ml for paclitaxel. This allows a significant reduction in volume of administration and therefore also allows the nab-paclitaxel to be administered faster. Like docetaxel, nab-paclitaxel exhibits linear pharmacokinetics [73]. The properties of albumin have contributed to several other differences between paclitaxel and nabpaclitaxel that give the latter further advantage. Albumin is the natural transporter of endogenous hydrophobic molecules such as water insoluble vitamins and hormones [74]. In this context, it binds to the gp60 receptor initiating caveolar- mediated endothelial transport of protein bound and unbound plasma constituents [75]. Another unexpected benefit of nabpaclitaxel is the fact that osteonectin, also known as SPARC (secreted protein acid rich in cystine) which shares sequence homology with gp60, also binds albumin [76, 77]. A number of human tumors express SPARC, thus providing a target for nab-paclitaxel binding [42, 78–81]. Additionally, recent studies have as have shown that albumin accumulates in some tumors, likely the result of binding to SPARC, potentially facilitating the intracellular accumulation of drug [82]. This has been shown convincingly by Desai et al. [83]. The authors used a nude mouse/human R tumor xenograft model to explore Cremophor-El paclitaxel and nab-paclitaxel transport. Lung, breast, ovarian, prostate and colon tumors were implanted in nude mice and the intra-tumor concentrations and endothelial cell transport of the compounds was calculated. Using the same dose of each compound, the

3

Taxanes and Epothilones in Cancer Treatment

intra-tumor accumulation of nab-paclitaxel as measured by the absorption constant, was 3.3-fold greater R paclitaxel; the difference was for Cremophor-El apparent as early as 5 min after injection. Similarly, the endothelial cell binding for nab-paclitaxel was 9.9-fold greater and the endothelial transport was R 4.3-fold greater compared with Cremophor-El paclitaxel. The volume of distribution for the taxanes is significantly higher than the volume of total body water, indicating that the taxanes are extensive bound to plasma proteins and other tissue constituents. The drugs are metabolized via the cytochrome P450 system with the CYP3A, CYP2B and CYP1A isoforms playing a major role in this regard [19, 84, 85]. Early studies of this class of drugs suggested that they do not penetrate into the brain as evidenced by the fact, that detection of the compounds in the cerebral spinal fluid (CSF) was negligible [86]. However, two recent studies measuring both bound and unbound paclitaxel and docetaxel in CSF, have demonstrated cytotoxic levels of both compounds [87, 88].

3.3.4 Dose and Schedule Paclitaxel – As mentioned above, the presence of R in the formulation of paclitaxel was Cremophor-El responsible for an unusually high incidence of hypersensitivity reactions (HSR). In an attempt to lessen the frequency of this clinically problematic side effect, paclitaxel was initially administered over 24 h. In fact, this was the schedule initially approved for clinical use inpatient with ovarian cancer. Paclitaxel was administered together with steroids, diphenhydramine and a H2 blocker in an attempt to further decrease the incidence of HSR’s. Further study of schedules demonstrated that a 3-h infusion was tolerated well and demonstrated that it was equally effective as the 24h schedule [67]. Since these early studies there have been a multitude of studies using paclitaxel as a single agent as well as in combination with other compounds, Currently the most commonly employed dosing schedules for paclitaxel range from135 to 175 mg/m2 when administered as a 3 h infusion every 3 weeks. Doses up to 250 mg/m2 given as a 24 h infusion have been reported in bladder and head and neck maligR nancies [89, 90]. The presence of Cremophor-El

45

also proved problematic during administration of the R can cause leaching compound. As the Cremophor-El of the polyvinylchloride out of containers or tubing, it must be administered in glass or polyolefin containers using a 0.22 μM filter and polyethylene-administration sets. One approach to decrease toxicity of various chemotherapeutic agents is to administer lower doses on a more frequent schedule [91]. In this fashion, toxicity is decreased while anti-tumor activity is maintained through the effect of dose intensity. Paclitaxel has been administered weekly both as a single agent as well as in combination regimens [92]. In single agent regimens, the dose of weekly paclitaxel ranged from 80 mg/m2 every week for 15 weeks with a 1 week rest to 175 mg/m2 weekly for 6 weeks followed by a 2 week rest [93, 94]. Overall response rates using the weekly schedule range from 22 to 78% [94, 95]. In general, the most common toxicities observed with weekly schedule include neutropenia, anemia, neuropathy, mucositis and diarrhea. Various other chemotherapeutic agents have been combined with weekly paclitaxel including anthracyclines, platinum agents, vinorelbine, and trastuzumab [96–100]. Overall response rates in patients with metastatic breast cancer have ranged from 48 to 88% with a toxicity spectrum similar to that observed with single agent weekly paclitaxel [96, 101]. Docetaxel – The every 3-week schedule of docetaxel is typically administered within a dose range between 60 and 100 mg/m2 as a 1-h infusion. As the polysorbate-80 formulation of docetaxel is less allerR used with paclitaxel, genic than the Cremophor-El it can be administered faster and without pretreatment using H1 and H2 blockers. Fluid retention, usually a minor problem, can be minimized through the use of dexamethasone. Weekly single agent docetaxel has also been the subject of intense study [92]. The dose range is quite a bit narrower for docetaxel in comparison to paclitaxel. Studies have tested docetaxel at a dose of 35–40 mg/m2 weekly for 6 weeks with 2 weeks off [102, 103]. The response rates range from 29 to 42% in patients with metastatic breast cancer with a spectrum of toxicity similar to that observed in patients treated with weekly paclitaxel [92]. Non-hematologic toxicity including alopecia, nail and skin changes, increased lacrimation resulting from cananicular stenosis and asthenia were also commonly observed [92, 104].

46

Combination regimens of weekly docetaxel include anthracyclines, gemcitabine, vinorelbine and trastuzumab [105–110]. Overall response rates for weekly docetaxel combinations in breast cancer patients range from 21 to 90% with complete response rates in the 0–33% range [106, 111, 112]. Toxicity has included neutropenia, leukopenia, thrombocytopenia, alopecia, anemia, neuropathy, nausea, vomiting and diarrhea [92]. Nab-paclitaxel – As mentioned above, this novel formulation delivers paclitaxel as a suspension of albumin bound particles in saline that range in size from 130 to 150 nm. This formulation allows for the delivR obviating ery of paclitaxel without Cremophor-El, the need for pre-medication with anti-histamines and steroids, provides for a much shorter infusion time and allows the use of standard infusion sets. Nab-paclitaxel is typically administered at a dose of 260 mg/m2 as a 30 min IV infusion one a q 3-week schedule. Nyman et al. investigated the pharmacokinetics of weekly nab-paclitaxel in a phase I trial [113]. The schedule for this trial was administration weekly for 3 weeks with 1 week off. The maximum tolerated dose (MTD) for patients with minimal previous treatment was 150 mg/m2 , while heavily pretreated patients had an MTD of 100 mg/m2 . Combination regimens with nab-paclitaxel are just beginning to be reported. Moreno-Aspitia and Perez reported the experience of the North Central Cancer Treatment Group Study NO531 which was a phase I study testing the combination of weekly nab-paclitaxel and gemcitabine, while Stinchcombe et al combined carboplatin with nab-paclitaxel three different doses and schedules [114, 115].

3.3.5 Toxicity Paclitaxel – As mentioned previously, the R component is responsible for Cremophor-El the HSR’s experienced with this compound with a reported incidence of 25–30% [14]. This potentially fatal toxicity typically occurs within 10 min of starting the infusion and is manifested by dyspnea with bronchospasm, urticaria and when severe hypotension. Pre-medication with H1 and H2 blockers along with steroids has decreased the incidence of major HSR’s to less than 3% [21]. Hematologic

E.F. McClay

toxicity, primarily in the form of neutropenia, is also a major problem with paclitaxel. The onset is typically around days 8–10 with recovery between days 15–20. Peripheral neuropathy represents the most common form of neurotoxicity. The distribution is in the usual glove-stocking pattern and is usually bilateral and symmetrical. Not uncommonly, there is loss of both large fibers important for proprioception and vibration as well as thin fibers important to temperature and pinprick. Several cardiac arrhythmias including sinus bradycardia, Mobitz type I and II, as well as third degree heart block have been observed. Myocardial ischemia, atrial arrhythmias, ventricular tachycardia and myocardial infarction have also been reported [116]. Like many other chemotherapeutic agents, paclitaxel has been associated with alopecia, nausea, vomiting, and mucositis. Paclitaxel is a vascular irritant and has been associated with radiation recall reactions [21, 117] Docetaxel – docetaxel has many side effects similar to paclitaxel, however, HSR’s are uncommon. Fluid retention characterized by edema, weight gain, pleural effusions and ascites is common and can be cumulative [19, 118]. Additionally, docetaxel is associated with a incidence of dermatologic complications including a macular papular rash on the forearms and hands as well as nail changes such as onchodystrophy, onycholysis and brittle nails [119–121]. Finally, asthenia is a complaint of 58–67% of patients and is occasionally severe enough to require a dose reduction [14, 19]. Nab-paclitaxel – Unlike the HSR’s for paclitaxel and the fluid retention for docetaxel, there does not appear to be a toxicity that is more or less unique to nab-paclitaxel. Anemia, neutropenia, alopecia and sensory neuropathy are the most commonly encountered toxicities using the q 3 week schedule [122]. A similar toxicity profile is observed with the weekly schedule [113].

3.3.6 Spectrum of Antitumor Activity As a class of chemotherapeutic agents, the taxanes have had a significant impact in several cancers. They have had their greatest effect in the treatment of breast, non-small cell lung, ovarian and prostate cancers. However, the spectrum of activity extends well beyond these cancers to include most major malignancies.

3

Taxanes and Epothilones in Cancer Treatment

3.3.6.1 Breast Cancer Metastatic Breast Cancer – Two prospective randomized trials have compared single agent paclitaxel to doxorubicin in patients with metastatic disease [123, 124]. Paridaens et al. randomized 331 patients between treatment with single agent paclitaxel (200 mg/m2 3h infusion q 3 weeks) and doxorubicin (75 mg/m2 IV bolus q 3 weeks) [123]. The overall response rate (ORR) for paclitaxel (25%) was inferior to the doxorubicin (41% p = 0.003) although there was no statistically significant difference in the overall survival (OS) (15.6 vs. 18.3 months). Sledge et al. randomized 739 patients between doxorubicin (d) (60 mg/m2 ), paclitaxel (P) (175 mg/m2 over 24 h) and the combination (D = 50 mg/m2 , P = 150 mg/m2 / 24 h) [124]. The ORR was 36%, 34% and 47% respectively. The comparison for the combination vs. each of the single agents was statistically significant. The medial time to treatment failure (TTF) was 5.8, 6.0 and 8.0 months respectively. Again the comparison of the combination vs. each of the single agents was statistically significant. Docetaxel has also been tested as a single agent and compared with doxorubicin in a prospective randomized fashion [125]. In this study 326 patients were randomly assigned to either docetaxel (100 mg/m2 ) or doxorubicin (75 mg/m2 ) administered every 3 weeks. Docetaxel produced a statistically significantly higher ORR (48% vs. 33%; p = 0.008) however, time to progression (TTP) and OS were similar. Single agent nab-Paclitaxel has also demonstrated significant activity in patients with metastatic breast cancer. Ibrahim et al. reported a study evaluating nabpaclitaxel in both untreated and previously treated patients [126]. In this study sixty-three patients (39 untreated for metastatic disease; 48 chemotherapy naive) received nab-paclitaxel at a dose of 400 mg/m2 as a 30-min infusion with no pre-medication. The ORR was 48% (95% CI, 35.3–60.0%) with an ORR of 64% (95% CI, 49.0–79.2%) for previously untreated patients and 21% (95% CI, 7.1–42.1%) for previously treated patients. The median time to progression was 26.6 weeks and median survival was 63.3 weeks. There were no episodes of severe hypersensitivity reactions. Toxicity was mild with neutropenia (24%) and peripheral neuropathy (11%) the most common problems encountered. Gradishar et al compared single agent nab-paclitaxel to paclitaxel in 454 previously untreated

47

patients with metastatic breast cancer [127]. In this phase III study both agents were administered on an every 3-week schedule. Nab-paclitaxel has a significantly higher response rate than paclitaxel (33% vs. 19%; P = 0.001) and a significantly longer TTP (23.0 b 16.9 weeks; P = 0.006). The incidence of grade 4 neutropenia was significantly lower for nab-paclitaxel compared with paclitaxel (9% vs. 22%; P < 0.001) despite the fact that the dose of nab-paclitaxel resulted in a 49% increase in the absolute of paclitaxel. Grade 3 sensory neuropathy was higher in the nab-paclitaxel arm (10% vs. 2%; P < 0.001) but was easily managed and resolved quickly. Paclitaxel/anthracycline containing combinations have been tested in several studies with modest benefit [124, 128–130]. Only the study of Jassem et al comparing doxorubicin/paclitaxel to fluorouracil, doxorubicin and cyclophosphamide demonstrated a benefit in TTP for the paclitaxel containing regimen (8.3 vs. 6.2 months; p < 0.05) [129]. In contrast, docetaxel/anthracycline containing regimens consistently demonstrated superior response in four distinct randomized studies [131]. Three of the four studies also demonstrated a significant improvement in TTP and two studies demonstrated superior OS [132–135]. Both paclitaxel and docetaxel have been extensively studied as single agents and in combination with a variety of other compounds using a weekly schedule in patients with metastatic breast cancer [92]. In general, the weekly schedule is active for both compounds, even in heavily pre-treated patients with refractory disease. It has been shown to be safe in elderly patients and those with poor performance status and is associated with a very low incidence of severe hematologic toxicities. Blum et al investigated nab-paclitaxel using the weekly schedule in heavily taxane treated patients with metastatic breast cancer [136]. Two doses 100 and 125 mg/m2 administered on days 1, 8 and 15 of a 28-day schedule were shown to have similar response rates (14 and 16% respectively), progression free (3.0 vs. 3.5 months respectively) and overall survival (9.2 vs. 9.1 months respectively) survival. Two groups have reported studies using nabpaclitaxel in combination with other agents treating patients with metastatic breast cancer. Roy et al. combined nab-paclitaxel with gemcitabine in previously untreated patients [137]. Nab-paclitaxel (125 mg/m2 ) and gemcitabine (1000 mg/m2 ) were administered

48

on days 1 and 8 of a 21-day cycle. Treatment was continued until disease progression. Fifty patients were treated with neutropenia the most frequently observed toxicity (42% grade 3 and 12% grades 4). Progression free survival and overall survival were 95 and 92% respectively. In a somewhat different approach link et al reported a retrospective review of 40 patients treated with the combination of bevacizumab and nab-paclitaxel [138]. In a group of heavily pre-treated group of women they observed an overall response rate of 48.5%. Median time to progression was 128 days in responding women with relatively modest toxicity (fatigue, neuropathy, pain and hypertension). Early Breast Cancer; Neo-adjuvant Treatment – Two prospective randomized studies have investigated paclitaxel in the neoadjuvant setting. In the Arbeitsgemeinschaft Gastorenterologische Onkologie (AGO) study, 631 patients were randomized to receive concurrent vs. sequential dose dense paclitaxel and epirubicin [139]. A benefit for sequential therapy was found. Green et al randomized 258 patients to receive paclitaxel either on a weekly schedule for 12 weeks or every 3 weeks followed by 4 cycles of fluorouracil, doxorubicin and cyclophosphamide (FAC)[140]. The weekly schedule was associated with a higher rate of pathologic complete remissions (pCR) (28% vs. 16%; p = .02) and a higher rate of breast conserving surgery (p=0.05). Several studies have investigated the benefit of docetaxel in the neo-adjuvant setting. The NSABP B-27 study compared 4 cycles of doxorubicin/cyclophosphamide (AC) vs. the same regimen followed by 4 cycles of docetaxel [141]. There was a statistically significant improvement in the pCR rate observed in the docetaxel treated group (26% vs. 14%). Achieving a pCR was associated with a significant improvement in both disease free survival (DFS) (HR, 0.45; p < 0.0001) and OS (HR, 0.33; p < 0.0001). The Aberdeen trial compared 8 cycles of cyclophosphamide, vincristine, doxorubicin and prednisone (CVAP) vs. 4 cycles of CVAP and 4 cycles of docetaxel [142]. The docetaxel-containing regimen was associated with a higher pCR rate (31% vs. 15%), 5-year DFS rate (90% vs. 72%; p = 0. 04) and 5-year OS rate (97% vs. 78%; p = 0.04). Similar findings of an improved pCR rate for docetaxel containing regimens was observed in both the German Pre-operative Adriamycin and Docetaxel Study III

E.F. McClay

and the Anglo-Celtic Cooperative Oncology Group Studies [143, 144]. Adjuvant Treatment – Henderson et al reported the results of CALGB 9344, a phase III study that compared four cycles of adjuvant adriamycin/cyclophosphamide (AC) vs. AC followed by 4 cycles of paclitaxel (175 mg/m2 q 3 weeks) in 3,121 patients with node positive breast cancer [145]. The study demonstrated a statistically significant improvement in both DFS (70% vs. 65%) and OS (80% vs. 77%) in favor of the patients receiving the paclitaxel. The addition of 4 cycles of paclitaxel resulted in a modest increase in toxicity. Similarly, NSABP B-28 randomized 3,060 patients with node-positive breast cancer to AC +/– paclitaxel (225 mg/m2 ) [146]. A statistically significant improvement in DFS but not OS was found. Martin et al., reporting for the Breast Cancer International Research Group 001, compared docetaxel, adriamycin, cyclophosphamide (TAC) to fluorouracil, adriamycin cyclophosphamide (FAC) in a prospective randomized trial in 1,491 patients with node-positive breast cancer [147]. Treatment with docetaxel resulted in a 28% reduction in the risk of relapse (p = 0.001) and a 30% reduction in the risk of death (p = 0.008). The estimated rates of overall survival at five years were 87 percent for patients treated with TAC and 81 percent for patients treated with FAC. There was a statistically significant increase in the incidence of grade 3/4 neutropenia, febrile neutropenia and infection for the TAC group, however, there were no deaths associated with this difference.

3.3.6.2 Prostate Cancer Hormone-refractory prostate cancer has proved to be a particularly difficult malignancy to treat. Until the introduction of docetaxel, there was little to be enthusiastic about in the chemotherapy world. Beginning in the 1990s, several phase I and II studies including docetaxel reported interesting response rates [148–150]. However, it wasn’t until 2004 that two phase III clinical trails were published demonstrating for the first time, a statistically significant improvement in survival of patients with metastatic prostate cancer [151, 152]. Tannock et al. reported the results of a phase III trial comparing docetaxel plus prednisone to mitoxantrone plus prednisone [151]. This study tested two

3

Taxanes and Epothilones in Cancer Treatment

doses and schedules of docetaxel in combination with a fixed dose of prednisone. No benefit was observed for patients treated with docetaxel administered every 3-weeks as compared with weekly schedule, however, both schedules were superior to the mitoxantrone arm. The median OS for the three arms is 19.2 vs. 17,8 vs. 16,3 months respectively [153]. Petrylak et al. and the South West Oncology Group (SWOG) conducted a phase III trial comparing the combination of docetaxel/estramustine vs. mitoxantrone/prednisone [152]. Treatment with the docetaxel-containing regimen resulted in a 20% reduction in the risk of death (hazard ratio [HR], 0.80; 95% CI 0.67–0.97). Median OS was improved for the docetaxel arm (17.5 vs. 15.6 months; logrank P = 0.020). A decline in PSA was observed in 50% of the patients treated with docetaxel vs. 27% on the mitoxantrone arm (P < 0.0001). A trend toward an improved ORR was also observed (17% vs. 11%). Together, these two studies have changed the standard treatment of patients with metastatic prostate cancer.

3.3.6.3 Lung Cancer Both paclitaxel and docetaxel have been an important part of the treatment of patients with lung cancer. For the most part, these compounds have been tested in combination with cisplatin or carboplatin and found to be effective in the previously untreated patient groups [154]. The best taxane, the best combination and the best schedule is yet to be determined and is the subject of intense investigation [155]. One-year survival rates in the range of 31–48% provided oncologists reason for optimism in an area where therapeutic nihilism was the rule. In a recent phase III study conducted by the Eastern Cooperative Oncology group (ECOG), the addition of bevacizumab to the combination of paclitaxel and carboplatin resulted in a statistically significant improvement in OS and has become the standard of care in many offices [156]. Docetaxel was the first agent approved for treatment of patients with metastatic lung cancer in the secondline setting [157]. While overall response rates were low (7–10%) the 1-year survival rates ranged from 19 to 37% [158–160]. More recently, Rizvi et al have reported their phase I/II experience with nab-paclitaxel administered on days 1, 8, and 15 of a 28-day schedule [161].

49

Nab-paclitaxel administered as a dose of 125 mg/m2 was found to be active and well tolerated. The overall response rate was encouraging at 30% with a median time to progression of 5 months and medial overall survival at 11 months.

3.3.6.4 Other Cancers The combination of a platinum compound plus a taxane has been the preferred first line chemotherapy regimen for patients with ovarian cancer. In 1996, the Gynecology Oncology Group (GOG) demonstrated that the combination of paclitaxel/cisplatin was superior to cyclophosphamide/cisplatin on the basis of the following results of that trial: an overall improved response rate (73% vs. 60%; P = 0.01); an increased clinical complete response rate (54% vs. 32%); an increase in progression-free survival (PFS; 18.1 vs. 13.6 months; P < 0.001); and, most importantly, an increased overall median survival (38 vs. 24 months; P < 0.001) [162]. A subsequent GOG study demonstrated that carboplatin could be substituted for cisplatin with equivalent efficacy and less toxicity [163]. More recently the benefit of administration of chemotherapeutic agents via the intraperitoneal (IP) route has been confirmed. Armstrong et al. reported the results of another GOG study testing the benefit of IP cisplatin and IV paclitaxel vs. IV administration of both agents [164]. This study once again demonstrated the benefit of the IP route. Patients treated with IP cisplatin and paclitaxel enjoyed a statistically significant improvement of both PFS (23.8 vs. 18.3 months; logrank P = 0.05) and OS (65.6 vs. 45.7 months; logrank P = 0.03). Teneriello et al. reported the results of a phase II trial testing nab-paclitaxel in patients with recurrent peritoneal, ovarian or fallopian tube carcinomas [165]. The patients were platinum sensitive and received a dose of 260 mg/m2 on an every 3 weeks schedule. The overall response rate was 64% with 7 patients achieving a complete remission. The estimated median progression-free survival was 8.5 months. The most frequent grade 3/4 treatment-related toxicities were neutropenia (24%) and neuropathy (9%). In addition to the above, the taxanes are an important part of the chemotherapy armamentarium and are currently used to treat patients with squamous cell

50

carcinoma of the head and neck, renal cell carcinoma, gastric cancer, esophageal cancer and bladder carcinoma to name a few [166–170]. To further underscore the importance of this class of anti-tumor compounds, there are at least 11 different formulations of taxanes in various stages of development ensuring that they will be important for the foreseeable future [171].

3.4 Epothilones The epothilones are a new class of anti-microtubule agents that were isolated as cytotoxic metabolites of the myxobacterium sorangium cellulosum [172]. They were originally described as antifungal macrolides; however, subsequent studies demonstrated that they stabilized microtubules at sub-micromolar concentrations [172, 173]. Similar to taxanes they induce microtubule bundling, formation of multipolar spindles and mitotic arrest [173]. Epothilones are similar to paclitaxel in that they compete with paclitaxel for binding to the microtubule and suppress the activity of these structures [174, 175]. Cell lines that are resistant to epothilones have a mutation in the β-tubulin-binding site that maps near the binding site for taxanes. This has lead to the suggestion that there is a common pharmacophore for microtubule binding. Nettles et al. using nuclear magnetic resonance spectroscopy, electron crystallography and molecular modeling derived the conformation of epothilone A in complex with β-tubulin subunits in zinc-stabilized tubulin sheets [176]. This study demonstrated that while epothilones and paclitaxel overlap in their occupation of a large common binding site, the ligands exploit the pocket in a unique and qualitatively different manner. A recent study demonstrated differences in binding between these two classes of compounds. Bode et al. found that epothilones stabilize the microtubules in Saccharomyces cervisiae whereas paclitaxel did not, demonstrating that there are differences in the binding interactions between the two compounds [177]. Taken together, these studies support the concept that the two classes of compounds have similar but unique binding sites. A variety of epothilone analogues have been synthesized and many are currently in clinical trials including patupilone (epothilone B, EPO906), ixabepilone (azaepothilone B; BMS-247550), BMS-310705 (a water

E.F. McClay

soluble semisynthetic analog of epothilone B), KOS862 (epothilone D) and ZK-EPO [178]. The natural epothilones (A and B) have significant anti-tumor activity even against taxane-resistant cell lines, however, because of their toxicity, they have met with limited success in the clinic. This has lead to the development of more then 350 semi-synthetic analogs. Modifications of the compounds near C12–13 seem to have the greatest effect on microtubule stabilizing activity [179]. The addition of a methyl group at this location yields epothilone B which is twice as potent as epothilone A in inducing microtubule polymerization [180]. To date, the epothilones have demonstrated broad spectrum activity against a variety of human malignances in cell culture and xenograft models [178]. Additionally, the epothilones are generally more cytotoxic than paclitaxel in cell culture studies with the typical IC50 values in the nano- or sub-nanomolar concentration range [181–183]. These same preclinical studies have demonstrated that there are important differences with regard to the mechanism of drug resistance between paclitaxel and the epothilones. Over-expression of p-glycoprotein has minimal effect on the cytotoxicity of epothilone B, aza-epothilone B and desoxyepothilone in cell culture models [173, 179, 181–183]. Additionally, the difference between the IC50 values for epothilones in the sensitive and p-glycoprotein expressing resistant cells are very small in comparison to the differences observed in paclitaxel-resistant cells. This suggests that the epothilones may be more active in p-glycoprotein expressing cancers. Aza-epothilone B is highly active in ovarian, colon and breast cancer xenograft models and has induced cures in the ovarian xenograft model Par-7 that is resistant to paclitaxel. Additionally, aza-epothilone B is active when administered orally. This likely relates to the fact that p-glycoprotein is expressed in the GI mucosa and therefore the absorption of paclitaxel is inhibited [184]. Point mutations in β-tubulin that confer resistance to paclitaxel do not affect epothilones. The alanine to threonine substitution at residue 364 in β-tubulin that confers resistance to paclitaxel has no effect on the sensitivity to epothilones [40, 174]. In contrast, a mutation of threonine to isolucine at residue 274 and arginine to glutamine at residue 282 in β-tubulin was found in ovarian cancer cells resistant to epothilones. Interestingly these cells are

3

Taxanes and Epothilones in Cancer Treatment

cross resistant to paclitaxel [185]. Similarly, desoxyepothilone resistant cells were found to have an alanine to threonine mutation in β-tubulin at residue 231 and are also cross-resistant to paclitaxel [186].

3.5 Clinical Activity of Epothiones Currently, there are five epothilones in clinical trials. The majority are either in phase I or II trials, as dose and schedule remains to be more clearly defined. Similarly, combinations regimens including epothilones are just beginning to be reported [187].

3.5.1 Ixabepilone (Ixempra) Ixabepilone is the furthest along in clinical development with regards to the number of clinical trials evaluating this compound. Due to solubility issues similar to paclitaxel, this compound is formulated R [188]. A single hypersensitivin Cremophor-EL ity reaction observed during a phase I trial at the 30 mg/m2 dose, has resulted in prophylaxis with oral H1 and H2 blockers [188]. The compound exhibits linear pharmacokinetics with an overall mean half-life of 36 h [189]. The mean steady state values for volume of distribution suggest extensive extravascular distribution. Additionally, the total body clearance did not correlate with body weight or surface area suggesting that non-BSA based dosing regimens should be explored [190]. The extent of microtubule bundling correlated well with AUC and negatively with clearance [191]. Microtubule bundling was also observed in tumor removed from a patient with a chest wall mass. The bundling was observed at 1 and 24 h after the infusion [191]. A variety if intravenous infusion schedules have been investigated to determine that best approach to the future development of this compound (Table 3.1). Phase I studies testing a single dose every 3 weeks, daily dose for 3 days every 3 weeks, a weekly schedule and a daily dose for 5 days every 3 weeks have been completed. The recommended phase II dose for the single dose every 3 weeks is 40–50 mg/m2 [178, 188, 189, 192, 193]. Dose limiting toxicity at this dose and schedule included neutropenia, peripheral

51

neuropathy, fatigue, nausea, and vomiting. For the daily × 3 and daily × 5 schedule every 3 weeks, neutropenia proved to be the dose limiting toxicity, while patients treated weekly schedules experienced neutropenia, fatigue and sensory neuropathy [190, 194–197]. In some patients, early signs of sensory neuropathic changes with increased vibration sensation were evident after only 2 cycles [189]. Two phase I studies evaluating ixabepilone in combination with other chemotherapeutic agents have been reported. Plummer et al. included ixabepilone with carboplatin while Smaletz et al. combined ixabepilone with estramustine [198, 199]. The combination arm was associated with an increased incidence of sensory neuropathy. An phase II trial that updates the estramustine combination trial included 92 chemotherapy naive patients randomized between ixabepilone alone (35 mg/m2 ) vs. the combination of ixabepilone and estramustine (280 mg PO TID × 5 days) administered every 3 weeks [200]. A PSA decline of > 50% was observed in 21 of 44 patients (48%; 95% CI, 33–64%) on the ixabepilone arm and 31 of 45 patients (69%; 95% CI, 55–82%) on the combination arm. In patients with measurable disease a PR was observed in 8 of 25 patients (32%; 95% CI, 14–50%) of patients on the ixabepilone arm and 11 of 23 patients (48%; 95% CI, 27–68%). In this previously untreated group of patients, the incidence of neuropathy was 13% on the ixabepilone arm and 7% on the combination arm. This supports the position of Gianni who has suggested that ixabepilone induced sensory neuropathy is observed much less frequently when ixabepilone is used in untreated patients [201]. To date, response has been observed in patients with melanoma, non-small cell lung cancer, (post docetaxel), ovarian cancer (post-paclitaxel) and breast cancer (both taxane naïve and refractory) [178]. Recent studies in patients with metastatic breast cancer have reported relatively low response rates for patients previously treated and resistant to taxanes (12%), and anthracyclines, taxanes and capecitabine (11.5%) [202, 203]. However, patients treated with an anthracycline based regimen (only 17% of patients had prior taxane exposure) in the adjuvant setting enjoyed a response rate of 41.5% [204]. While patients with no previous taxane exposure had an ORR of 57%. Vansteenkiste et al. randomized patients with previous platinum based treatment to receive ixabepilone either as a single dose every 3 weeks (Arm A) or as

52

E.F. McClay

Table 3.1 Representative phase I and II studies with ixabepilone Number of Phase patients Schedule Dose MTD (mg) Response (%)

Toxicity

References

6

Neutropenia, peripheral neuropathy, fatigue Neutropenia

[189, 192, 193] [190]

6–18

8–10

Neutropenia

[194]

1–30 6

25

Neutropenia, fatigue Neutorpenia, fatigue, diarrhea, nausea,vomiting Myalgia, arthralgia, neuropathy, neutropenia Neuropathy, fatigue, mucositis Neutropenia, mucositis, myalgia, arthralgia

[195–197] [207]

I

Q 21 days

7.4–64

40, 50

I

Daily × 5 q 3 weeks Daily × 3 q 3 weeks Weekly Daily × 5 q 3 weeks

1.5–8

I I II

37

II

49

Q 21 days

40

6(12)

II

126

Q 21 days

40

14(11.5)

II

164

Q 21 days

40

31(19)

a 5-day program every 3 weeks (Arm B) [205]. More than 90% of patients on both arms had previous exposure to taxanes. There was essentially no difference in the ORR of either arm (14.3% Arm A; 11.6% Arm B). While the ORR is low, it is encouraging that refractory patients respond to this compound. Additionally, based upon the experience observed in patients with breast cancer, we would expect this ORR to increase in untreated patients. In 2007, Thomas et al reported the results of a randomized prospective open-label phase III trial comparing the combination of ixabepilone and capecitabine vs. capecitabine alone in patients with metastatic breast cancer who progressed after treatment with an anthracycline and taxane [206]. Ixabepilone was administered at a dose of 40 mg/m2 every 3 weeks in combination with capecitabine (1000 mg/m2 bid × 2 weeks). The authors demonstrated an improvement in progression free survival from 4.1 months to 5.7 months (p < 0.001) in comparison to capecitabine monotherapy. As a result of this study, ixabepilone became the first epothilone to be approved for clinical use in the United States.

3.5.2 Patupilone (EPO906) Patupilone, formulated using polyethylene glycol 300, has been tested at several doses and schedules in phase I study (Table 3.2) and has entered phase II

8(22)

[208]

[202] [209]

testing. Elimination is consistent with first order kinetics and the volume of distribution suggests extensive tissue binding [210]. Consistent with this observation, investigators found tissue levels of patupilone 10-fold higher in tumor removed from a patient with a soft tissue sarcoma when compared to plasma levels [211]. Elimination is prolonged in humans with a mean terminal half-life of 4 days with essentially no renal clearance. Diarrhea has been the most commonly encountered dose limiting toxicity although nausea, vomiting and fatigue have also been encountered. In contrast to ixabepilone, significant neuropathy is uncommon and there was essentially no grade 3/4 myelosuppression [211, 212]. Early phase I combination regimens have included carboplatin, capecitabine, gemcitabine and estramustine [178]. Response has been observed in patients with breast, colon, and unknown primary and ovarian cancers. Ten Bokkel Huinink have reported their phase I experience with patupilone in women with advanced ovarian, fallopian tube and peritoneal cancers [213]. Previous experience with this compound identified diarrhea as the dose limiting toxicity therefore a standardized aggressive anti-diarrhea program was employed. The dose was escalated from 6.5 to 11 mg/m2 administered as a 20 min infusion. While the overall response rate was low (19.5%) the median duration of disease stabilization was prolonged at 15.8 months,

3

Taxanes and Epothilones in Cancer Treatment

53

Table 3.2 Phase I studies of selected epothilones Drug name Schedule Dose (mg/m2 )

MTD (mg)

Toxicity

References

Patupilone

0.3–8

6

Diarrhea

[212]

0.3–3.6

2.5

Diarrhea

[222]

0.6–70

40

[216]

Weekly × 3 Q 28 days Day 1,8,15 Q 21 days Day 1 and 8 Q 21 days Q 21 days

5–30

15

Neutropenia, hyponatremia Diarrhea

[223]

5–30

15

Diarrhea, paresthesia

[224]

5–30

20

Diarrhea

[224]

9–185

120

[217]

Daily × 3 Q 21 days Weekly × 3 Q 28 days 24 or 72 h infusion Q 2 weeks Q 21 days

20–50

40

16–100

100

Gait, cognitive dysfunction Chest pain, sensory neuropathy Not observed

[218]

1–6 mg/h

Not reported

Sensory neuropathy

[225]

0.6–29

Not reached

Peripheral neuropathy, ataxia

[220]

Patupilone

BMS-310705 BMS-310705 BMS-310705 BMS-310705 KOS-862 KOS-862 KOS-862 KOS-862

ZK-EPO

5–10 min bolus Q 21 days Weekly × 6 every 9 weeks Q 21 days

Patupilone has been combined with both carboplatin and gemcitabine in phase I studies [214, 215]. These studies represent early attempts using new combinations that will require additional study.

[217]

non-small cell lung cancer experiencing a complete remission [188]

3.5.4 KOS-862 (Epothilone D) 3.5.3 BMS-310705 BMS-310705, a semi-synthetic analog of epothilone B, is water-soluble and therefore does not require R Preliminary pharmaformulation in Cremophor-EL. cokinetic studies suggest linearity across the range of doses studied with an elimination half–life of 42 h [212, 216]. No pre-medications have been used and only one hypersensitivity reaction has been encountered. This occurred in a patient receiving the compound weekly for 3 consecutive weeks and occurred despite the incorporation of steroid prophylaxis after the first episode. The dose limiting toxicities have included neutropenia and hyponatremia. Sensory neuropathy was observed at higher doses. Responses have been observed in patients with ovarian, bladder, gastric and breast cancer with one patient with

KOS-862 demonstrates linear pharmacokinetics regardless of the dose or schedule that is used [217, 218]. The mean half-life is approximately 10 h, considerably shorter than ixabepilone, patupilone or BMS310705. In phase I studies (Table 3.2), dose limiting toxicities have been primarily neurologic in nature. The symptoms most commonly appear within 1–2 days of the infusion, reverse within 1 week and do not appear to be cumulative. Response to the single agent has been observed in patients with breast, testicular, ovarian and pancreatic cancers, Phase Ib and II studies combining KOS-862 with gemcitabine, carboplatin and trastuzumab have been reported [178, 188, 219]. The trastuzumab was administered in a loading dose of 4 mg/kg followed by 2 mg/kg weekly while KOS-862 was administered as a 90 min infusion every 3 weeks

54

[219]. The KOS0862 was escalated up to 100 mg/m2 without encountering dose limiting toxicity although cumulative neurotoxicity was observed.

3.5.5 Sagopilone (ZK-EPO) ZK-EPO is a fully synthetic epothilone designed to overcome multi-drug resistance [220]. Development of this compound is in the early stages. In the reported phase I trial neuropathy was encountered and proved to be dose limiting. Response has been observed in patients with breast cancer with prolonged stable disease observed in patients with non-small cell lung cancer, cholangiocarcinoma, head and neck cancer uveal melanoma and adrenal carcinoma. More recently, Arnold et al have reported a phase I trial employing a weekly schedule [221]. Twentyseven pre-treated patients were entered onto this trial that escalated the dose from 6 to 7 mg/m2 . The dose of 5.3 mg/m2 was identified as the MTD with stable disease as the best-observed response.

References 1. Hastie SB (1991) Interactions of colchicine with tubulin. Pharmacol Ther 51(3):377–401 2. Malkinson F (1981) Colchicine new uses for an old, old drug. Arch Dermatol 118:453–457 3. Dumontet C, Sikic BI (1999) Mechanisms of action of and resistance to antitubulin agents: microtubule dynamics, drug transport, and cell death. J Clin Oncol 17(3): 1061–1070 4. Dustin P (1984) Microtubules, 2nd edn. Springer, New York 5. Hyams JL, Lloyd CW (1993) Microtubules. Wiley-Liss, New York 6. Baker TS, Amos LA (1978) Structure of the tubulin dimer in zinc-induced sheets. J Mol Biol 123(1):89–106 7. Lewis SG, Gilmartin ME, Hall JL, Cowan NJ (1985) Three expressed sequences within the human btea-tubulin multigene family each define a distinct isotyope. J Mol Biol 182(1):11–20 8. Dobner PR et al (1987) Alternative 5 exons either provide or deny an initiator methionine codon to the same alphatubulin coding region. Nucleic Acids Res 15(1):199–218 9. Amos LA, Baker TS (1979) The three-dimensional structure of tubulin protofilaments. Nature 279(5714):607–612 10. Schulze E et al (1987) Posttranslational modification and microtubule stability. J Cell Biol 105(5):2167–2177 11. Vallee RB, Bloom GS, Theurkauf WE (1984) Microtubule-associated proteins: subunits of the cytomatrix. J Cell Biol 99(1 Pt 2):38s–44s

E.F. McClay 12. Desai A, Mitchison TJ (1997) Microtubule polymerization dynamics. Annu Rev Cell Dev Biol 13:83–117 13. Wilson L, Panda D, Jordan MA (1999) Modulation of microtubule dynamics by drugs: a paradigm for the actions of cellular regulators. Cell Struct Funct 24(5): 329–335 14. Rowinsky, ED, Donehower RC (1996) Antimicrotubule agents In: BA Chabner, Longo DL (eds) Cancer chemotherapy and biotherapy; principles and practice, 2nd edn. Lippincott-Raven, Philadelphia, New York 15. Wani MC et al (1971) Plant antitumor agents. VI. The isolation and structure of taxol, a novel antileukemic and antitumor agent from Taxus brevifolia. J Am Chem Soc 93(9):2325–2327 16. Wall ME and Wani MC (1995) Camptothecin and taxol: discovery to clinic – thirteenth Bruce F. Cain memorial award lecture. Cancer Res 55(4):753–760 17. Schiff PB, Fant J, Horwitz SB (1979) Promotion of microtubule assembly in vitro by taxol. Nature 277(5698): 665–667 18. Schiff PB, Horwitz SB (1980) Taxol stabilizes microtubules in mouse fibroblast cells. Proc Natl Acad Sci USA 77(3):1561–1565 19. Cortes JE, Pazdur R (1995) Docetaxel. J Clin Oncol 13(10):2643–2655 20. Gligorov J, Lotz JP (2004) Preclinical pharmacology of the taxanes: implications of the differences. Oncologist 9(Suppl 2):3–8 21. Rowinsky EK, Donehower RC (1995) Paclitaxel (taxol). N Engl J Med 332(15):1004–1014 22. Nogales E et al (1999) High-resolution model of the microtubule. Cell 96(1):79–88 23. De Brabander M et al (1981) Taxol induces the assembly of free microtubules in living cells and blocks the organizing capacity of the centrosomes and kinetochores. Proc Natl Acad Sci USA 78(9):5608–5612 24. Peyrot V, Briand C (1992) c. Biophysical characterization of the assembly of purified tubulin induced by Taxol and Taxotere (RP 56976) in Second Interface of Clinical and Laboratory Responses to Anticancer Drugs: Drugs and Microtubules. Marseille, France 25. Derry WB, Wilson L, Jordan MA (1995) Substoichiometric binding of taxol suppresses microtubule dynamics. Biochemistry 34(7):2203–2211 26. Wilson L (1975) Microtubules as drug receptors: pharmacological properties of microtubule protein. Annu NY Acad Sci 253:213 27. Rowinsky EK et al (1988) Microtubule changes and cytotoxicity in leukemic cell lines treated with taxol. Cancer Res 48(14):4093–4100 28. Roberts RL et al (1982) Effects of taxol on human neutrophils. J Immunol 129(5):2134–2141 29. Ding AH et al (1990) Shared actions of endotoxin and taxol on TNF receptors and TNF release. Science 248(4953):370–372 30. Haldar S, Jena N, Croce CM (1995) Inactivation of Bcl-2 by phosphorylation. Proc Natl Acad Sci USA 92(10):4507–4511 31. Belotti D et al (1996) The microtubule-affecting drug paclitaxel has antiangiogenic activity. Clin Cancer Res 2(11):1843–1849

3

Taxanes and Epothilones in Cancer Treatment 32. Hennequin C, Giocanti N, Favaudon V (1995) Sphase specificity of cell killing by docetaxel (Taxotere) in synchronised HeLa cells. Br J Cancer 71(6): 1194–1198 33. Riou JP, Petitgenet O, Combeau C et al (1994) Cellular uptake and efflux of docetaxel (Taxotere) and paclitaxel (Taxol) in P388 cell line. Proc AM Assoc Can Res 35:385:Abstract #2292 34. Maguire HC, Ettore VL (1967) Enhancement of dinitrochlorobenzene (DNCB) contact sensitization by cyclophosphamide in the guinea pig. J Invest Dermatol 48:39–43 35. Berd D et al (1982) Augmentation of the human immune response by cyclophosphamide. Cancer Res 42: 4862–4866 36. Berd D, Maguire HC, Mastrangelo MJ (1986) Induction of cell-mediated immunity to autologous melanoma cells and regression of metastases after treatment with a melanoma cell vaccine preceeded by cyclophosphamide. Cancer Res 46:2572–2577 37. Machiels JP et al (2001) Cyclophosphamide, doxorubicin, and paclitaxel enhance the antitumor immune response of granulocyte/macrophage-colony stimulating factor-secreting whole-cell vaccines in HER-2/neu tolerized mice. Cancer Res 61(9):3689–3697 38. Arlen, PM et al (2006) A randomized phase II study of concurrent docetaxel plus vaccine versus vaccine alone in metastatic androgen-independent prostate cancer. Clin Cancer Res 12(4):1260–1269 39. Cabral F et al (1983) Taxol-requiring mutant of Chinese hamster ovary cells with impaired mitotic spindle assembly. J Cell Biol 97(1):30–39 40. Giannakakou P et al (1997) Paclitaxel-resistant human ovarian cancer cells have mutant beta-tubulins that exhibit impaired paclitaxel-driven polymerization. J Biol Chem 272(27):17118–17125 41. Ranganathan S et al (1996) Increase of beta(III)- and beta(IVa)-tubulin isotopes in human prostate carcinoma cells as a result of estramustine resistance. Cancer Res 56(11):2584–2589 42. Kartner N, Riordan JR, Ling V (1983) Cell surface P-glycoprotein associated with multidrug resistance in mammalian cell lines. Science 221(4617):1285–1288 43. Ling V (1992) Charles F. Kettering Prize. P-glycoprotein and resistance to anticancer drugs. Cancer 69(10): 2603–2609 44. Horwitz SBL, Liao LL, Greenberger L (1989) Mode of action of taxol and characterization of a multidrugresistant cell line resistant to taxol. In: Kessel D (ed) Resistance to antineoplastic drugs. CRC, Boca Raton, FL, pp 109–126 45. Masuda A et al (2003) Association between mitotic spindle checkpoint impairment and susceptibility to the induction of apoptosis by anti-microtubule agents in human lung cancers. Am J Pathol 163(3): 1109–1116 46. Rudner AD, Murray AW (1996) The spindle assembly checkpoint. Curr Opin Cell Biol 8(6):773–780 47. Rouzier R et al (2005) Microtubule-associated protein tau: a marker of paclitaxel sensitivity in breast cancer. Proc Natl Acad Sci USA 102(23):8315–8320

55 48. Wagner P et al (2005) Microtubule Associated Protein (MAP)-Tau: a novel mediator of paclitaxel sensitivity in vitro and in vivo. Cell Cycle 4(9):1149–1152 49. Kar S et al (2003) Repeat motifs of tau bind to the insides of microtubules in the absence of taxol. Embo J 22(1): 70–77 50. Ramanathan B et al (2005) Resistance to paclitaxel is proportional to cellular total antioxidant capacity. Cancer Res 65(18):8455–8460 51. Van Poznak C et al (2002) Assessment of molecular markers of clinical sensitivity to single-agent taxane therapy for metastatic breast cancer. J Clin Oncol 20(9):2319–2326 52. Schmidt M et al (2003) p53 expression and resistance against paclitaxel in patients with metastatic breast cancer. J Cancer Res Clin Oncol 129(5):295–302 53. Slamon DJ et al (1987) Human breast cancer: correlation of relapse and survival with amplification of the HER-2/neu oncogene. Science 235(4785):177–182 54. Slamon DJ et al (1989) Studies of the HER-2/neu protooncogene in human breast and ovarian cancer. Science 244(4905):707–712 55. Gandour-Edwards R et al (2002) Does HER2/neu expression provide prognostic information in patients with advanced urothelial carcinoma? Cancer 95(5):1009–1015 56. Yu D et al (1996) Overexpression of c-erbB-2/neu in breast cancer cells confers increased resistance to Taxol via mdr-1-independent mechanisms. Oncogene 13(6):1359–1365 57. Perez-Soler R et al (2000) Response and determinants of sensitivity to paclitaxel in human non-small cell lung cancer tumors heterotransplanted in nude mice. Clin Cancer Res 6(12):4932–4938 58. Witters LM et al (2003) Decreased response to paclitaxel versus docetaxel in HER-2/neu transfected human breast cancer cells. Am J Clin Oncol 26(1):50–54 59. O’Brien ML, Tew KD (1996) Glutathione and related enzymes in multidrug resistance. Eur J Cancer 32A(6):967–978 60. O’Brien ML et al (1999) Glutathione peptidomimetic drug modulator of multidrug resistance-associated protein. J Pharmacol Exp Ther 291(3):1348–1355 61. Arai T et al (2008) Association of GSTP1 expression with resistance to docetaxel and paclitaxel in human breast cancers. Eur J Surg Oncol 34(7):734–738 62. Waris G, Ahsan H (2006) Reactive oxygen species: role in the development of cancer and various chronic conditions. J Carcinog 5:14 63. Alexandre J et al (2006) Accumulation of hydrogen peroxide is an early and crucial step for paclitaxel-induced cancer cell death both in vitro and in vivo. Int J Cancer 119(1):41–48 64. Alexandre J et al (2006) Improvement of the therapeutic index of anticancer drugs by the superoxide dismutase mimic mangafodipir. J Natl Cancer Inst 98(4): 236–244 65. Alexandre J et al (2007) Novel action of paclitaxel against cancer cells: bystander effect mediated by reactive oxygen species. Cancer Res 67(8):3512–3517 66. Rowinsky EK et al (1992) Taxol: the first of the taxanes, an important new class of antitumor agents. Semin Oncol 19(6):646–662

56 67. Eisenhauer EA et al (1994) European-Canadian randomized trial of paclitaxel in relapsed ovarian cancer: highdose versus low-dose and long versus short infusion. J Clin Oncol 12(12):2654–2666 68. Sparreboom A et al (1996) Nonlinear pharmacokinetics of paclitaxel in mice results from the pharmaceutical vehicle Cremophor EL. Cancer Res 56(9):2112–2115 69. Gianni L et al (1995) Nonlinear pharmacokinetics and metabolism of paclitaxel and its pharmacokinetic/pharmacodynamic relationships in humans. J Clin Oncol 13(1):180–190 70. Sparreboom A et al (1999) Cremophor EL-mediated alteration of paclitaxel distribution in human blood: clinical pharmacokinetic implications. Cancer Res 59(7): 1454–1457 71. Clarke SJ, Rivory LP (1999) Clinical pharmacokinetics of docetaxel. Clin Pharmacokinet 36(2):99–114 72. Desai NP, Louie L, Ron N, Magdassi S, Soon-Shiong P (2000) Proetin-bound nanoparticles for drug delivery of paclitaxel. Trans World Biomater Congr 1:199 73. Ibrahim NK et al (2002) Phase I and pharmacokinetic study of ABI-007, a Cremophor-free, protein-stabilized, nanoparticle formulation of paclitaxel. Clin Cancer Res 8(5):1038–1044 74. Vorum H (1999) Reversible ligand binding to human serum albumin. Theoretical and clinical aspects. Dan Med Bull 46(5):379–399 75. John TA et al (2003) Quantitative analysis of albumin uptake and transport in the rat microvessel endothelial monolayer. Am J Physiol Lung Cell Mol Physiol 284(1):L187–L196 76. Rempel SA, Ge S, Gutierrez JA (1999) SPARC: a potential diagnostic marker of invasive meningiomas. Clin Cancer Res 5(2):237–241 77. Schnitzer JE, Oh P (1992) Antibodies to SPARC inhibit albumin binding to SPARC, gp60, and microvascular endothelium. Am J Physiol 263(6 Pt 2):H1872–H1879 78. Porter PL et al (1995) Distribution of SPARC in normal and neoplastic human tissue. J Histochem Cytochem 43(8):791–800 79. Thomas R et al (2000) Differential expression of osteonectin/SPARC during human prostate cancer progression. Clin Cancer Res 6(3):1140–1149 80. Brown TJ et al (1999) Activation of SPARC expression in reactive stroma associated with human epithelial ovarian cancer. Gynecol Oncol 75(1):25–33 81. Ledda F et al (1997) The expression of the secreted protein acidic and rich in cysteine (SPARC) is associated with the neoplastic progression of human melanoma. J Invest Dermatol 108(2):210–214 82. Schilling U, Friedrich EA, Sinn H (1992) Design of compounds having enhanced tumor uptale, using serum albumin as a carrier: part II In vivo studies. Int J Rad Appl Instrum B 19:685–695 83. Desai N et al (2006) Increased antitumor activity, intratumor paclitaxel concentrations, and endothelial cell transport of cremophor-free, albumin-bound paclitaxel, ABI007, compared with cremophor-based paclitaxel. Clin Cancer Res 12(4):1317–1324 84. Cresteil T et al (1994) Taxol metabolism by human liver microsomes: identification of cytochrome P450 isozymes

E.F. McClay

85.

86.

87.

88. 89.

90.

91.

92.

93.

94.

95.

96.

97.

98.

99.

100.

involved in its biotransformation. Cancer Res 54(2): 386–392 Harris JW et al (1994) Metabolism of taxol by human hepatic microsomes and liver slices: participation of cytochrome P450 3A4 and an unknown P450 enzyme. Cancer Res 54(15):4026–4035 Rowinsky EK et al (1989) Phase I and pharmacodynamic study of taxol in refractory acute leukemias. Cancer Res 49(16):4640–4647 Gelderblom H et al (2003) Distribution of paclitaxel in plasma and cerebrospinal fluid. Anticancer Drugs 14(5):365–368 ten Tije AJ et al (2004) Limited cerebrospinal fluid penetration of docetaxel. Anticancer Drugs 15(7):715–718 Forastiere AA et al (2001) Phase III comparison of high-dose paclitaxel + cisplatin + granulocyte colonystimulating factor versus low-dose paclitaxel + cisplatin in advanced head and neck cancer: eastern cooperative oncology group study E1393. J Clin Oncol 19(4): 1088–1095 Roth BJ et al (1994) Significant activity of paclitaxel in advanced transitional-cell carcinoma of the urothelium: a phase II trial of the eastern cooperative oncology group. J Clin Oncol 12(11):2264–2270 Van Poznak C, Seidman AD (2002) Critical review of current treatment strategies for advanced hormone insensitive breast cancer. Cancer Invest 20(Suppl 2):1–14 Eniu A, Palmieri FM, Perez EA (2005) Weekly administration of docetaxel and paclitaxel in metastatic or advanced breast cancer. Oncologist 10(9):665–685 Sikov WM, Akerly W, Kahanic S et al (2002) Multicenter, 3-armed randomized study of high-dose weekly paclitaxel, (HWDP) versus standard-dose weekly paclitaxel (SWDP) for metastatic breast cancer, (MBC) Proc ASCO 21:34a Akerley W et al (1997) Weekly paclitaxel in patients with advanced lung cancer: preliminary data from a phase II trial. Semin Oncol 24(4 Suppl 12):S12–10– S12–13 Perez EA et al (2001) Multicenter phase II trial of weekly paclitaxel in women with metastatic breast cancer. J Clin Oncol 19(22):4216–4223 Panday VR et al (1998) Phase I and pharmacologic study of weekly doxorubicin and 1 h infusional paclitaxel in patients with advanced breast cancer. Anticancer Drugs 9(8):665–673 Schwonzen M, Kurbacher CM, Mallmann P (2000) Liposomal doxorubicin and weekly paclitaxel in the treatment of metastatic breast cancer. Anticancer Drugs 11(9):681–685 Frasci G et al (1998) Weekly paclitaxel-cisplatin administration with G-CSF support in advanced breast cancer. A phase II study. Breast Cancer Res Treat 49(1): 13–26 Spano JP et al (2004) Phase II study of paclitaxel combined with vinorelbine in patients with advanced breast cancer. Am J Clin Oncol 27(3):317–321 Seidman AD et al (2001) Weekly trastuzumab and paclitaxel therapy for metastatic breast cancer with analysis of efficacy by HER2 immunophenotype and gene amplification. J Clin Oncol 19(10):2587–2595

3

Taxanes and Epothilones in Cancer Treatment

101. Frasci G et al (2006) Weekly cisplatin, epirubicin, and paclitaxel with granulocyte colony-stimulating factor support vs. triweekly epirubicin and paclitaxel in locally advanced breast cancer: final analysis of a sicog phase III study. Br J Cancer 95(8):1005–1012 102. Ford HE et al (2006) A phase II study of weekly docetaxel in patients with anthracycline pretreated metastatic breast cancer. Cancer Chemother Pharmacol 58(6):809–815 103. Burstein HJ et al (2000) Docetaxel administered on a weekly basis for metastatic breast cancer. J Clin Oncol 18(6):1212–1219 104. Ramos M et al (2003) Weekly docetaxel as second-line therapy for patients with advanced breast cancer resistant to previous anthracycline treatment. J Chemother 15(2):192–197 105. Ito Y et al (2001) Dose-finding phase I study of simultaneous weekly infusion with doxorubicin and docetaxel in patients with advanced breast cancer. Int J Clin Oncol 6(5):242–247 106. Wenzel C et al (2002) Phase I/II trial of weekly epidoxorubicin and docetaxel (wED) in the neoadjuvant and palliative treatment of patients with breast cancer. Cancer Chemother Pharmacol 50(2):155–159 107. Frasci G et al (2000) Weekly docetaxel plus gemcitabine or vinorelbine in refractory advanced breast cancer patients: a parallel dose-finding study. Southern Italy Cooperative Oncology Group (SICOG). Ann Oncol 11(3):367–371 108. Kornek GV et al (2001) Treatment of advanced breast cancer with vinorelbine and docetaxel with or without human granulocyte colony-stimulating factor. J Clin Oncol 19(3):621–627 109. Esteva FJ et al (2002) Phase II study of weekly docetaxel and trastuzumab for patients with HER-2-overexpressing metastatic breast cancer. J Clin Oncol 20(7):1800–1808 110. Tedesco KL et al (2004) Docetaxel combined with trastuzumab is an active regimen in HER-2 3+ overexpressing and fluorescent in situ hybridization-positive metastatic breast cancer: a multi-institutional phase II trial. J Clin Oncol 22(6):1071–1077 111. Raff JP et al (2004) Phase II study of weekly docetaxel alone or in combination with trastuzumab in patients with metastatic breast cancer. Clin Breast Cancer 4(6):420–427 112. Wenzel C et al (2004) Preoperative therapy with epidoxorubicin and docetaxel plus trastuzumab in patients with primary breast cancer: a pilot study. J Cancer Res Clin Oncol 130(7):400–404 113. Nyman DW et al (2005) Phase I and pharmacokinetics trial of ABI-007, a novel nanoparticle formulation of paclitaxel in patients with advanced nonhematologic malignancies. J Clin Oncol 23(31):7785–7793 114. Moreno-Aspitia A, Perez EA (2005) North Central Cancer Treatment Group N0531: phase II trial of weekly albuminbound paclitaxel (ABI-007; Abraxane) in combination with gemcitabine in patients with metastatic breast cancer. Clin Breast Cancer 6(4):361–364 115. Stinchcombe TE et al (2007) Phase I and pharmacokinetic trial of carboplatin and albumin-bound paclitaxel, ABI-007 (Abraxane((R))) on three treatment schedules in patients with solid tumors. Cancer Chemother Pharmacol 60(5):759–766

57 116. Rowinsky EK et al (1991) Cardiac disturbances during the administration of taxol. J Clin Oncol 9(9):1704–1712 117. Shenkier T, Gelmon K (1994), Paclitaxel and radiation recall dermatitis [Letter]. J Clin Oncol 12:439 118. Francis PA et al (1994) Phase II trial of docetaxel in patients with stage III and IV non-small-cell lung cancer. J Clin Oncol 12(6):1232–1237 119. Extra JM et al (1993) Phase I and pharmacokinetic study of Taxotere (RP 56976; NSC 628503) given as a short intravenous infusion. Cancer Res 53(5):1037–1042 120. Pazdur R et al (1992) Phase I trial of Taxotere: five-day schedule. J Natl Cancer Inst 84(23):1781–1788 121. Bissett D et al (1993) Phase I and pharmacokinetic study of taxotere (RP 56976) administered as a 24-hour infusion. Cancer Res 53(3):523–527 122. Green MR et al (2006) Abraxane, a novel Cremophor-free, albumin-bound particle form of paclitaxel for the treatment of advanced non-small-cell lung cancer. Ann Oncol 17(8):1263–1268 123. Paridaens R et al (2000) Paclitaxel versus doxorubicin as first-line single-agent chemotherapy for metastatic breast cancer: a European Organization for Research and Treatment of Cancer randomized study with cross-over. J Clin Oncol 18(4):724–733 124. Sledge GW et al (2003) Phase III trial of doxorubicin, paclitaxel, and the combination of doxorubicin and paclitaxel as front-line chemotherapy for metastatic breast cancer: an Intergroup trial (E1193). J Clin Oncol 21(4): 588–592 125. Chan S et al (1999) Prospective randomized trial of docetaxel versus doxorubicin in patients with metastatic breast cancer. J Clin Oncol 17(8):2341–2354 126. Ibrahim NK et al (2005) Multicenter phase II trial of ABI-007, an albumin-bound paclitaxel, in women with metastatic breast cancer. J Clin Oncol 23(25): 6019–6026 127. Gradishar WJ et al (2005) Phase III trial of nanoparticle albumin-bound paclitaxel compared with polyethylated castor oil-based paclitaxel in women with breast cancer. J Clin Oncol 23(31):7794–7803 128. Biganzoli L et al (2002) Doxorubicin and paclitaxel versus doxorubicin and cyclophosphamide as first-line chemotherapy in metastatic breast cancer: the European Organization for Research and Treatment of Cancer 10961 multicenter phase III trial. J Clin Oncol 20(14): 3114–3121 129. Jassem J et al (2001) Doxorubicin and paclitaxel versus fluorouracil, doxorubicin, and cyclophosphamide as firstline therapy for women with metastatic breast cancer: final results of a randomized phase III multicenter trial. J Clin Oncol 19(6):1707–1715 130. Luck H, Thomssen C, Untch M, Kuhn W, Eidtmann H, du Bois A, Olbricht S, Moebus V, Steinfeld D, Bauknecht T, Schroeder W, Jackisch C (2000) Multicentric phase III study in first line treatment of advanced metastatic breast cancer (ABC). Epirubicin/Paclitaxel (ET) Vs Epirubicin/Cyclophosphamide (EC). A Study of the Ago Breast Cancer Group. Proc ASCO 19:73a 131. Crown J, O’Leary M, Ooi WS (2004) Docetaxel and paclitaxel in the treatment of breast cancer: a review of clinical experience. Oncologist 9(Suppl 2):24–32

58 132. Bonneterre J et al (2004) Phase II multicentre randomised study of docetaxel plus epirubicin vs 5-fluorouracil plus epirubicin and cyclophosphamide in metastatic breast cancer. Br J Cancer 91(8):1466–1471 133. Mackey JR, Paterson A, Drix LY et al (2002) Final results of the phase III randomized trial comparing docetaxel (T), doxorubicin (A) and cyclophosphamide (C) to FAC as first line chemotherapy (CT) for patients (pts) with metastatic breast cancer (MBC). in Proc ASCO 21:35a 134. Nabholtz JM et al (2003) Docetaxel and doxorubicin compared with doxorubicin and cyclophosphamide as firstline chemotherapy for metastatic breast cancer: results of a randomized, multicenter, phase III trial. J Clin Oncol 21(6):968–975 135. Bontenbal M et al (2005) Phase II to III study comparing doxorubicin and docetaxel with fluorouracil, doxorubicin, and cyclophosphamide as first-line chemotherapy in patients with metastatic breast cancer: results of a Dutch community setting trial for the clinical trial group of the comprehensive cancer centre. J Clin Oncol 23(28): 7081–7088 136. Blum JL et al (2007) Phase II study of weekly albuminbound paclitaxel for patients with metastatic breast cancer heavily pretreated with taxanes. Clin Breast Cancer 7(11):850–856 137. Roy V et al (2009) Phase II trial of weekly nab (nanoparticle albumin-bound)-paclitaxel (nab-paclitaxel) (Abraxane) in combination with gemcitabine in patients with metastatic breast cancer (N0531). Ann Oncol 20(3):449–453 138. Link JS et al (2007) Bevacizumab and albumin-bound paclitaxel treatment in metastatic breast cancer. Clin Breast Cancer 7(10):779–783 139. Untch M, Konecny G, Ditsch N et al (2002) Dose-dense sequential epirubicin-paclitaxel as preoperative treatment of breast cancer: results of a randomized AGO study. Proc ASCO 21:133a 140. Green MC et al (2005) Weekly paclitaxel improves pathologic complete remission in operable breast cancer when compared with paclitaxel once every 3 weeks. J Clin Oncol 23(25):5983–5992 141. Bear HD et al (2006) Sequential preoperative or postoperative docetaxel added to preoperative doxorubicin plus cyclophosphamide for operable breast cancer: national surgical adjuvant breast and bowel project protocol B-27. J Clin Oncol 24(13):2019–2027 142. Hutcheon AW, Heys SD, Sarkar TK (2003) Neoadjuvant docetaxel in locally advanced breast cancer. Breast Cancer Res Treat 79(Suppl 1):S19–S24 143. von Minckwitz G et al (2005) Doxorubicin with cyclophosphamide followed by docetaxel every 21 days compared with doxorubicin and docetaxel every 14 days as preoperative treatment in operable breast cancer: the GEPARDUO study of the German breast group. J Clin Oncol 23(12):2676–2685 144. Evans TR et al (2005) Phase III randomized trial of doxorubicin and docetaxel versus doxorubicin and cyclophosphamide as primary medical therapy in women with breast cancer: an anglo-celtic cooperative oncology group study. J Clin Oncol 23(13):2988–2995

E.F. McClay 145. Henderson IC et al (2003) Improved outcomes from adding sequential Paclitaxel but not from escalating Doxorubicin dose in an adjuvant chemotherapy regimen for patients with node-positive primary breast cancer. J Clin Oncol 21(6):976–983 146. Mamounas EP et al (2005) Paclitaxel after doxorubicin plus cyclophosphamide as adjuvant chemotherapy for node-positive breast cancer: results from NSABP B-28. J Clin Oncol 23(16):3686–3696 147. Martin M et al (2005) Adjuvant docetaxel for nodepositive breast cancer. N Engl J Med 352(22): 2302–2313 148. Pienta KJ (2001) Preclinical mechanisms of action of docetaxel and docetaxel combinations in prostate cancer. Semin Oncol 28(4 Suppl 15):3–7 149. Raghavan D (2004) Chemotherapy for prostate cancer: small steps or leaps and bounds? No huzzahs just yet! Br J Cancer 91(6):1003–1004 150. Canil CM, Tannock IF (2004) Is there a role for chemotherapy in prostate cancer? Br J Cancer 91(6):1005–1011 151. Tannock IF et al (2004) Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer. N Engl J Med 351(15):1502–1512 152. Petrylak DP et al (2004) Docetaxel and estramustine compared with mitoxantrone and prednisone for advanced refractory prostate cancer. N Engl J Med 351(15):1513– 1520 153. Berthold DR, Pond G, de Wit R et al (2007) Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer: updated survival of the TAX 327 study. Proc ASCO Abstract #147 Prostate Cancer Symposium 154. Ramalingam S, Belani C (2008) Systemic chemotherapy for advanced non-small cell lung cancer: recent advances and future directions. Oncologist 13(Suppl 1): 5–13 155. Ramalingam S, Sandler AB (2006) Salvage therapy for advanced non-small cell lung cancer: factors influencing treatment selection. Oncologist 11(6):655–665 156. Sandler A et al (2006) Paclitaxel-carboplatin alone or with bevacizumab for non-small-cell lung cancer. N Engl J Med 355(24):2542–2550 157. Stinchcombe TE, Socinski MA (2008) Considerations for second-line therapy of non-small cell lung cancer. Oncologist 13(Suppl 1):28–36 158. Hanna N et al (2004) Randomized phase III trial of pemetrexed versus docetaxel in patients with non-small-cell lung cancer previously treated with chemotherapy. J Clin Oncol 22(9):1589–1597 159. Shepherd FA et al (2000) Prospective randomized trial of docetaxel versus best supportive care in patients with non-small-cell lung cancer previously treated with platinum-based chemotherapy. J Clin Oncol 18(10): 2095–2103 160. Fossella FV et al (2000) Randomized phase III trial of docetaxel versus vinorelbine or ifosfamide in patients with advanced non-small-cell lung cancer previously treated with platinum-containing chemotherapy regimens. The TAX 320 non-small cell lung cancer study group. J Clin Oncol 18(12):2354–2362

3

Taxanes and Epothilones in Cancer Treatment

161. Rizvi NA et al (2008) Phase I/II trial of weekly intravenous 130-nm albumin-bound paclitaxel as initial chemotherapy in patients with stage IV non-small-cell lung cancer. J Clin Oncol 26(4):639–643 162. McGuire WP et al (1996) Cyclophosphamide and cisplatin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer. N Engl J Med 334(1):1–6 163. Ozols RF et al (2003) Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a gynecologic oncology group study. J Clin Oncol 21(17):3194–3200 164. Armstrong DK et al (2006) Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med 354(1): 34–43 165. Teneriello MG et al (2009) Phase II evaluation of nanoparticle albumin-bound paclitaxel in platinum-sensitive patients with recurrent ovarian, peritoneal, or fallopian tube cancer. J Clin Oncol 27(9):1426–1431 166. Bourhis J (2005) New approaches to enhance chemotherapy in SCCHN. Ann Oncol 16(Suppl 6):vi20–vi24 167. Amato RJ (2005) Renal cell carcinoma: review of novel single-agent therapeutics and combination regimens. Ann Oncol 16(1):7–15 168. Roth AD, Ajani J (2003) Docetaxel-based chemotherapy in the treatment of gastric cancer. Ann Oncol 14(Suppl 2):ii41–ii44 169. Scheithauer W (2004) Esophageal cancer: chemotherapy as palliative therapy. Ann Oncol 15(Suppl 4):iv97–iv100 170. Galsky MD (2005) The role of taxanes in the management of bladder cancer. Oncologist 10(10):792–798 171. Hennenfent KL, Govindan R (2006) Novel formulations of taxanes: a review. Old wine in a new bottle? Ann Oncol 17(5):735–749 172. Gerth K et al (1996) Epothilons A and B: antifungal and cytotoxic compounds from Sorangium cellulosum (Myxobacteria). Production, physico-chemical and biological properties. J Antibiot (Tokyo) 49(6): 560–563 173. Bollag DM et al (1995) Epothilones, a new class of microtubule-stabilizing agents with a taxollike mechanism of action. Cancer Res 55(11): 2325–2333 174. Kowalski RJ, Giannakakou P, Hamel E (1997) Activities of the microtubule-stabilizing agents epothilones A and B with purified tubulin and in cells resistant to paclitaxel (Taxol(R)). J Biol Chem 272(4):2534–2541 175. Kamath K, Jordan MA (2003) Suppression of microtubule dynamics by epothilone B is associated with mitotic arrest. Cancer Res 63(18):6026–6031 176. Nettles JH et al (2004) The binding mode of epothilone A on alpha,beta-tubulin by electron crystallography. Science 305(5685):866–869 177. Bode CJ et al (2002) Epothilone and paclitaxel: unexpected differences in promoting the assembly and stabilization of yeast microtubules. Biochemistry 41(12):3870–3874 178. Cortes J, Baselga J (2007) Targeting the microtubules in breast cancer beyond taxanes: the epothilones. Oncologist 12(3):271–280

59 179. Wartmann M, Altmann KH (2002) The biology and medicinal chemistry of epothilones. Curr Med Chem Anticancer Agents 2(1):123–148 180. Nicolaou KC et al (1997) Synthesis of epothilones A and B in solid and solution phase. Nature 387(6630):268–272 181. Lee FY et al (2001) BMS-247550: a novel epothilone analog with a mode of action similar to paclitaxel but possessing superior antitumor efficacy. Clin Cancer Res 7(5):1429–1437 182. Chou TC et al (1998) Desoxyepothilone B: an efficacious microtubule-targeted antitumor agent with a promising in vivo profile relative to epothilone B. Proc Natl Acad Sci USA 95(16):9642–9647 183. Newman RA et al (2001) Antitumor efficacy of 26-fluoroepothilone B against human prostate cancer xenografts. Cancer Chemother Pharmacol 48(4):319–326 184. Schinkel AH (1997) The physiological function of drug-transporting P-glycoproteins. Semin Cancer Biol 8(3):161–170 185. Giannakakou P et al (2000) A common pharmacophore for epothilone and taxanes: molecular basis for drug resistance conferred by tubulin mutations in human cancer cells. Proc Natl Acad Sci USA 97(6):2904–2909 186. Verrills NM et al (2003) Microtubule alterations and mutations induced by desoxyepothilone B: implications for drug-target interactions. Chem Biol 10(7):597–607 187. Forster M et al (2007) A phase Ib and pharmacokinetic trial of patupilone combined with carboplatin in patients with advanced cancer. Clin Cancer Res 13(14):4178–4184 188. Goodin S, Kane MP, Rubin EH (2004) Epothilones: mechanism of action and biologic activity. J Clin Oncol 22(10):2015–2025 189. Mani S et al (2004) Phase I clinical and pharmacokinetic study of BMS-247550, a novel derivative of epothilone B, in solid tumors. Clin Cancer Res 10(4):1289–1298 190. Abraham J et al (2003) Phase I trial and pharmacokinetic study of BMS-247550, an epothilone B analog, administered intravenously on a daily schedule for five days. J Clin Oncol 21(9):1866–1873 191. McDaid HM et al (2002) Validation of the pharmacodynamics of BMS-247550, an analogue of epothilone B, during a phase I clinical study. Clin Cancer Res 8(7):2035–2043 192. Spriggs D, Soignet SA, Bienvenu B et al (2001) Phase I first in man study of epothilone B analog BMS-247550 in patients with advanced cancer. Proc ASCO 20:108a, Abstract #428 193. Gadgeel SM et al (2005) Phase I clinical trial of BMS-247550, a derivative of epothilone B, using accelerated titration 2B design. Clin Cancer Res 11(17): 6233–6239 194. Zhuang SH et al (2005) A Phase I clinical trial of ixabepilone (BMS-247550), an epothilone B analog, administered intravenously on a daily schedule for 3 days. Cancer 103(9):1932–1938 195. Awada A, Bleiberg H, de Valeriola D et al (2001) Phase I clinical and pharmacology study of the epothilone analog BMS-247550 given weekly in patients with advanced solid tumors. Proc ASCO 20:103a, Abstract #421 196. Hao D, Hammond LA, deBono JS et al (2002) Continuous weekly administration of the epothilone-B derivative,

60

197.

198.

199.

200.

201.

202.

203.

204.

205.

206.

207.

208.

209.

210.

E.F. McClay BMS-247550 (NSC710428): a phase I and pharmacokinetic study. Proc ASCO 21:103a, Abstract #411 Burris HA 3rd, Jones S et al (2002) Phase I study of the novel epothilone BMS-247550 administered weekly in patients with advanced malignancies. Proc ASCO 21:103a, Abstract #412a Plummeer R, Molife R, Verrill M et al (2002) Phase I and pharmacokinetic study of BMS-247550 in combination with carboplatin in patients with advanced solid malignancies. Proc Am Soc Clin Oncol 21:78b Smaletz O et al (2003) Pilot study of epothilone B analog (BMS-247550) and estramustine phosphate in patients with progressive metastatic prostate cancer following castration. Ann Oncol 14(10):1518–1524 Galsky MD et al (2005) Multi-institutional randomized phase II trial of the epothilone B analog ixabepilone (BMS-247550) with or without estramustine phosphate in patients with progressive castrate metastatic prostate cancer. J Clin Oncol 23(7):1439–1446 Gianni L (2007) Ixabepilone and the narrow path to developing new cytotoxic drugs. J Clin Oncol 25(23): 3389–3391 Perez EA et al (2007) Efficacy and safety of ixabepilone (BMS-247550) in a phase II study of patients with advanced breast cancer resistant to an anthracycline, a taxane, and capecitabine. J Clin Oncol 25(23):3407–3414 Denduluri N et al (2007) Phase II trial of ixabepilone, an epothilone B analog, in patients with metastatic breast cancer previously untreated with taxanes. J Clin Oncol 25(23):3421–3427 Roche H et al (2007) Phase II clinical trial of ixabepilone (BMS-247550), an epothilone B analog, as first-line therapy in patients with metastatic breast cancer previously treated with anthracycline chemotherapy. J Clin Oncol 25(23):3415–3420 Vansteenkiste J et al (2007) Phase II clinical trial of the epothilone B analog, ixabepilone, in patients with non small-cell lung cancer whose tumors have failed firstline platinum-based chemotherapy. J Clin Oncol 25(23): 3448–3455 Thomas ES et al (2007) Ixabepilone plus capecitabine for metastatic breast cancer progressing after anthracycline and taxane treatment. J Clin Oncol 25(33):5210–2517 Low JA et al (2005) Phase II clinical trial of ixabepilone (BMS-247550), an epothilone B analog, in metastatic and locally advanced breast cancer. J Clin Oncol 23(12): 2726–2734 Roche H, Cure H, Bunnell C et al (2003) A phase II study of epothilone analog BMS-247550 in patients with metastatic breast cancer previously treated with an anthracycline. Proc ASCO 24:586a Llombart A, Baselga J, Manikhas G et al (2005) Phase II genomics study in patients receiving ixabepilone as neoadjuvant treatment for breast cancer: preliminary efficacy and safety data. Proc ASCO 24:586a Chen TL, Calvert AH et al (2002) Pharmacokinetics of EPO906 in cancer patients receiving EPO906 by short intravenous infusion once every 3 weeks. Proc ASCO 21:91a, Abstract #413

211. Rubin, EH, Siu, LL, Beers S et al (2001) A phase I and pharmacokindtic trial of weekly epothiline B in patients with advanced malignancies. Proc ASCO 20:68a, Abstract #270 212. Calvert AH, O’Neill V, Twelves C et al (2001) A phase I and pharmacokinetic study of EPO906 (epothilone B), given every three weeks, in patients with advanced solid malignancies. Proc ASCO 20:108a, Abstract #429 213. Ten Bokkel Huinink WW et al (2009) Safety and efficacy of patupilone in patients with advanced ovarian, primary fallopian, or primary peritoneal cancer: a phase I, open-label, dose-escalation study. J Clin Oncol 27(19): 3097–3103 214. Forster M, Kaye S, Oza A, Sklenar I, Johri A, Cheung W, Zaknoen S, Gore M (2007) A phase Ib and pharmacokinetic trial of patupilone combined with carboplatin in patients with advanced cancer. Clin Cancer Res 13(14):4178–4184 215. Schelman W et al (2008) A phase I trial of gemcitabine in combination with patupilone in patients with advanced solid tumors. Cancer Chemother Pharmacol 62(4): 727–733 216. Mekhail T et al (2003) Phase I trial of novel epothilone B analog BMS-310705 IV q 21 days. Proc ASCO 22:130, Abstract #515 217. Piro LD, Rosen LS, Parson M et al (2003) KOS862 (Epothilone D) a comparison of two schedules in patients with advanced malignancies. Proc ASCO 22:135, Abstract #539 218. Spriggs D, Pezzulli S et al (2003) KOS-862 (epothilone D): phase I dose escalating and pharmacokinetic study in patients with advanced malignancies. Proc ASCO 22:223, Abstract #894 219. Cortes J, Gomez P et al (2006) A phase I trial of weekly combination KOS-862 (epothilone D) and trastuzumab in HER-2 overexpressing melignancies. Proc ASCO 25:2028a 220. Schmid P, Kuehnhardt D et al (2005) A phase I study of the novel, third generation epothilone ZK-EPO in patients with advanced solid tumors. Proc ASCO 24:2051a 221. Arnold D et al (2009) Weekly administration of sagopilone (ZK-EPO), a fully synthetic epothilone, in patients with refractory solid tumours: results of a phase I trial. Br J Cancer 101(8):1241–1247 222. Rubin EH et al (2005) Phase I dose-finding study of weekly single-agent patupilone in patients with advanced solid tumors. J Clin Oncol 23(36):9120–9129 223. Sessa C, Malossi A et al (2003) Phase I and pharmacokinetic study of the novel epothilone BMS-31–705 in patients with advanced solid cancer. Proc ASCO 22:519a 224. Sessa C et al (2007) Phase I clinical study of the novel epothilone B analogue BMS-310705 given on a weekly schedule. Ann Oncol 18(9):1548–1553 225. Holen KZD, Hannah AL et al (2004) Phase I study using continuous intravenous KOS-862 (Epothilone D) in patients with solid tumors. Proc ASCO 23:2024a

Chapter 4

Alkylating Agents Laurent Gate and Kenneth D. Tew

4.1 Introduction Anticancer chemotherapy along with surgery and radiotherapy represent the primary treatment modalities in cancer patients. Chemotherapy emerged during the 1940s from the work of Gilman and Phillips [71] who demonstrated the clinical utility of nitrogen mustards. These agents were derived from the deadly sulphur mustard gas developed and used as a military weapon during World War I which had been shown to be effective against squamous cell carcinoma [2]. These drugs were the first generation of anticancer agents used to treat cancer patients. Since the identification of nitrogen mustards as clinically useful anticancer agents, tremendous efforts have been made by academic scientists and pharmaceutical companies to develop new generations of alkylating agents with less toxicity and more therapeutic efficacy.

4.2 Mechanism of Action Due to their chemical properties, alkylating agents can, either directly or after biological activation react and form covalent bonds with nucleophilic centers found in DNA, RNA and proteins. Traditionally, alkylating reactions have been divided into two groups termed SN 1 (nucleophilic substitution, first order) and SN 2 (nucleophilic substitution, second order), respectively (Fig. 4.1). In the SN 1 reaction, a highly reactive

K.D. Tew () Department of Pharmacology, 173 Ashley Ave, Charleston, SC 29466, USA e-mail: [email protected]

Fig. 4.1 SN1 and SN2 reactions of alkylating agents

intermediate is initially formed and this reacts with a nucleophilic molecule to produce a covalently alkylated product. In this reaction, the rate-limiting step is the initial formation of the reactive intermediate. Therefore, the reaction exhibits first-order kinetics with regard to the concentration of the original alkylating agent, and the rate is essentially independent of the concentration of the substrate. The SN 2 alkylation reaction represents a bimolecular nucleophilic displacement. The rate of this reaction is dependent of the concentration of both alkylating agent and the nucleophilic target. Thus, this reaction follows second-order kinetics. In consequence, the drugs that alkylate via a highly reactive intermediate such as the aliphatic nitrogen mustard mechlorethamine, would be expected to be less selective in their targets than the less reactive SN 2 reagents, like the alkyl alkane sulfonate busulfan. However, there is no direct relationship between the cytoxicity of the alkylating agents and their chemical reactivity. Anticancer drugs used in chemotherapy include agents that alkylate through both SN 1 and SN 2 mechanisms. The antitumor effect of these agents is primarily based on their high reactivity with DNA. When bifunctional alkylating agents are used, this can lead

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_4, © Springer Science+Business Media B.V. 2011

61

62

to the formation of monoadducts and subsequently interstrand or intrastrand DNA crosslinks. In contrast, monofunctional drugs that also form covalent bonds with DNA cannot induce DNA crosslinks. Although, it has been suggested that virtually all the oxygen and nitrogen atoms of the purine and pyrimidine bases can be alkylated, usually, alkylating drugs show nucleophilic selectivity towards the N7 position of the guanine. These covalent bonds occur preferentially at G-G-C sequences, which are potential sites for various bifunctional alkylations involving guanine N7 [21]. DNA alteration will cause either cell cycle arrest to allow DNA repair or cell death if the DNA is too damaged. Based on their chemical reactivity, alkylating agents will tend to target tumor cells that proliferate quickly and are characterized by uncontrolled proliferation. However, these drugs are also toxic in normal cells (e.g. hematopoietic or gastrointestinal cells) which, due to their physiological function, divide often. This is responsible for the main side-effects of alkylating agents, including myelosuppression.

4.3 Types of Agent 4.3.1 Nitrogen Mustards Although, many nitrogen mustards have been developed and tested in preclinical models, only 5 are currently used in chemotherapy. These are mechlorethamine, cyclophosphamide, ifosfamide, melphalan and chlorambucil (Fig. 4.2). They are characterized by a bis-chloroethyl group and react with nucleophilic sites through an aziridinium intermediate (Fig. 4.3). They commonly alkylate the N7 of guanine and alternatively can react with the O6 of guanine and the N3 and N7 of adenine [45]. Mechlorethamine was the first used, with the other four derived from it by substituting the methyl group with a variety of side groups. Despite their lower intrinsic alkylating activity, these analogs have a higher therapeutic index and a broader range of clinical activity and can be administrated either orally or intravenously. In contrast to mechlorethamine that reacts spontaneously with cellular nucleophiles at physiological pH, cyclophosphamide and ifosfamide possess no alkylating activity until they are metabolically

L. Gate and K.D. Tew

activated (Fig. 4.4). Cyclophos-phamide which is the most commonly prescribed member of this family, is first activated in the liver by cytochrome P450’s which mediate its microsomal oxidation to 4-hydroxycyclophosphamide which is in spontaneous equilibrium with its tautomer aldophosphamide. This metabolite will then distribute throughout the body and because of its non-polar properties will penetrate the cell membrane. This intermediate will be further degraded into acrolein and phosphoramide mustard. The latter is a potent cytotoxic alkylating agent that will induce cell death [155, 195]. The 4-hydroxycyclophosphamide and aldophosphamide are also susceptible to oxidation by soluble enzymes to generate 4-ketocyclophosphamide and carboxyphosphamide respectively. These non-toxic metabolites which are excreted in the urine, represent about 80% of the administered cyclophosphamide [164]. In principle, phosphoramide mustard could also be spontaneously generated in the plasma. However due to its polar nature, it is not likely that it will cross the cell membrane and might not be a therapeutically meaningful reservoir for the active component of the drug. In addition, it has been shown that the other product of degradation of 4-hydroxycyclophosphamide, acrolein does not exhibit potent antitumor activity, however it is considered to be the cause of a variety of dose-limiting side effects including haemorrhagic cystitis [6, 47]. Ifosfamide was first introduced in clinical treatment in the early seventies and is an isomeric analog of cyclophosphamide. Like cyclophosphamide, it is a prodrug which undergoes the same metabolic activation, but because of the different location of the chloroethyl groups, its quantitative metabolism and subsequently its pharmacological properties differ from that of cyclophosphamide [43]. Ifosfamide is first metabolized and activated in the liver by cytochrome P-450’s to produce its active intermediates that are found in urine and plasma. Similar to cyclophosphamide, it undergoes hepatic activation into aldoifosfamide which will be degraded into acrolein and an alkylating agent [88]. The rate of hepatic activation of ifosfamide is lower than that of cyclophosphamide. Because of this, about 4 times as much drug is required to give the same cytotoxic effect as cyclophosphamide. However, this also results in a higher level of acrolein which is a dose-limiting factor. Aldophosphamide and aldoifosfamide can be further metabolized and inactivated

4

Alkylating Agents

63

Fig. 4.2 Structures of nitrogen mustards

Cl CH2CH2

Cl CH2CH2 S

N

Cl CH2CH2

Cl CH2CH2

CH2CHCOOH NH2

Sulfur mustard (bischloroethylsulfide) Cl CH2CH2 Cl CH2CH2

Melphalan

Cl CH2CH2

N-CH3

CH2CH2COOH

N

Cl CH2CH2

Mechlorethamine

Chlorambucil CH2CH2

Cl CH2CH2

O HN N

Cl CH2CH2

N

O H Cl CH2CH2 N

P

P

O

O

Cyclophosphamide

Fig. 4.3 Mechanism of alkylation by nitrogen mustards

Ifosfamide

RN

CH2CH2Cl CH2CH2

CH2CH2Cl

RN

RN

CH2CH2Cl

H2C

Nitrogen mustard

O

H 2N

N

CH2CH2Cl

O

N

CH2

N

Aziridium intermediate

H2CH2C

HN

+

Cl

NH N

NH2

DNA

(N7 - guanyl)-DNA monoadduct

H N CH2CH2

N

N

N

N

DNA

DNA

O NH N

NH2

Bis(N7 - guanyl)-DNA interstrand cross-link

by aldehyde dehydrogenase. This enzyme is highly expressed in both hematopoietic and gastrointestinal tissues and does contribute to the protection of these tissues from both cyclophosphamide and ifosfamide toxicity [44]. Melphalan is an amino acid analog that can cross cell membranes and the blood-brain barrier through an active transport system. It has been suggested that this drug uses a specific amino acid transporter to access membrane barriers [23, 182, 183]. Chlorambucil has been also used extensively in the treatment of various tumors [7, 16, 77] and since it is well tolerated it is a valuable alternative to melphalan or cyclophosphamide in patients who have drug related nausea and vomiting triggered by these drugs.

4.3.2 Aziridines Aziridine alkylating agents are characterized by an aziridine ring that is structurally similar to the iminium ring in nitrogen mustards. Because this group is uncharged in aziridines, they are less reactive than nitrogen mustards. However, the reactivity of the aziridine group is increased by protonation and thus is enhanced at low pH. The opening of the aziridine ring is believed to be responsible for the alkylating activity of the molecule. However, by comparison with the nitrogen mustards, the mechanism of action of these drugs has not been as extensively studied. Three of these drugs, thiotepa (triethylenethiophosphoramide), mitomycin C and diaziquone (AZQ) are currently used

64

L. Gate and K.D. Tew

Fig. 4.4 Metabolism of cyclophosphamide

NH O P

O

CH2CH2Cl

N

H

O

H

Monochloroethylcyclophosphamide

Chloroacetaldehyde

OOH

NH O N

P

NH O

CH2CH2Cl

P

CH2CH2Cl

O

O

NH O N

NH O

CH2CH2Cl

P

4-Ketocyclophosphamide

H2N N

CH2CH2Cl

Aldehyde

CH2CH2Cl dehydrogenase

CH2CH2 C O

Aldophosphamide

O

H2 N

O P

-

O

N

OH CHCH2C O O

O P

N

CH2CH2Cl CH2CH2Cl

Carboxyphosphamide

O

CH2 CH2 Cl +

CH2 CHC

CH2 CH2 Cl

Phosphoramide mustard

in chemotherapy (Fig. 4.5). Thiotepa has been frequently prescribed for the treatments of breast and ovarian carcinomas [52, 99, 168]. Thiotepa is oxidatively desulfurated by hepatic cytochrome P450’s to produce TEPA, a less cytotoxic form of the molecule [111, 122]. Both compounds are found in the patient plasma. The aziridines can be activated by enzymatic oxidation or spontaneously produce an active species that can alkylate the N1 of thymidine, O2 of cytosine, N1, N6 and N7 of adenine, and N1, N7 and O6 of guanine [106]. As previously mentioned, the N7 of guanine is the preferential site of alkylation leading to the formation of guanine-guanine and adenineguanine interstrand cross-links [11]. The formation of DNA adducts by Thiotepa can follow two pathways, the first involves a sequential reaction that leads to DNA cross-link formation (Fig. 4.6). In the second

CH2CH2Cl

O

4-Hydroxycyclophosphamide

O

CH2CH2Cl

N

P

CH2CH2Cl

O

H

CH2CH2Cl

4-Hydroperoxycyclophosphamide

OH

H2N

CH2CH2Cl

N

O

Cyclophosphamide

P

C

ClH2C

+

H

Acrolein

pathway, a hydrolytic cleavage liberates the aziridine group which induces monofunctional adducts [106] (Fig. 4.7). Mitomycin C is a natural product that has been used in the treatment of breast cancer and tumors of the gastrointestinal tract [9, 29, 80, 95]. Like the other members of the aziridine family, this drug induces DNA-crosslinks that have been suggested to be sequence specific [27, 28]. Mitomycin C undergoes reduction by cytochrome P450’s increasing its affinity for nucleophilic sites in DNA [184]. AZQ is a synthetic and lipophilic aziridine designed to cross cell membranes and the blood brain barrier. This drug has been used in cancer of the CNS and has demonstrated therapeutic activities toward those tumors [49]. AZQ has also been used in the treatment of other solid tumors and leukemia [32, 167].

4

Alkylating Agents

Fig. 4.5 Structures of aziridine alkylating agents

65 O S

H2C N

H2C

CH2

P N

CH2

N H2C

O

H3CH2COCN H H 2C N H2C

CH2

Thiotepa

CH2

N

CH2 O NCOCH2CH3 H

O

Diaziquone (AZQ) O O CH2O C NH2 OCH3

H3C H3C

N

O

NH

Mitomycin C

Fig. 4.6 Mechanisms of cross-linking by thiotepa. Alkylation and cross-linking by sequential reaction of a single aziridine group

N

S P N

S P N

+

H

N

N

HN+

N

S P N NH

+

CH2 N

N H2O

S P N

N

P N +

H2 C

+ CH2

N

N

NH2 CH2

+

N

O

N HN

N HN N

R-N

N

O NH

+

N

N

H2C CH2 N+

O NH

N-R

S P N NH CH2

+

N

N-R

N-R O

R-N

N HN

S P N +

NH2

H2C+

O + NH3

OH

S N

N-R

N-R

N

O HN

N

O HN

66 Fig. 4.7 Mechanisms of cross-linking by thiotepa. Cross-linking produced by sequencial alkylating reactions of two aziridine groups from the same parent drug

L. Gate and K.D. Tew S N

P

S

H+

N

N

+

P

HN

N

N-R

N

N

N

O HN

S N+ P NH H N

+

H +

N-R

O

S P NH N +

N-R

N

O N

N

N

N

O

N

HN

HN

N HN

S HN

P NH N

R-N

N+

N

+

O

O

NH

4.3.3 Epoxides

N-R

N

N HN

H2C

CH2Br O

The epoxides are also called hexitol derivatives (Fig. 4.8). Their reactive groups are chemically related to those of the aziridines and are believed to alkylate nucleophilic macromolecules in a similar manner. Phase I and II clinical trials have shown that dianhydrogalacticol demonstrates therapeutic activities against cancers of the CNS but was shown to be less effective against other solid tumors [38, 83, 87]. Another epoxide, dibromodulcitol has also shown some antitumor activity and is a prodrug that can be hydrolyzed to dianhydrogalacticol [83, 131].

H2 C

CHOH

CHOH

CHOH

CHOH

CHOH

CH

CHOH O

H2C

Dianhydrogalactitol

CH2Br

Dibromodulcitol

Fig. 4.8 Structures of epoxide alkylating agents

N-R

4

Alkylating Agents

67

4.3.4 Alkyl Sulfonate

O

O H3C

Busulfan (Fig. 4.9) is the major representative of this family and has been extensively used in the treatment of chronic myeloid leukemias [142]. This molecule has a higher reactivity towards thiol groups of amino acids and proteins than the other nitrogen mustards. Indeed, it has been suggested that this function could be responsible for the cytotoxic properties of busulfan [53, 132]. However, it has also been shown that this alkyl sulfonate can react with the N7 of guanine and induce DNA cross-links and that this correlates with its cytotoxicity (Fig. 4.10) [22]. Another alkyl sulfonate, hepsulfam has a higher cytotoxic activity toward L1210 in vitro and in vivo, and this correlates with an increase in DNA interstrand cross-linking [132]. Because of their strong myelosuppressive properties, due to their toxicity toward hematopoietic stem cells [65], high dose protocols with alkyl sulfonates are frequently employed in bone marrow transplant procedures [177].

4.3.5 Nitrosoureas Clinically useful nitrosoureas are derived from methylnitrosoguanidine and methylnitrosourea agents initially screened by the National Cancer Institute (NCI) and shown to exhibit antitumor activities

S

O CH2CH2CH2CH2

S

O

Busulfan

O

O O

S

H3C

CH2CH2CH2CH2CH2CH2CH2

O

O

S

CH3

O

Hepsulfam Fig. 4.9 Structure of alkyl sulfonates

against experimental mouse cancer models [157]. Structure:function studies have demonstrated that chloroethyl derivatives such as chloroethylnitrosourea (CENU), BCNU (carmustine), CCNU (lomustine) and Methyl-CCNU (semustine) had more potent anticancer activities than the parent compounds (Fig. 4.11) [86, 152]. Under physiological conditions, proton abstraction by a hydroxyl ion initiates spontaneous decomposition and activation of the molecule into a number of metabolites including an isocyanate and a highly unstable 2-chloroethyldiazene hydroxide molecule that becomes an alkylating 2-chloroethyl carbonium ion (Fig. 4.12) [102]. This reactive ion will akylate predominantly at the N7 position of guanine in a sequence dependent manner [100]. The alkylation of nitrogen in DNA yields chloroethylamino groups on the nucleotide, and these are capable through a R

O O

CH3

S

O

O H3C

O

CH2CH2CH2CH2

O

S

CH3 + H

N

H

O

O

R H

O H3C

S

O

H

CH2CH2CH2CH2

O

S CH3

H

O H3 C

S

O

CH2CH2CH2CH2 +

O

O O

Fig. 4.10 Mechanism of alkylation by busulfan

N

O O

H+ + O

S CH3

O

N

R

68

L. Gate and K.D. Tew

Fig. 4.11 Structures of nitrosoureas

O

ClH2CH2C

O

N

O

H

N

C

N

CH2CH2Cl

ClH2CH2C

BCNU (Carmustine)

N

O

H

N

C

N

CCNU (Lomustine)

O

ClH2CH2C

N

O

H

N

C

N

CH3

Methyl-CCNU (Semustine) O

ClH2CH2C

NH2

N

O

H

H

N

C

N

C

ACNU

O

ClH2CH2C

O

H

N

C

N

N

O

H 3C

OH O CH OH 2

Chlorozotocin OH

CH3

H

OH

N

dehalogenation step of a second alkylation to produce a DNA-DNA or DNA-protein cross-link [102]. Alkylating 2-chloroethyl carbonium ions can also alkylate at the O6 position of guanine (Fig. 4.12); this mono-functional O6 DNA adduct can be removed from DNA by O6-alkylguanine-DNA alkyltransferase, also referred to as the Mer phenotype [30, 58]. Overexpression of this enzyme increases resistance to nitrosoureas [8, 18]. In large part, the promise of nitrosoureas in early preclinical mouse studies did not translate into humans. As research on the Mer phenotype progressed an explanation for this species-specific effect became apparent. Despite the effective response (frequent cures) of mouse tumors to nitrosourea therapy, human tumors were always more resistant to the drugs. The high expression of O6-alkylguanine-DNA alkyltransferase in human tumors provided the explanation for this disparity. The relative low expression of this enzyme in mice made them more sensitive to either methyl or chloroethyl nitrosourea treatment [70]. The other product of nitrosourea decomposition is an isocyanate species. This product has been shown

N

OH

N

O

H

N

C

N

OH O CH OH 2

Streptozotocin OH

to carbamoylate a broad range of proteins with sensitive lysine residues as the primary target (Fig. 4.12). The consequence of carbamoylation is the inhibition of the activity of a variety of enzymes, including DNA polymerase [17], DNA ligase, RNA related enzymes [89, 90] and glutathione reductase [134, 135]. Despite their pharmacological activities, there is no direct link between the carbamoylation function of the isocyanate compound and the cytotoxicity of the parent drug. For example chlorozotocin and streptozotocin, have low carbamoylation activities but have a strong cytotoxic activity [4]. BCNU is currently used for the treatment of primary brain tumors [63, 129] and occasionally in the treatment of lymphomas, lung and colon cancers [42, 55, 56, 91]. CCNU and methyl-CCNU which present a greater activity against solid tumors in preclinical studies [151], are used in the treatment of brain tumors [146], lymphomas [165], gastrointestinal cancers [35]. ACNU, a more water-soluble nitrosourea has been used in the treatment of brain tumors and other solid tumors [150, 191, 193].

4

Alkylating Agents

69

Fig. 4.12 Mechanism of BCNU activation and alkylation of guanine

O C

N H

N

CH2CH2Cl

NO

ClH2CH2C

NO O

H

N

N

C

O CH2CH2Cl

HOH2 CH2C

N

C

N H

CH2 CH2 Cl

NO NOH

NOH ClH2CH2C N Chloroethyldiazene hydroxide

O

HOH2CH2C N Hydroxyethyldiazene hydroxide

N CH2CH2Cl Isocyanate

C

Protein

O N2 + OH− + +CH2CH2Cl

Protein

Cl-carbonium ion

O

N CH2CH2Cl H Carbamoylation

CH2CH2Cl

O

N

HN

H2N

C

N

DNA N7 -(chloroethyl)guanyl DNA monoadduct HN

H2N

O-CH2CH2Cl N

N

N

DNA O6 -(chloroethyl)guanyl DNA monoadduct

Streptozotocin, a natural nitrosourea isolated from Streptomyces species, is a potent antileukemic agent that, in contrast to the other nitrosoureas, presents limited myelotoxicity [153]. However, this drug has been shown to be a strong diabetogenic; because of this specific toxicity, streptozotocin has been used against islet cell carcinoma and showed significant clinical activity [116]. In order to increase the antitumor activity of the drug while keeping its bone marrow-sparing properties, a derivative of streptozotocin, chlorozotocin in which 1-methyl group was replaced by a chloroethyl group, was synthesized and tested [10]. Despite its clinical antitumor property, it induced myelosuppression in patients [34, 74, 75].

H 2N

OH-carbonium ion

CH2CH2OH N

HN N

N2 + OH– + +CH2CH2OH

N

N

DNA N7-(hydroxyethyl)guanyl DNA monoadduct HN

H2N

O-CH2CH2OH N

N

N

DNA O6 -(Hydroxyethyl)guanyl DNA monoadduct

4.3.6 Triazene Compounds Procarbazine, dacarbazine and temozolomide are three of the most commonly used members of this family of agents (Fig. 4.13). Procarbazine and dacarbazine spontaneously decompose or can be metabolized to produce methyl diazonium intermediates that can alkylate biological molecules [120]. Both drugs have been used in the treatment of Hodgkin’s disease [169]. Procarbazine is also given to patients with brain tumors [180] while dacarbazine is used in the treatment of melanomas [175]. Temozolomide (TMZ) is a relatively novel anticancer drug which undergoes spontaneous hydrolysis

70

L. Gate and K.D. Tew

H3C

H

H

H

O

H

CH3

N

N

C

C

N

CH CH3

H

Procarbazine O

O N

N

C

H2N NH2

N CH3

N

N

C

N

N

N

N

N

CH3 CH3

Dacarbazine

O

Temozolomide

Fig. 4.13 Structures of triazenes

to form the same active metabolite as produced from dacarbazine [162]. Because of its high bioavailability, its small size and its lipophilic properties, high amounts of TMZ are able to cross the blood-brain barrier. These pharmacologic properties have made it an agent of choice for the treatment of central nervous system malignancies [1]. This alkylating agent has demonstrated promising activity in brain tumors [1, 51, 66] and melanomas [85], but was less effective in the treatment of mesotheliomas and prostate cancers [179, 181].

4.3.7 Prodrugs of Alkylating Agents 4.3.7.1 Glutathione S-Transferase-Activated Prodrug The development of new antitumor drugs able to target preferentially, and even specifically, tumor tissues represents an emerging alternative to the standard anticancer agents currently used in chemotherapy. These new molecules are frequently inactive precursors that are preferentially activated in tumors as a consequence of the overexpression of an enzyme responsible for the metabolism of the prodrug and subsequent release of the pharmacological active form of the agent. Potential advantages of these new molecules include (1) decrease in the amount of the active chemotherapeutic agent which reaches normal

dose-limiting tissues; (2) increase in the intracellular localization and bioavailability of the active drug and (3) preferential tumor targeting. Although cyclophosphamide is an inactive prodrug, the cytochrome P450’s activation step is not localized to the targeted tumor. Other detoxification enzymes do have a less random distribution. For example, within the phase II glutathione S-transferase family, the GSTπ isoform is overexpressed with a high frequency in many tumors particularly those that are resistant to a range of alkylating drugs [170, 173]. For this reason, a prodrug, TLK286 (Telcyta) [(γ-glutamyl-α-amino-β-(2-ethyl-N,N,N,Ntetrakis(2-chloroethyl)-phosphorodiamidate)-sulfonylpropio-nyl-(R)-phenylglycine] (Fig. 4.14) was designed to be preferentially activated by GSTP1–1. In this compound, the sulfhydryl group of a glutathione conjugate has been oxidized to a sulfone, the tyrosine-7 located in the active site of GSTπ promotes a β-elimination reaction that cleaves the compound. The cleavage products are a glutathione analogue (vinyl sulfone derivative) and a phosphorodiaminidate, which in turn, spontaneously forms an aziridinium species, the actual alkylating moiety that reacts with cellular nucleophiles [103] (Fig. 4.14). The efficacy of this new compound was tested in cancer cell lines and in animal tumor models. TLK286 exhibited cytotoxic activity against a broad range of cell lines and tumors [119]. An M7609 human colon carcinoma cell line resistant to doxorubicin and an MCF-7 breast carcinoma cell line resistant to cyclophosphamide, which both expressed high levels of GSTπ, were more sensitive to TLK286 than their respective wild type counterparts. Antitumor activity was also shown in murine xenografts of M7609 expressing different levels of GSTπ, and in xenografted MX1 human breast carcinomas. The extent of the responses to this prodrug was positively correlated with the expression levels of GSTπ. In rodents, the myelosuppressive effect of this compound was found to be relatively mild, causing a marginal depletion of bone marrow stem cells, with a similarly modest depletion of peripheral white blood cells [119]. Using transfected NIH3T3 cell lines, resistance to TLK286 was associated with overexpression of the de novo glutathione synthetic enzyme, γ-glutamylcysteinylglycine synthetase (γ-GCS) and the ABC transporter with specificity for transport of glutathione conjugates, MRP. Resistance to the drug could be

4

Alkylating Agents

71

Fig. 4.14 Structure and mechanism of activation of GSTP1–1 activated prodrug TLK286

Cl

GST

Cl

Active site tyrosine residue

N

O O

TLK286

P

–

H

N

O

Cl

O S

Cl

O

O H N

H2N

COOH

N H COOH

Cl

O S

O

Cl

O H N

H 2N

O

+

COOH

N P

N H

O-

N

Cl

COOH Cl

Vinyl Sulfone Derivative

+ N

O

+

P O

Active Alkylating Agent

partially abrogated by the forced over-expression of GSTπ [125]. Interestingly, while high levels of catalase were evident in an HL60 human promyelocytic cell line made resistant to TLK286, increases in γ-GCS and MRP protein and mRNA levels were not observed [147]. However, a two-fold decreased expression of GSTP1–1 was found in the resistant cell line and this would serve to decrease the activation of the drug. Down-regulation of GSTP1–1 is the obverse of the situation most frequently described in acquired drug resistant phenotypes [166]. This result reflects the unusual principles involved in the structure:activity design of the drug. In addition, it has been shown that TLK286 inhibits the activity of DNAPK (a holoenzyme complex involved in DNA repair). Mechanistically, this inhibition was achieved through drug-induced destabilization of the interaction of the

N

Cl Cl

catalytic subunit of DNA-PK with Ku70 and Ku80, two accessory proteins required for DNA-PK function [176]. This prodrug has undergone preclinical testing, toxicology and phase I clinical analysis [148] and has shown promising antitumor activities against refractory ovarian, colorectal and small cell lung cancers in phase II trials.

4.3.7.2 Antibody- and Gene-Directed Enzyme Prodrug Therapy Antibody-directed enzyme prodrug therapy (ADEPT) is a further approach recently developed to diminish the non-specific toxicity observed with common chemotherapeutic agents by increasing the specific activation of the drug at the tumor site. Most ADEPT

72

systems incorporate a prodrug that is activated by a bacterial enzyme fused to an antibody designed to recognize specific epitopes on a cancer cell. One of the best examples of this strategy is the phenyl mustard glutamate prodrug ZD2767P (4-[N,N-bis(2-iodoethyl) amino] phenol) which is converted at the tumor site to an active bifunctional alkylating drug ZD2767D by the bacterial enzyme carboxypeptidase G2 conjugated to the F(ab’)2 fragment of the anti-CEA antibody A5B7 [160]. Upon activation, this drug induces DNA damage and DNA interstrand crosslinks and subsequently induces apoptosis in tumor cells [117, 188]. This ADEPT system has been shown to induce a regression of colorectal tumor xenografts in nude mice [26] and has undergone phase I clinical trial [188]. Building on this technology, Wentworth et al. used a catalytic antibody instead of a bacterial enzyme, naming this approach antibody-directed “abzyme” prodrug therapy (ADAPT). This was shown to be efficient in tissue culture systems and was suggested to compensate for possible toxicities that may have resulted from a host mediated immunologic response to the bacterial enzyme [192]. Another approach called gene-directed enzyme prodrug (GDEPT) requires the transfection of an enzyme that will specifically activate a prodrug in cancer cells. For example, CB1954 (5-(aziridine-1-yl)-2, 4-dinitrobenzamide) is a weak monofunctional alkylating agent which can be reduced by the nitroreductase from E-coli to a potent cytotoxic species that generates interstrand crosslinks in DNA. Various in vitro studies have shown that the transfection of this enzyme into tumor cells increased their sensitivity to CB1954 [189]. A primary limitation of this strategy is the problem of overexpressing this enzyme specifically in tumor cells. To achieve this goal Bilsland et al. took advantage of the highly specific activation of the telomerase promoter in cancer cells to target them using an adenovirus system containing the bacterial nitroreductase under the control of the telomerase promoter [24]. CB1954 can also be activated by the human NADPH quinone oxidoreductase 2 (NQO2), an enzyme commonly found in cancer cells. However, the enzyme is usually inactive and requires a co-substrate such as nicotinamide riboside to be functional. A lipophilic synthetic analogue of this was synthesized and was co-administered with CB1954; the drug combination increased the cytotoxicity of the prodrug in different in vitro models [92].

L. Gate and K.D. Tew

Other enzymes such as the cytochrome P450’s and DT-diaphorase (NQO1) have been shown to play an important role in the activation of cyclophosphamide and mitomycin C respectively. As would be expected, high expression of these enzymes in targeted tumor cells does provide a promising therapeutic index and in this regard, promising in vitro results have been obtained [15, 114].

4.3.8 Alkylating Agent-Steroid Conjugates Using the rationale that steroid receptors could serve to focus and concentrate hormones, a number of synthetic conjugates of nitrogen mustards and steroids have been developed. Among those, prednimustine, an ester-linked conjugate of chlorambucil and prednisolone and estramustine, a carbamate ester-linked conjugate of nor-nitrogen mustard and estradiol have been synthesized and are currently used to varying degrees in the clinic. Serum esterases readily cleave the ester bond of prednimustine leading to the release of the steroid and the active alkylating agent. The therapeutic advantage that has been seen to accrue with prednimustine has been attributed primarily to the altered pharmacokinetics with respect to prolonging the half life of chlorambucil, a consequence of the slow hydrolysis of the ester link [121]. In addition, the elimination phase of chlorambucil in patient plasma was significantly longer after administration of prednimustine than after chlorambucil [19]. Although estramustine was designed as an alkylating agent, the marked stability of the carbamate linkage to the steroid carrier molecule prevents the formation of any alkylating intermediates [172]. Detailed studies of the mechanism of action have indicated that the drug has anticancer activity through inhibition of mitotis. Unusually, the drug binds to tubulin and microtubule associated proteins causing depolymerization of the cytoskeleton. Spindle microtubules are particularly sensitive to the drug [98, 161]. At this time, estramustine is used in combination regimens as a front line treatment for hormone refractory prostate cancer [84]. It remains a pharmacological irony that the design and synthetic rationale for estramustine produced an active agent with none of the properties that were initially proposed [174].

4

Alkylating Agents

4.3.9 Alkylating Agent Resistance and Modulation Resistance to anticancer drugs represents one of the main reasons for chemotherapy failure. This process has been extensively studied and various cellular mechanisms of resistance have been discovered and described. Some of these are presented below. Decreased cellular content of alkylating agents in cancer cells could result from a decrease of cell uptake or an increase of efflux. Active cellular uptake of some alkylating agents has been shown. For melphalan, this is because of the structural similarity of the drug with the physiological amino acid substrate of the membrane transporter. Two amino acid transport carriers, the sodium-dependent carrier with substrate preference for alanine, serine and cysteine, and a sodium-independent carrier with preference for leucine have been implicated. In L5178Y cells resistant to melphalan, it was shown that a specific mutation in the low-affinity, high-velocity leucine transport system resulted in a decreased affinity of the carrier protein for leucine and melphalan and subsequently to a decrease in cellular accumulation of the drug [72, 76]. It was also shown that the uptake of melphalan was inversely proportional to the cytosolic concentration of calcium [113]. In contrast to melphalan, mechlorethamine uses the cholinergic membrane transporter expressed on the surface of various cell lines [101]. Enhanced cellular efflux has been also reported as a mechanism of resistance to alkylating agents. Cellular export of these anticancer drugs is mainly mediated by the multidrug resistance-associated protein 1 (MRP1) which is a member of the ATP binding cassette family expressed on the cell membrane. MRP1 is overexpressed in various cell lines resistant to such agents as nitrosoureas, chlorambucil and melphalan [73, 137]. Chlorambucil and melphalan are not direct substrates of MRP1, but their glutathione conjugated forms may be actively transported by this transporter. The conjugation of alkylating agents to glutathione can be spontaneous or mediated by the glutathione S-transferases (GST). For example, the conjugation of chlorambucil to glutathione has been shown to be both spontaneous and mediated by GSTs, both reactions occurring in cells but with different kinetics [39]. Similarly, the formation of GSH-conjugate of melphalan was suggested

73

not to require enzymatic catalysis in melanoma cells [78]. Spontaneous conjugation can occur because of the high degree of nucleophilic selectivity of the thiol group of cysteine in the glutathione molecule with the electrophilic alkylating carbonium ions produced by the majority of alkylating agents. Because of the important role of glutathione in resistance to alkylating agents, an inhibitor of the γ-glutamylcysteinyl synthetase (GGS), a key enzyme of GSH synthesis, L-S, R-buthionine sulfoximine (BSO) was investigated as a potential modulator of resistance. However, contradictory results were obtained; for example BSO was able to potentiate cytotoxic activities of melphalan, BCNU and 4-hydroperoxycyclophosphamide in human breast cancer cells [36], whereas this agent failed to increase sensitivity to busulfan in a busulfan resistant xenograft [79] or to drug combinations including melphalan and cyclophosphamide in vivo [159]. Although BSO increased tumor sensitivity to melphalan in mouse models, it also increased the toxicity of this drug against normal tissues [156]. Because of the limited clinical benefits of BSO, the use of this compound in clinical trials [67, 127], at least for now, has been curtailed. GSTs have been shown to catalyze the formation of glutathione conjugates of alkylating agents and high expression of certain GST isozymes has been linked with resistance to these anticancer drugs. In many cell lines exposed to incremental selective concentrations of alkylating agents, an increased expression of GSTs has been observed [186]. For example, GSTμ was overexpressed in an ovarian carcinoma cell line resistant to chlorambucil [82]. GSTα expression was also stimulated in mammary carcinoma cells following chlorambucil exposure [41]. Alkylating agents can be direct substrates of GSTs. However, specific isoenzymes have been shown to express preferential substrate specificity. For example, Dirven et al. observed that GST A1–1 and P1–1 catalyzed the formation of monoglutathionylthioTepa while A2–2 and M1a1a isozymes poorly catalyzed this reaction. Such a result would suggest that some isoforms have a higher affinity for the aziridine moieties of thiotepa than others [50]. In addition others have observed that GSTμ has activity toward BCNU [158], while GSTα participates in chorambucil and melphalan metabolism [40]. In contrast, GSTπ has a weaker affinity for the majority of the anticancer agents [40] even though increased

74

L. Gate and K.D. Tew

expression of this isoform is frequently associated with the development of multidrug resistance phenotype. Because of the importance of GSTs in resistance to alkylating agents, inhibitors of these enzymes were developed in an effort to potentiate the effects of these drugs. Ethacrynic acid is a phenolic acid extracted from plant sources (Fig. 4.15). It is a substrate based inhibitor of GST that yields an ethacrynic acid-GSH conjugate. This conjugate is formed both enzymatically and non-enzymatically and is itself a potent inhibitor of GST with the concomitant potential to deplete GSH [13]. Ethacrynic acid has been shown to enhance the cytotoxicity of chlorambucil and melphalan in tissue culture [166, 171]. Ethacrynic acid

underwent a phase I clinical trial in combination with thiotepa. The results obtained showed that the area under the curve (AUC) of thiotepa was approximately twice, and the clearance about one-half, of the values obtained in a previous study of single agent thiotepa. The AUC of TEPA, the main metabolite of thiotepa, was lower than that previously observed with the alkylating agent alone. The data suggest that ethacrynic acid inhibits enzymes involved in the metabolic disposition of thiotepa, including its oxidative desulfuration to TEPA [128]. However, ethacrynic acid is a potent diuretic and because of this side effect the clinical use of this agent was limited by fluid and electrolyte imbalance. The comparative lack of efficacy of

OCH2COOH SH Cl

O H N

H2N N H

Cl COOH

COCCH2CH3

O

Glutathione

CH2

Ethacrynic Acid

S O H N

H2N

COOCH2CH3

N H

TLK199

O

COOCH2CH3

Cellular esterases

S O H N

H2N N H

TLK117 COOH

Fig. 4.15 Structures of glutathione, TLK117, TLK199 and ethacrynic acid

O

COOH

COOH

4

Alkylating Agents

modulators of glutathione synthesis or GST activity in some cellular models has been explained by the requirement of a specific intracellular environment. It has been suggested that glutathione synthesis, glutathione conjugation and GSH-conjugate efflux are processes tightly linked together and the combination of such coordinated mechanisms is required for optimal drug detoxification. O’Brien et al. showed that the co-transfection of MRP1, GSTP1–1 and γ-GCS in NIH 3T3 cells conferred a resistance titer to alkylating agents that was more significant than transfection of any combination of two of these proteins or each of them separately [125]. Thus, the overall conclusion from this approach is that these proteins act synergistically and in a coordinated fashion in the detoxification of the alkylating agents. Since ethacrynic acid and other inhibitors of GSTs had significant dose limiting toxicities and were not highly specific of GST isoforms, new inhibitors with pronounced inhibition constants for each isoform were developed. Using combinatorial chemistry with glutathione as a general backbone and substituting sulfydryl and carboxyl groups with a series of substituents, TLK117 (γ-glutamyl-S-(benzyl)cysteinyl-Rphenyl- glycine) (Fig. 4.15) was developed as a specific inhibitor of GSTP1–1. The drug is a peptidomimetic of GSH designed to bind to the “G-site” of GSTP1–1. An esterified form of TLK117, TLK199 was synthesized to enhance cellular uptake and became the lead drug candidate. The inhibition constant (Ki) for GSTP1–1 catalytic activity (chlorodinitrobenzene as substrate) was calculated to be 400 nM. This demonstrates significant specificity for the π-family, since the Ki for the GSTα and μ families range from approximately 20 to 75 μM [104]. This drug enhanced significantly the cytotoxic effect of melphalan in cancer cells resistant to alkylating agents, both in vitro and in animal models [114]. TLK199 also presented an unexpected preclinical result in rodents. The drug administration resulted in myelostimulation. This property has been mechanistically linked with its capacity to interfere with the interaction between GSTπ and cJun N-terminal kinase [3, 68, 149]. As a result of this beneficial therapeutic effect, this inhibitor is now undergoing a phase I/II clinical trial in patients with myelodysplatic syndrome. Others mechanisms involved in alkylating agent detoxification have been reported. Weber et al. observed that microsomal GSTs and cytochrome P450

75

were involved in the inactivation of BCNU by denitrosation [187]. Ranganathan et al. demonstrated that the transfection of glyoxalase I, an enzyme involved in the detoxification of methyglyoxal (a byproduct of the glycolytic pathway) increased the cellular resistance to mitomycin C but not to chlorambucil [143]. As previously described, alkylating agents have the capacity to produce DNA adducts on many of the nucleophilic oxygen and nitrogen atoms of purines and pyimidines. O6-alkylguanines formed by many of these drugs can lead to mutations and apoptosis unless repaired. As discussed previously, the enzyme O6-alkylguanine-DNA alkyltransferase can transfer the alkyl group from the DNA base to a cysteine acceptor site in the enzyme. The DNA integrity is restored completely by the action of this single protein, but the cysteine acceptor site is not regenerated and the number of O6-alkylguanines that can be repaired is equal to the number of active alkyltransferase molecules [138]. Expression of O6-alkylguanine-DNA alkyl-transferase which can be induced by alkylating agents has been linked with resistance, particularly to nitrosoureas [109, 185]. In order to circumvent resistance associated with this enzyme, inhibitors such as O6-benzylguanine were developed [139]. Despite its antitumor efficacy, O6-benzylguanine was found to potentiate the hematopoietic toxicity induced by alkylating agents [37, 60]. In addition, mutant forms of O6-alkylguanine-DNA alkyltransferase insensitive to O6-benzylguanine have now been described [48]. Alkylating agents mediate the death of the cancer cells mainly by altering the integrity of DNA. P53 is a key protein in the recognition of DNA damage. Drug induced damage to DNA causes p53 cellular levels to increase mainly as a consequence of the stabilization of the protein. The result of this is a blockade of cell-cycle progression. Then, the cell initiates attempts to repair DNA and if it fails, will ultimately activate apoptotic pathways. The absence of p53 expression has been associated with an increased sensitivity to alkylating agents [81, 97] probably because of the reduced capacity to repair DNA in a timely fashion resulting in the accumulation of DNA damage. Generally, induction of apoptosis in response to anticancer drugs is tightly regulated at the level of the mitochondria by proteins of the Bcl-2 family. These molecules are divided into two sub-families, one antiapoptotic (including Bcl-2, Bcl-XL ), the other pro-apoptotic (comprising Bax, BclXS , Bad). The balance between pro- and anti-apoptotic

76

members of this family is responsible for the fate of the cell, primarily survival or death [107]. Therefore, any deregulation of the expression of these proteins could contribute to drug resistance. In a human glioma cell line resistant to temozolomide, it was observed that the expression of pro-apoptotic molecules Bad, Bax and Bcl-XS was decreased, whereas no change in the expression of anti-apoptotic members of Bcl-2 family was found [105]. Kojima and colleagues showed that the release of mitochondrial cytochrome c and the activation of caspase-3 was abolished in an alkylating agent resistant cell line, possibly because of the overexpression of Bcl-XL [93]. Because of the protective role of Bcl-2 against the cytotoxic effect of the alkylating agent, Fairbairn et al. transduced hematopoietic progenitors with Bcl-2 and successfully protected these cells against the toxicity of nitrosoureas [59].

4.4 Toxicity

L. Gate and K.D. Tew

of the enzyme aldehyde dehydrogenase in early hematopoietic progenitors [44]. In contrast, busulfan seems to be especially damaging to hematopoietic stem cells [65] and prolonged hypoplasia of bone marrow is often observed after busulfan administration. Because of its myeloablative properties, busulfan is used extensively in clinical bone marrow transplantation [194]. The hematopoietic depression induced by the nitrosoureas is characteristically delayed. The onset of leukocyte and platelet depression occurs 3–4 weeks after drug administration and may last an additional 2–3 weeks [33]. Myelosupression induced by cyclophosphamide can be partially prevented by the aminothiol WR-2721 (Amifostine) without interfering with the chemotherapeutic effect of the alkylating agent [12]. Amifostine offers the prospect of increasing the therapeutic index of current cancer treatment by allowing the administration of higher thresholds of maximal tolerated doses.

4.4.1 Hematopoietic Suppression 4.4.2 Gastrointestinal Toxicity The usual dose-limiting tissue for alkylating agents is bone marrow. The hematopoietic suppression seems to affect all the hematopoietic lineages leading to a decrease in circulating leukocytes, platelets and erythrocytes. However the degree, time course and cellular pattern of the hematopoietic suppression generally differ dependent upon the type of alkylating agent used. For example, Nissen-Meyer et al. observed that administration of cyclophosphamide (60 mg/kg/day for 4 days) induces a decrease of circulating white blood cells but has no significant effect on platelet counts. In contrast, the authors showed that mechlorethamine (0.1 mg/kg/day for 4 days) leads to a strong fall in both leukocyte and platelet counts [124]. In addition, in vivo studies have suggested that cyclophosphamide has hematopoietic stem cell sparing activities. High doses of cyclophosphamide (4 g/m2 ) followed by G-CSF have even been used for the mobilization of peripheral blood stem cells in patients undergoing autologous blood stem cell transplantation in the treatment of Hodgkin’s lymphomas [145]. The biochemical basis for the stem cell-sparing effect of cyclophosphamide is not entirely understood, but has been associated with the high expression

Damage to the gastrointestinal tract is frequently observed with high-dose regimens. Mucositis, stomatitis, oesophagitis, and diarrhea occur preferentially with high doses of melphalan and thiotepa [175]. In contrast, cyclophosphamide and isofosfamide have low gastrointestinal toxicity because of the high levels of aldehyde dehydrogenase activity in the epithelial cells of the gastrointestinal tract [44]. Nausea and vomiting are also frequent side effects that are mediated through the central nervous system and are apparently not a direct consequence of gastrointestinal cytotoxicity [62]. Although these side effects are not life threatening, they represent major discomforts to the patients and this can sometimes result in delay or discontinuation of therapy. The frequency and degree of these effects are variable among patients, where some can tolerate high doses of alkylating agents without nausea, while others are incapacitated at even low concentrations. However, the frequency of nausea and vomiting increases as the dose of alkylating agent is increased. Antiemetic drugs are usually given to the patients along with the chemotherapeutic agents.

4

Alkylating Agents

4.4.3 Pulmonary Toxicity In general, the initial clinical appearance of pulmonary toxicity includes both constitutional signs of malaise and fever as well as pulmonary complaints. Pulmonary fibrosis has been described as a complication for longterm busulfan therapy which is presumably due to a cytotoxic effect of alkylating agents to pulmonary epithelial cells. The clinical features of this adverse effect are a nonproductive cough and dyspnea which may progress to severe pulmonary insufficiency and death [20]. Similar pulmonary toxicity has been occasionally observed with cyclophosphamide, nitrogen mustards and mitomycin C [14, 130, 136].

4.4.4 Renal Toxicity Urotoxicity is observed with cyclophosphamide and ifosfamide. This effect has been shown to be the consequence of the urinary excretion of the metabolite acrolein, which has been shown to irritate bladder mucosa. The subsequent hemorrhagic cystitis may range from a mild cystitis to severe bladder damage with massive hemorrhage [163]. This side effect can be minimized by adequate hydration, frequent bladder emptying and administration of N-acetylcysteine. Thus, this adverse effect of the oxazaphosphorines can be alleviated by thiol loading of the local environment [133]. The most active agent for prevention of cyclophoshamide- or ifosfamide-induced urotoxicity is 3-mercaptoethane sulfonate (MESNA). This agent dimerizes to an inactive metabolite in plasma, but hydrolyzes in urine to yield the active compound that conjugates acrolein and prevents cystitis. MESNA is usually administrated continuously to patients treated with oxazaphosphorines. Subcutaneous administration of the compound is preferred because it is not associated with inadequate urinary MESNA accumulation and clinical experience suggests that it represents a safe and practical method of drug delivery [108].

4.4.5 Alopecia Alopecia has been mainly observed with cyclophosphamide-based therapy [5]. The degree of alopecia may be severe especially when the drug

77

is used in combination with vincristine sulfate or doxorubicin. Hair regrowth occurs after cessation of the therapy but may be associated with a change in texture [69].

4.4.6 Reproductive Toxicity Alkylating agents have profound effects on reproductive tissue. Aspermia has been observed in patients undergoing therapy with mechlorethamine, chlorambucil and cyclophosphamide [112]. Testicular biopsies have demonstrated that this effect was in most cases associated with germinal aplasia and preservation of Sertoli cells [61]. High frequency of aspermia and oligospermia have been observed in patients for up to 3 years after cessation of therapy. However, in some cases, patients off therapy demonstrated complete spermatogenesis restoration and even fathered children [154]. Amenorrhea and ovarian atrophy have been observed in female patients treated with busulfan and cyclophosphamide [46, 112]. Biopsies of ovaries after cyclophosphamide administration reveal the absence of mature or primordial follicles. This has been associated with a decrease in estrogen and progesterone levels and an elevation of follicle-stimulating hormone and luteinizing hormone plasma concentrations often characteristic of menopause [130].

4.4.7 Teratogenecity Teratogenic activities have been linked with all alkylating agents [25, 57]. This seems to be caused by a direct cytotoxicity to developing embryos by the same DNA damage mechanisms that occur in tumor cells [31]. Because of the teratogenicity of these agents, limits are placed on the use of alkylating agents during pregnancy. It has been shown that if these drugs are given during the first trimester of pregnancy, a high incidence of birth defects is observed. However, if the alkylating agents are administered during the second or third trimester of pregnancy, fetuses do not suffer malformations. Such results suggest that though it is unsafe to administer these chemotherapeutic agents to pregnant women, the risk of birth defects are more restricted during the two last trimesters of pregnancy [123].

78

4.4.8 Carcinogenesis In a large number of studies, it was observed that alkylating agent therapy was associated with the appearance of secondary leukemias [54, 144] suggesting that the oncogenic effect of these drugs represents a significant complication of alkylating agent therapy. Because of their structure and mechanism of action, alkylating agents can induce DNA adducts similar to those observed with the carcinogenic polycyclic aromatic hydrocarbons [110, 196].

4.4.9 Immunosuppression Cyclophosphamide is among the most immunossupressive alkylating agents [64] and because of this property it has been utilized in the treatment of auto-immune diseases [178, 190]. However, low doses of cyclophosphamide or melphalan can enhance immune response. Because of this effect, these drugs have been used in combination with cytokines such as IL-2 [96, 115]. One of the main consequences and concerns of immunosuppression is the increased risk and susceptibility to infectious diseases in patients treated with cyclophosphamide [126].

4.4.10 Hypersensitivity Reactions Because alkylating agents covalently bind to biologic macromolecules, these compounds are suspected to act as haptens and can induce allergic reactions. Skin eruption, urticaria and anaphylatic reactions have been reported following the administration of alkylating agents [94, 141]. Although allergic reactions do not represent a frequent side effect observed during chemotherapy, they may be fatal if they lead to anaphylactic shock.

4.5 Conclusion Over the past three decades, the scientific community has gained a better understanding of the biology of cancer cells and identified enzymes and signaling pathways that are specifically dysregulated in tumors.

L. Gate and K.D. Tew

The design of new alkylating agents could take advantage of this knowledge by synthesizing new drugs that could be activated preferentially by tumor cells and consequently could lack the side effects that limits the use of current alkylating drugs. At this time, one of the best examples of this is TLK286, a prodrug preferentially activated by GSTπ. Any clinically proven activity of this drug should lead the way to a new generation of anticancer drugs that will make chemotherapy more efficient and tolerable for patients.

References 1. Abrey LE, Olson JD, Raizer JJ, Mack M, Rodavitch A, Boutros DY et al (2001) A phase II trial of temozolomide for patients with recurrent or progressive brain metastases. J Neurooncol 53(3):259–265 2. Adair CPJ, Bagg HJ (1931) Experimental and clinical studies on the treatment of cancer by dichloroethylsulphide (mustard gas). Ann Surg 93:190–199 3. Adler V, Yin Z, Fuchs SY, Benezra M, Rosario L, Tew KD et al (1999) Regulation of JNK signaling by GSTp. Embo J 18(5):1321–1334 4. Ahlgren JD, Green DC, Tew KD, Schein PS (1982) Repair of DNA alkylation induced in L1210 leukemia and murine bone marrow by three chloroethylnitrosoureas. Cancer Res 42(7):2605–2608 5. Ahmed AR, Hombal SM (1984) Cyclophosphamide (Cytoxan). A review on relevant pharmacology and clinical uses. J Am Acad Dermatol 11(6):1115–1126 6. Alarcon RA, Meienhofer J, Atherton E (1972) Isophosphamide as a new acrolein-producing antineoplastic isomer of cyclophosphamide. Cancer Res 32(11):2519–2523 7. Alberts DS, Chang SY, Chen HS, Larcom BJ, Evans TL (1980) Comparative pharmacokinetics of chlorambucil and melphalan in man. Recent Results Cancer Res 74:124–131 8. Allay E, Veigl M, Gerson SL (1999) Mice over-expressing human O6 alkylguanine-DNA alkyltransferase selectively reduce O6 methylguanine mediated carcinogenic mutations to threshold levels after N-methyl-N-nitrosourea. Oncogene 18(25):3783–3787 9. Anderson N, Lokich J, Moore C, Bern M, Coco F (1999) A dose-escalation phase II clinical trial of infusional mitomycin C for 7 days in patients with advanced measurable colorectal cancer refractory or resistant to 5-fluorouracil. Cancer Invest 17(8):586–593 10. Anderson T, McMenamin MG, Schein PS (1975) Chlorozotocin 2-(3-(2-chloroethyl)-3-nitrosoureido)-Dglucopyranose, an antitumor agent with modified bone marrow toxicity. Cancer Res 35(3):761–765 11. Andrievsky GV, Sukhodub LF, Pyatigorskaya TL, Boryak OA, Limanskaya O, Shelkovsky VS (1991) Direct observation of the alkylation products of deoxyguanosine and

4

Alkylating Agents

12.

13.

14.

15.

16.

17.

18.

19.

20. 21.

22.

23.

24.

25. 26.

DNA by fast atom bombardment mass spectrometry. Biol Mass Spectrom 20(11):665–668 Aviles A, Diaz-Maqueo JC, Talavera A, Garcia EL, Guzman R, Nambo MJ (1997) Bone marrow protection with amifostine in the treatment of high-risk malignant lymphoma. Eur J Cancer 33(8):1323–1325 Awasthi S, Srivastava SK, Ahmad F, Ahmad H, Ansari GA (1993) Interactions of glutathione S-transferase-pi with ethacrynic acid and its glutathione conjugate. Biochim Biophys Acta 1164(2):173–178 Bailey CC, Marsden HB, Jones PH (1978) Fatal pulmonary fibrosis following 1,3-bis(2-chloroethyl)-1nitrosourea (BCNU) therapy. Cancer 42(1):74–76 Baldwin A, Huang Z, Jounaidi Y, Waxman DJ (2003) Identification of novel enzyme-prodrug combinations for use in cytochrome P450-based gene therapy for cancer. Arch Biochem Biophys 409(1):197–206 Bank BB, Kanganis D, Liebes LF, Silber R (1989) Chlorambucil pharmacokinetics and DNA binding in chronic lymphocytic leukemia lymphocytes. Cancer Res 49(3):554–559 Baril BB, Baril EF, Laszlo J, Wheeler GP (1975) Inhibition of rat liver DNA polymerase by nitrosoureas and isocyanates. Cancer Res 35(1):1–5 Barrows LR, Borchers AH, Paxton MB (1987) Transfectant CHO cells expressing O6-alkylguanineDNA-alkyltransferase display increased resistance to DNA damage other than O6-guanine alkylation. Carcinogenesis 8(12):1853–1859 Bastholt L, Johansson CJ, Pfeiffer P, Svensson L, Johansson SA, Gunnarsson PO et al (1991) A pharmacokinetic study of prednimustine as compared with prednisolone plus chlorambucil in cancer patients. Cancer Chemother Pharmacol 28(3):205–210 Batist G, Andrews JL Jr (1981) Pulmonary toxicity of antineoplastic drugs. Jama 246(13):1449–1453 Bauer GB, Povirk LF (1997) Specificity and kinetics of interstrand and intrastrand bifunctional alkylation by nitrogen mustards at a G-G-C sequence. Nucleic Acids Res 25(6):1211–1218 Bedford P, Fox BW (1983) DNA-DNA interstrand crosslinking by dimethyanesulphonic acid esters. Correlation with cytotoxicity and antitumour activity in the Yoshida lymphosarcoma model and relationship to chain length. Biochem Pharmacol 32(15):2297–2301 Begleiter A, Lam HY, Grover J, Froese E, Goldenberg GJ (1979) Evidence for active transport of melphalan by two amino acid carriers in L5178Y lymphoblasts in vitro. Cancer Res 39(2 Pt 1):353–359 Bilsland AE, Anderson CJ, Fletcher-Monaghan AJ, McGregor F, Evans TR, Ganly I et al (2003) Selective ablation of human cancer cells by telomerase-specific adenoviral suicide gene therapy vectors expressing bacterial nitroreductase. Oncogene 22(3):370–380 Bishop JB, Wassom JS (1986) Toxicological review of busulfan (Myleran). Mutat Res 168(1):15–45 Blakey DC, Burke PJ, Davies DH, Dowell RI, East SJ, Eckersley KP et al (1996) ZD2767:an improved system for antibody-directed enzyme prodrug therapy that results in tumor regressions in colorectal tumor xenografts. Cancer Res 56(14):3287–3292

79 27. Borowy-Borowski H, Lipman R, Chowdary D, Tomasz M (1990) Duplex oligodeoxyribonucleotides cross-linked by mitomycin C at a single site: synthesis, properties, and cross-link reversibility. Biochemistry 29(12): 2992–2999 28. Borowy-Borowski H, Lipman R, Tomasz M (1990) Recognition between mitomycin C and specific DNA sequences for cross-link formation. Biochemistry 29(12):2999–3006 29. Bradner WT (2001) Mitomycin C: a clinical update. Cancer Treat Rev 27(1):35–50 30. Brent TP, Remack JS (1988) Formation of covalent complexes between human O6-alkylguanine-DNA alkyltransferase and BCNU-treated defined length synthetic oligodeoxynucleotides. Nucleic Acids Res 16(14B):6779–6788 31. Brummett ES, Johnson EM (1979) Morphological alterations in the developing fetal rat limb due to maternal injection of chlorambucil. Teratology 20(2):279–287 32. Budman DR, Forastiere A, Perloff M, Perry M, Aisner J, Weinberg V et al (1982) Aziridinylbenzoquinone (AZQ) in advanced breast cancer: a Cancer and Leukemia group B phase II trial. Cancer Treat Rep 66(10):1875–1876 33. Cantrell JE Jr, Green D, Schein PS (1986) Antitumor activity and bone marrow toxicity of aminoglucose mustard anticancer agents in mice. Cancer Res 46(5): 2340–2343 34. Casper ES, Gralla RJ (1979) Phase II evaluation of chlorozotocin in patients with non-small cell carcinoma of the lung. Cancer Treat Rep 63(4):549–550 35. Cedermark BJ, Gunven P, Hammarberg C (1983) Adriamycin CCNU, and 5-fluorouracil in patients with advanced gastrointestinal cancer. J Surg Oncol 22(2):125–128 36. Chen G, Waxman DJ (1994) Role of cellular glutathione and glutathione S-transferase in the expression of alkylating agent cytotoxicity in human breast cancer cells. Biochem Pharmacol 47(6):1079–1087 37. Chinnasamy N, Rafferty JA, Hickson I, Ashby J, Tinwell H, Margison GP et al (1997) O6-benzylguanine potentiates the in vivo toxicity and clastogenicity of temozolomide and BCNU in mouse bone marrow. Blood 89(5):1566–1573 38. Chiuten DF, Rozencweig M, Von Hoff DD, Muggia FM (1981) Clinical trials with the hexitol derivatives in the U.S. Cancer 47(3):442–451 39. Ciaccio PJ, Tew KD, LaCreta FP (1990) The spontaneous and glutathione S-transferase-mediated reaction of chlorambucil with glutathione. Cancer Commun 2(8): 279–285 40. Ciaccio PJ, Tew KD, LaCreta FP (1991) Enzymatic conjugation of chlorambucil with glutathione by human glutathione S-transferases and inhibition by ethacrynic acid. Biochem Pharmacol 42(7):1504–1507 41. Clapper ML, Kuzmich S, Seestaller LM, Tew KD (1993) Time course of glutathione S-transferase elevation in Walker mammary carcinoma cells following chlorambucil exposure. Biochem Pharmacol 45(3):683–690 42. Cohen AM, Schaeffer N, Higgins J (1986) Treatment of metastatic colorectal cancer with hepatic artery combination chemotherapy. Cancer 57(6):1115–1117

80 43. Colvin M (1982) The comparative pharmacology of cyclophosphamide and ifosfamide. Semin Oncol 9 (4 Suppl 1):2–7 44. Colvin M, Russo JE, Hilton J, Dulik DM, Fenselau C (1988) Enzymatic mechanisms of resistance to alkylating agents in tumor cells and normal tissues. Adv Enzyme Regul 27:211–221 45. Colvin ME, Sasaki JC, Tran NL (1999) Chemical factors in the action of phosphoramidic mustard alkylating anticancer drugs: roles for computational chemistry. Curr Pharm Des 5(8):645–663 46. Cornbleet MA, Leonard RC, Smyth JF (1984) High-dose alkylating agent therapy: a review of clinical experiences. Cancer Drug Deliv 1(3):227–238 47. Cox PJ (1979) Cyclophosphamide cystitis – identification of acrolein as the causative agent. Biochem Pharmacol 28(13):2045–2049 48. Crone TM, Goodtzova K, Edara S, Pegg AE (1994) Mutations in human O6-alkylguanine-DNA alkyltransferase imparting resistance to O6-benzylguanine. Cancer Res 54(23):6221–6227 49. Curt GA, Kelley JA, Kufta CV, Smith BH, Kornblith PL, Young RC et al (1983) Phase II and pharmacokinetic study of aziridinylbenzoquinone [2,5-diaziridinyl-3,6bis(carboethoxyamino)-1,4-benzoquinone, diaziquone NSC 182986] in high-grade gliomas. Cancer Res 43(12 Pt 1):6102–6105 50. Dirven HA, Dictus EL, Broeders NL, van Ommen B, van Bladeren PJ (1995) The role of human glutathione S-transferase isoenzymes in the formation of glutathione conjugates of the alkylating cytostatic drug thiotepa. Cancer Res 55(8):1701–1706 51. Ebert BL, Niemierko E, Shaffer K, Salgia R (2003) Use of temozolomide with other cytotoxic chemotherapy in the treatment of patients with recurrent brain metastases from lung cancer. Oncologist 8(1):69–75 52. Eder JP, Elias A, Shea TC, Schryber SM, Teicher BA, Hunt M et al (1990) A phase I-II study of cyclophosphamide, thiotepa, and carboplatin with autologous bone marrow transplantation in solid tumor patients. J Clin Oncol 8(7):1239–1245 53. Ehrsson H, Hassan M (1984) Binding of busulfan to plasma proteins and blood cells. J Pharm Pharmacol 36(10):694–696 54. Einhorn N (1978) Acute leukemia after chemotherapy (melphalan). Cancer 41(2):444–447 55. Elias A (1993) Chemotherapy and radiotherapy for regionally advanced non-small-cell lung cancer. Chest 103(4 Suppl):362S–366S 56. Elias AD, Ayash L, Skarin AT, Wheeler C, Schwartz G, Mazanet R et al (1993) High-dose combined alkylating agent therapy with autologous stem cell support and chest radiotherapy for limited small-cell lung cancer. Chest 103(4 Suppl):433S–435S 57. Enns GM, Roeder E, Chan RT, Ali-Khan Catts Z, Cox VA, Golabi M (1999) Apparent cyclophosphamide (cytoxan) embryopathy: a distinct phenotype? Am J Med Genet 86(3):237–241 58. Erickson LC, Laurent G, Sharkey NA, Kohn KW (1980) DNA cross-linking and monoadduct repair in nitrosoureatreated human tumour cells. Nature 288(5792):727–729

L. Gate and K.D. Tew 59. Fairbairn LJ, Cowling GJ, Dexter TM, Rafferty JA, Margison GP, Reipert B (1994) bcl-2 delay of alkylating agent-induced apoptotic death in a murine hemopoietic stem cell line. Mol Carcinog 11(1):49–55 60. Fairbairn LJ, Watson AJ, Rafferty JA, Elder RH, Margison GP (1995) O6-benzylguanine increases the sensitivity of human primary bone marrow cells to the cytotoxic effects of temozolomide. Exp Hematol 23(2):112–116 61. Fairley KF, Barrie JU, Johnson W (1972) Sterility and testicular atrophy related to cyclophosphamide therapy. Lancet 1(7750):568–569 62. Fetting JH, McCarthy LE, Borison HL, Colvin M (1982) Vomiting induced by cyclophosphamide and phosphoramide mustard in cats. Cancer Treat Rep 66(8): 1625–1629 63. Fine HA, Wen PY, Maher EA, Viscosi E, Batchelor T, Lakhani N et al (2003) Phase II trial of thalidomide and carmustine for patients with recurrent high-grade gliomas. J Clin Oncol 21(12):2299–2304 64. Fraiser LH, Kanekal S, Kehrer JP (1991) Cyclophosphamide toxicity. Characterising and avoiding the problem. Drugs 42(5):781–795 65. Fried W, Kedo A, Barone J (1977) Effects of cyclophosphamide and of busulfan on spleen colony-forming units and on hematopoietic stroma. Cancer Res 37(4): 1205–1209 66. Friedman HS, Kerby T, Calvert H (2000) Temozolomide and treatment of malignant glioma. Clin Cancer Res 6(7):2585–2597 67. Gallo JM, Brennan J, Hamilton TC, Halbherr T, Laub PB, Ozols RF et al (1995) Time-dependent pharmacodynamic models in cancer chemotherapy: population pharmacodynamic model for glutathione depletion following modulation by buthionine sulfoximine (BSO) in a Phase I trial of melphalan and BSO. Cancer Res 55(20):4507–4511 68. Gate L, Majumdar RS, Lunk A, Tew KD (2004) myeloproliferation in glutathione S-transferase p deficient mice is associated with a deregulation of c-Jun-NH2-terminal kinase and Janus kinase/signal transducer and activator of transcription pathways. J Biol Chem In press 69. George SL, Whitton A, Plowman PN (1983) Hair regrowth after cancer therapy. Hum Toxicol 2(3):465–472 70. Gibson NW, Zlotogorski C, Erickson LC (1985) Specific DNA repair mechanisms may protect some human tumor cells from DNA interstrand crosslinking by chloroethylnitrosoureas but not from crosslinking by other anti-tumor alkylating agents. Carcinogenesis 6(3):445–450 71. Gilman A, Phillips FS (1946) The biologicals actions an therapeutic applications of β-chloroethyla amines and sulfides. Sciences 103:409–436 72. Goldenberg GJ, Lee M, Lam HY, Begleiter A (1977) Evidence for carrier-mediated transport of melphalan by L5178Y lymphoblasts in vitro. Cancer Res 37(3):755–760 73. Gomi A, Shinoda S, Masuzawa T, Ishikawa T, Kuo MT (1997) Transient induction of the MRP/GS-X pump and gamma-glutamylcysteine synthetase by 1-(4-amino-2methyl-5-pyrimidinyl)methyl-3-(2-chloroethyl)-3- nitrosourea in human glioma cells. Cancer Res 57(23): 5292–5299 74. Gralla RJ, Tan CT, Young CW (1979) Phase I trial of chlorozotocin. Cancer Treat Rep 63(1):17–20

4

Alkylating Agents 75. Gralla RJ, Yagoda A (1979) Phase II evaluation of chlorozotocin in patients with renal cell carcinoma. Cancer Treat Rep 63(6):1007–1008 76. Green JA, Vistica DT, Young RC, Hamilton TC, Rogan AM, Ozols RF (1984) Potentiation of melphalan cytotoxicity in human ovarian cancer cell lines by glutathione depletion. Cancer Res 44(11):5427–5431 77. Greig NH, Daly EM, Sweeney DJ, Rapoport SI (1990) Pharmacokinetics of chlorambucil-tertiary butyl ester, a lipophilic chlorambucil derivative that achieves and maintains high concentrations in brain. Cancer Chemother Pharmacol 25(5):320–325 78. Guenthner TM, Whalen R, Jevtovic-Todorovic V (1992) Direct measurement of melphalan conjugation with glutathione: studies with human melanoma cells and mammalian liver. J Pharmacol Exp Ther 260(3):1331–1336 79. Hare CB, Elion GB, Colvin OM, Ali-Osman F, Griffith OW, Petros WP et al (1997) Characterization of the mechanisms of busulfan resistance in a human glioblastoma multiforme xenograft. Cancer Chemother Pharmacol 40(5):409–414 80. Hartmann JT, Kanz L, Bokemeyer C (2000) Phase II study of continuous 120-hour-infusion of mitomycin C as salvage chemotherapy in patients with progressive or rapidly recurrent gastrointestinal adenocarcinoma. Anticancer Res 20(2B):1177–1182 81. Hawkins DS, Demers GW, Galloway DA (1996) Inactivation of p53 enhances sensitivity to multiple chemotherapeutic agents. Cancer Res 56(4):892–898 82. Horton JK, Roy G, Piper JT, Van Houten B, Awasthi YC, Mitra S et al (1999) Characterization of a chlorambucilresistant human ovarian carcinoma cell line overexpressing glutathione S-transferase mu. Biochem Pharmacol 58(4):693–702 83. Horvath IP, Somfai-Relle S, Hegedus L, Jarman M (1982) Toxicity, antitumour and haematological effects of 1,2anhydro-6-bromogalactitol and d-mannitol: a comparison with the related dibromo- and dianhydro-derivatives. Eur J Cancer Clin Oncol 18(6):573–577 84. Hudes G (1997) Estramustine-based chemotherapy. Semin Urol Oncol 15(1):13–19 85. Hwu WJ (2000) New approaches in the treatment of metastatic melanoma: thalidomide and temozolomide. Oncology (Huntingt) 14(12 Suppl 13):25–28 86. Hyde KA, Acton E, Skinner WA, Goodman L, Greenberg J, Baker BR (1962) Potential Anticancer Agents. Lxii. The Relationship of Chemical Structure to Antileukemic Activity with Analogs of 1-Methyl-3-Nitro1-Nitrosoguanidine (Nsc-9369). Ii. J Med Pharm Chem 52:1–14 87. Jeney A, Kopper L, Lapis K, Vidra L, Institoris L (1984) Antitumour action of 1,5-dihalogeno-, and 1:2–4: 5-dianhydro-xylitol derivatives. Anticancer Res 4(1–2): 23–25 88. Kaijser GP, Korst A, Beijnen JH, Bult A, Underberg WJ (1993) The analysis of ifosfamide and its metabolites (review). Anticancer Res 13(5A):1311–1324 89. Kann HE Jr, Kohn KW, Lyles JM (1974) Inhibition of DNA repair by the 1,3-bis(2-chloroethyl)-1-nitrosourea breakdown product 2-chloroethyl isocyanate. Cancer Res 34(2):398–402

81 90. Kann HE Jr, Kohn KW, Widerlite L, Gullion D (1974) Effects of 1,3-bis(2-chloroethyl)-1-nitrosourea and related compounds on nuclear RNA metabolism. Cancer Res 34(8):1982–1988 91. Kluin-Nelemans HC, Zagonel V, Anastasopoulou A, Bron D, Roozendaal KJ, Noordijk EM et al (2001) Standard chemotherapy with or without high-dose chemotherapy for aggressive non-Hodgkin’s lymphoma: randomized phase III EORTC study. J Natl Cancer Inst 93(1): 22–30 92. Knox RJ, Jenkins TC, Hobbs SM, Chen S, Melton RG, Burke PJ (2000) Bioactivation of 5-(aziridin-1-yl)-2,4dinitrobenzamide (CB 1954) by human NAD(P)H quinone oxidoreductase 2: a novel co-substratemediated antitumor prodrug therapy. Cancer Res 60(15): 4179–4186 93. Kojima H, Endo K, Moriyama H, Tanaka Y, Alnemri ES, Slapak CA et al (1998) Abrogation of mitochondrial cytochrome c release and caspase-3 activation in acquired multidrug resistance. J Biol Chem 273(27): 16647–16650 94. Krutchik AN, Buzdar AU, Tashima CK (1978) Cyclophosphamide-induced urticaria. Occurrence in a patient with no cross-sensitivity to chlorambucil. Arch Intern Med 138(11):1725–1726 95. Kuroi K, Osaki A, Kawami H, Murakami S, Toge T (1997) A combination therapy with mitomycin C, etoposide doxifluridine and medroxyprogesterone acetate as second line therapy for advanced breast cancer refractory to combination chemotherapy of cyclo-phoshamide doxorubicin and 5-fluorouracil. Breast Cancer 4(2):115–119 96. Kusnierczyk H, Pajtasz-Piasecka E, Radzikowski C (1999) Synergistic antitumour effects of chemoimmunotherapy with an oxazaphosphorine drug and IL-2-secreting cells in a mouse colon cancer model. Med Oncol 16(4):267–278 97. Lackinger D, Kaina B (2000) Primary mouse fibroblasts deficient for c-Fos, p53 or for both proteins are hypersensitive to UV light and alkylating agent-induced chromosomal breakage and apoptosis. Mutat Res 457 (1–2):113–123 98. Laing N, Dahllof B, Hartley-Asp B, Ranganathan S, Tew KD (1997) Interaction of estramustine with tubulin isotypes. Biochemistry 36(4):871–878 99. Langer CJ, Nash S, Catalano R, Rosenblum NG, Hogan WM, Comis RL et al (1991) Phase II trial of thio-TEPA in relapsed and refractory ovarian carcinoma. Gynecol Oncol 43(3):242–246 100. Lemoine A, Lucas C, Ings RM (1991) Metabolism of the chloroethylnitrosoureas. Xenobiotica 21(6):775–791 101. Li Z, Brendel M (1994) Sensitivity to nitrogen mustard in Saccharomyces cerevisiae is independently determined by regulated choline permease and DNA repair. Mutat Res 315(2):139–145 102. Ludlum DB (1997) The chloroethylnitrosoureas: sensitivity and resistance to cancer chemotherapy at the molecular level. Cancer Invest 15(6):588–598 103. Lyttle MH, Hocker MD, Hui HC, Caldwell CG, Aaron DT, Engqvist-Goldstein A et al (1994) Isozyme-specific glutathione-S-transferase inhibitors: design and synthesis. J Med Chem 37(1):189–194

82 104. Lyttle MH, Satyam A, Hocker MD, Bauer KE, Caldwell CG, Hui HC et al (1994) Glutathione-Stransferase activates novel alkylating agents. J Med Chem 37(10):1501–1507 105. Ma J, Murphy M, O’Dwyer PJ, Berman E, Reed K, Gallo JM (2002) Biochemical changes associated with a multidrug-resistant phenotype of a human glioma cell line with temozolomide-acquired resistance. Biochem Pharmacol 63(7):1219–1228 106. Maanen MJ, Smeets CJ, Beijnen JH (2000) Chemistry, pharmacology and pharmacokinetics of N,N ,N -triethylenethiophosphoramide (ThioTEPA). Cancer Treat Rev 26(4): 257–268 107. Makin G, Hickman JA (2000) Apoptosis and cancer chemotherapy. Cell Tissue Res 301(1):143–152 108. Markman M, Kennedy A, Webster K, Kulp B, Peterson G, Belinson J (1996) Continuous subcutaneous administration of mesna to prevent ifosfamide-induced hemorrhagic cystitis. Semin Oncol 23(3 Suppl 6):97–98 109. Maynard K, Parsons PG, Cerny T, Margison GP (1989) Relationships among cell survival O6-alkylguanine-DNA alkyltransferase activity, and reactivation of methylated adenovirus 5 and herpes simplex virus type 1 in human melanoma cell lines. Cancer Res 49(17):4813–4817 110. McCormick JJ, Maher VM (1985) Cytotoxic and mutagenic effects of specific carcinogen-DNA adducts in diploid human fibroblasts. Environ Health Perspect 62:145–155 111. Miller B, Tenenholz T, Egorin MJ, Sosnovsky G, Rao NU, Gutierrez PL (1988) Cellular pharmacology of N,N ,N triethylenethiophosphoramide. Cancer Lett 41(2): 157–168 112. Miller DG (1971) Alkylating agents and human spermatogenesis. JAMA 217(12):1662–1665 113. Miller L, Deffie AM, Bose R, Goldenberg GJ (1992) Modulation of melphalan uptake in murine L5178Y lymphoblasts in vitro by changes in ionic environment. Biochem Pharmacol 43(5):1154–1158 114. Misra V, Klamut HJ, Rauth AM (2002) Expression of the prodrug-activating enzyme DT-diaphorase via Ad5 delivery to human colon carcinoma cells in vitro. Cancer Gene Ther 9(2):209–217 115. Mitchell MS (2003) Combinations of anticancer drugs and immunotherapy. Cancer Immunol Immunother 52(11):686–692 116. Moertel CG, Hanley JA, Johnson LA (1980) Streptozocin alone compared with streptozocin plus fluorouracil in the treatment of advanced islet-cell carcinoma. N Engl J Med 303(21):1189–1194 117. Monks NR, Blakey DC, Curtin NJ, East SJ, Heuze A, Newell DR (2001) Induction of apoptosis by the ADEPT agent ZD2767: comparison with the classical nitrogen mustard chlorambucil and a monofunctional ZD2767 analogue. Br J Cancer 85(5):764–771 118. Morgan AS, Ciaccio PJ, Tew KD, Kauvar LM (1996) Isozyme-specific glutathione S-transferase inhibitors potentiate drug sensitivity in cultured human tumor cell lines. Cancer Chemother Pharmacol 37(4):363–370 119. Morgan AS, Sanderson PE, Borch RF, Tew KD, Niitsu Y, Takayama T et al (1998) Tumor efficacy and bone marrow-sparing properties of TER286:a cytotoxin

L. Gate and K.D. Tew

120.

121.

122.

123.

124.

125.

126.

127.

128.

129.

130.

131.

132.

133.

134.

135.

activated by glutathione S-transferase. Cancer Res 58(12):2568–2575 Newell D, Gescher A, Harland S, Ross D, Rutty C (1987) N-methyl antitumour agents. A distinct class of anticancer drugs? Cancer Chemother Pharmacol 19(2):91–102 Newell DR, Shepherd CR, Harrap KR (1981) The pharmacokinetics of prednimustine and chlorambucil in the rat. Cancer Chemother Pharmacol 6(1):85–91 Ng SF, Waxman DJ (1991) N,N ,N -triethylenethiophosphoramide (thio-TEPA) oxygenation by constitutive hepatic P450 enzymes and modulation of drug metabolism and clearance in vivo by P450-inducing agents. Cancer Res 51(9):2340–2345 Nicholson HO (1968) Cytotoxic drugs in pregnancy. Review of reported cases. J Obstet Gynaecol Br Commonw 75(3):307–312 Nissen-Meyer R, Host H (1960) A comparison between the hematological side effects of cyclophosphamide and nitrogen mustard. Cancer Chemother Rep 9:51–55 O’Brien M, Kruh GD, Tew KD (2000) The influence of coordinate overexpression of glutathione phase II detoxification gene products on drug resistance. J Pharmacol Exp Ther 294(2):480–487 O’Brien SM, Kantarjian HM, Cortes J, Beran M, Koller CA, Giles FJ et al (2001) Results of the fludarabine and cyclophosphamide combination regimen in chronic lymphocytic leukemia. J Clin Oncol 19(5): 1414–1420 O’Dwyer PJ, Hamilton TC, LaCreta FP, Gallo JM, Kilpatrick D, Halbherr T et al (1996) Phase I trial of buthionine sulfoximine in combination with melphalan in patients with cancer. J Clin Oncol 14(1):249–256 O’Dwyer PJ, LaCreta F, Nash S, Tinsley PW, Schilder R, Clapper ML et al (1991) Phase I study of thiotepa in combination with the glutathione transferase inhibitor ethacrynic acid. Cancer Res 51(22):6059–6065 Olivi A, Grossman SA, Tatter S, Barker F, Judy K, Olsen J et al (2003) Dose escalation of carmustine in surgically implanted polymers in patients with recurrent malignant glioma: a new approaches to brain tumor therapy CNS consortium trial. J Clin Oncol 21(9):1845–1849 Orwoll ES, Kiessling PJ, Patterson JR (1978) Interstitial pneumonia from mitomycin. Ann Intern Med 89(3):352–355 Paal C, Erdelyi-Toth V, Pap E, Csaki C, Ferencz T, Schuler D et al (1994) Pharmacokinetic studies on Elobromol in children with brain tumors. Anticancer Drugs 5(5):539–547 Pacheco DY, Stratton NK, Gibson NW (1989) Comparison of the mechanism of action of busulfan with hepsulfam, a new antileukemic agent, in the L1210 cell line. Cancer Res 49(18):5108–5110 Palma PC, Villaca Junior CJ, Netto Junior NR (1986) N-acetylcysteine in the prevention of cyclophosphamide induced haemorrhagic cystitis. Int Surg 71(1):36–37 Panasci LC, Fox PA, Schein PS (1977) Structureactivity studies of methylnitrosourea antitumor agents with reduced murine bone marrow toxicity. Cancer Res 37(9):3321–3328 Panasci LC, Green D, Nagourney R, Fox P, Schein PS (1977) A structure-activity analysis of chemical and

4

Alkylating Agents

136.

137.

138. 139.

140.

141.

142.

143.

144.

145.

146.

147.

148.

149.

biological parameters of chloroethylnitrosoureas in mice. Cancer Res 37(8 Pt 1):2615–2618 Patel AR, Shah PC, Rhee HL, Sassoon H, Rao KP (1976) Cyclophosphamide therapy and interstitial pulmonary fibrosis. Cancer 38(4):1542–1549 Paumi CM, Ledford BG, Smitherman PK, Townsend AJ, Morrow CS (2001) Role of multidrug resistance protein 1 (MRP1) and glutathione S-transferase A1–1 in alkylating agent resistance. Kinetics of glutathione conjugate formation and efflux govern differential cellular sensitivity to chlorambucil versus melphalan toxicity. J Biol Chem 276(11):7952–7956 Pegg AE, Byers TL (1992) Repair of DNA containing O6alkylguanine. Faseb J 6(6):2302–2310 Pegg AE, Goodtzova K, Loktionova NA, Kanugula S, Pauly GT, Moschel RC (2001) Inactivation of human O(6)-alkylguanine-DNA alkyltransferase by modified oligodeoxyribonucleotides containing O(6)-benzylguanine. J Pharmacol Exp Ther 296(3):958–965 Plowchalk DR, Mattison DR (1992) Reproductive toxicity of cyclophosphamide in the C57BL/6 N mouse: 1. Effects on ovarian structure and function. Reprod Toxicol 6(5):411–421 Posada JG, O’Dwyer PJ, Hoth DF (1984) Anaphylactic reactions to diaziquone. Cancer Treat Rep 68(10):1215–1217 Przepiorka D, Khouri I, Thall P, Mehra R, Lee MS, Ippoliti C et al (1999) Thiotepa, busulfan and cyclophosphamide as a preparative regimen for allogeneic transplantation for advanced chronic myelogenous leukemia. Bone Marrow Transplant 23(10):977–981 Ranganathan S, Walsh ES, Tew KD (1995) Glyoxalase I in detoxification: studies using a glyoxalase I transfectant cell line. Biochem J 309 ( Pt 1):127–131 Reimer RR, Hoover R, Fraumeni JF Jr, Young RC (1977) Acute leukemia after alkylating-agent therapy of ovarian cancer. N Engl J Med 297(4):177–181 Reiser M, Josting A, Draube A, Mapara MY, Scheid C, Chemnitz J et al (1999) Successful peripheral blood stem cell mobilization with etoposide (VP-16) in patients with relapsed or resistant lymphoma who failed cyclophosphamide mobilization. Bone Marrow Transplant 23(12): 1223–1228 Rodriguez LA, Prados M, Fulton D, Edwards MS, Silver P, Levin V (1988) Treatment of recurrent brain stem gliomas and other central nervous system tumors with 5-fluorouracil CCNU, hydroxyurea, and 6-mercaptopurine. Neurosurgery 22(4): 691–693 Rosario LA, O’Brien ML, Henderson CJ, Wolf CR, Tew KD (2000) Cellular response to a glutathione S-transferase P1–1 activated prodrug. Mol Pharmacol 58(1):167–174 Rosen LS, Brown J, Laxa B, Boulos L, Reiswig L, Henner WD et al (2003) Phase I study of TLK286 (glutathione S-transferase P1–1 activated glutathione analogue) in advanced refractory solid malignancies. Clin Cancer Res 9(5):1628–1638 Ruscoe JE, Rosario LA, Wang T, Gate L, Arifoglu P, Wolf CR et al (2001) Pharmacologic or genetic manipulation of glutathione S-transferase P1–1 (GSTpi)

83

150.

151.

152.

153.

154.

155.

156.

157.

158.

159.

160.

161.

162.

influences cell proliferation pathways. J Pharmacol Exp Ther 298(1):339–345 Sasaki Y, Saijo N, Shimizu E, Eguchi K, Shinkai T, Tominaga K et al (1985) Phase II of ACNU for non-small cell lung cancer. Eur J Cancer Clin Oncol 21(12):1557–1559 Schabel FM Jr (1976) Nitrosoureas: a review of experimental antitumor activity. Cancer Treat Rep 60(6):665–698 Schabel FM Jr, Johnston TP, Mc CG, Montgomery JA, Laster WR, Skipper HE (1963) Experimental evaluation of potential anticancer agents VIII. Effects of certain nitrosoureas on intracerebral L1210 leukemia. Cancer Res 23:725–733 Schein PS, Cooney DA, Vernon ML (1967) The use of nicotinamide to modify the toxicity of streptozotocin diabetes without loss of antitumor activity. Cancer Res 27(12):2324–2332 Sherins RJ, DeVita VT Jr (1973) Effect of drug treatment for lymphoma on male reproductive capacity. Studies of men in remission after therapy. Ann Intern Med 79(2):216–220 Shulman-Roskes EM, Noe DA, Gamcsik MP, Marlow AL, Hilton J, Hausheer FH et al (1998) The partitioning of phosphoramide mustard and its aziridinium ions among alkylation and P-N bond hydrolysis reactions. J Med Chem 41(4):515–529 Siemann DW, Beyers KL (1993) In vivo therapeutic potential of combination thiol depletion and alkylating chemotherapy. Br J Cancer 68(6):1071–1079 Skinner WA, Gram HF, Greene MO, Greenberg J, Baker BR (1960) Potential anticancer agents. XXXI. The relationship of chemical structure to antileukaemic activity with analogues of 1-methyl-3-nitro-1nitrosoguanidine (NSC-9369). J Med Pharm Chem 2: 299–333 Smith MT, Evans CG, Doane-Setzer P, Castro VM, Tahir MK, Mannervik B (1989) Denitrosation of 1,3-bis (2-chloroethyl)-1-nitrosourea by class mu glutathione transferases and its role in cellular resistance in rat brain tumor cells. Cancer Res 49(10):2621–2625 Soble MJ, Dorr RT (1988) Lack of enhanced antitumor efficacy for L-buthionine sulfoximine in combination with carmustine, cyclophosphamide, doxorubicin or melphalan in mice. Anticancer Res 8(1):17–22 Springer CJ, Dowell R, Burke PJ, Hadley E, Davis DH, Blakey DC et al (1995) Optimization of alkylating agent prodrugs derived from phenol and aniline mustards: a new clinical candidate prodrug (ZD2767) for antibodydirected enzyme prodrug therapy (ADEPT). J Med Chem 38(26):5051–5065 Stearns ME, Tew KD (1985) Antimicrotubule effects of estramustine, an antiprostatic tumor drug. Cancer Res 45(8):3891–3897 Stevens MF, Hickman JA, Langdon SP, Chubb D, Vickers L, Stone R et al (1987) Antitumor activity and pharmacokinetics in mice of 8-carbamoyl-3methyl-imidazo[5,1-d]-1,2,3,5-tetrazin-4(3H)-one (CCRG 81045; M & B 39831), a novel drug with potential as an alternative to dacarbazine. Cancer Res 47(22): 5846–5852

84 163. Stillwell TJ, Benson RC Jr (1988) Cyclophosphamideinduced hemorrhagic cystitis. A review of 100 patients. Cancer 61(3):451–457 164. Struck RF, Kirk MC, Mellett LB, el Dareer S, Hill DL (1971) Urinary metabolites of the antitumor agent cyclophosphamide. Mol Pharmacol 7(5):519–529 165. Stuart MJ, Chao NS, Horning SJ, Wong RM, Negrin RS, Johnston LJ et al (2001) Efficacy and toxicity of a CCNU-containing high-dose chemotherapy regimen followed by autologous hematopoietic cell transplantation in relapsed or refractory Hodgkin’s disease. Biol Blood Marrow Transplant 7(10):552–560 166. Supino R, Caserini C, Orlandi L, Zaffaroni N, Silvestrini R, Vaglini M et al (1996) Modulation of melphalan cytotoxic activity in human melanoma cell lines. Anticancer Drugs 7(5):604–612 167. Tan CT, Hancock CH, Mondora A, Hoffman NW (1984) Phase I study of aziridinylbenzoquinone (AZQ, NSC 182986) in children with cancer. Cancer Res 44(2): 831–835 168. Teicher BA, Herman TS, Holden SA, Epelbaum R, Liu SD, Frei E. 3rd (1991) Lonidamine as a modulator of alkylating agent activity in vitro and in vivo. Cancer Res 51(3):780–784 169. Tesch H, Sieber M, Diehl V (2001) Treatment of advanced stage Hodgkin’s disease. Oncology 60(2):101–109 170. Tew KD (1994) Glutathione-associated enzymes in anticancer drug resistance. Cancer Res 54(16):4313–4320 171. Tew KD, Bomber AM, Hoffman SJ (1988) Ethacrynic acid and piriprost as enhancers of cytotoxicity in drug resistant and sensitive cell lines. Cancer Res 48(13): 3622–3625 172. Tew KD, Glusker JP, Hartley-Asp B, Hudes G, Speicher LA (1992) Preclinical and clinical perspectives on the use of estramustine as an antimitotic drug. Pharmacol Ther 56(3):323–339 173. Tew KD, Monks A, Barone L, Rosser D, Akerman G, Montali JA et al (1996) Glutathione-associated enzymes in the human cell lines of the National Cancer Institute Drug Screening Program. Mol Pharmacol 50(1):149–159 174. Tew KD, Stearns ME (1989) Estramustine – a nitrogen mustard/steroid with antimicrotubule activity. Pharmacol Ther 43(3):299–319 175. Thatcher D, Lind M, Morgenstern G, Carr T, Chadwick G, Jones R et al (1989) High-dose, double alkylating agent chemotherapy with DTIC, melphalan, or ifosfamide and marrow rescue for metastatic malignant melanoma. Cancer 63(7):1296–1302 176. Townsend DM, Shen H, Staros AL, Gate L, Tew KD (2002) Efficacy of a glutathione S-transferase pi-activated prodrug in platinum-resistant ovarian cancer cells. Mol Cancer Ther 1(12):1089–1095 177. Tutschka PJ, Copelan EA, Klein JP (1987) Bone marrow transplantation for leukemia following a new busulfan and cyclophosphamide regimen. Blood 70(5):1382–1388 178. Tyndall A, Matucci-Cerinic M (2003) Haematopoietic stem cell transplantation for the treatment of systemic sclerosis and other autoimmune disorders. Expert Opin Biol Ther 3(7):1041–1049 179. van Brussel JP, Busstra MB, Lang MS, Catsburg T, Schroder FH, Mickisch GH (2000) A phase II study

L. Gate and K.D. Tew

180.

181.

182.

183.

184.

185.

186.

187.

188.

189.

190.

191.

192.

193.

of temozolomide in hormone-refractory prostate cancer. Cancer Chemother Pharmacol 45(6):509–512 van den Bent MJ, Chinot O, Boogerd W, Bravo Marques J, Taphoorn MJ, Kros JM et al (2003) Second-line chemotherapy with temozolomide in recurrent oligodendroglioma after PCV (procarbazine, lomustine and vincristine) chemotherapy: EORTC Brain Tumor Group phase II study 26972. Ann Oncol 14(4):599–602 van Meerbeeck JP, Baas P, Debruyne C, Smit EF, van Klaveren RJ, Galdermans D et al (2002) A phase II EORTC study of temozolomide in patients with malignant pleural mesothelioma. Eur J Cancer 38(6):779–783 Vistica DT, Rabon A, Rabinovitz M (1979) Cytotoxicities of the L and D isomers of phenylalanine mustard in L 1210 cells. Biochem Pharmacol 28(21):3221–3225 Vistica DT, Schuette B (1979) Substrate specificity of a high-affinity, monovalent cation-dependent amino acid carrier. Biochem Biophys Res Commun 90(1):247–252 Vromans RM, van de Straat R, Groeneveld M, Vermeulen NP (1990) One-electron reduction of mitomycin c by rat liver: role of cytochrome P-450 and NADPH-cytochrome P-450 reductase. Xenobiotica 20(9):967–978 Walker MC, Masters JR, Margison GP (1992) O6alkylguanine-DNA-alkyltransferase activity and nitrosourea sensitivity in human cancer cell lines. Br J Cancer 66(5):840–843 Wang AL, Tew KD (1985) Increased glutathione-Stransferase activity in a cell line with acquired resistance to nitrogen mustards. Cancer Treat Rep 69(6):677–682 Weber GF, Waxman DJ (1993) Denitrosation of the anti-cancer drug 1,3-bis(2-chloroethyl)-1-nitrosourea catalyzed by microsomal glutathione S-transferase and cytochrome P450 monooxygenases. Arch Biochem Biophys 307(2):369–378 Webley SD, Francis RJ, Pedley RB, Sharma SK, Begent RH, Hartley JA et al (2001) Measurement of the critical DNA lesions produced by antibody-directed enzyme prodrug therapy (ADEPT) in vitro, in vivo and in clinical material. Br J Cancer 84(12):1671–1676 Weedon SJ, Green NK, McNeish IA, Gilligan MG, Mautner V, Wrighton CJ et al (2000) Sensitisation of human carcinoma cells to the prodrug CB1954 by adenovirus vector-mediated expression of E. coli nitroreductase. Int J Cancer 86(6):848–854 Weiner HL, Cohen JA (2002) Treatment of multiple sclerosis with cyclophosphamide: critical review of clinical and immunologic effects. Mult Scler 8(2):142–154 Weller M, Muller B, Koch R, Bamberg M, Krauseneck P (2003) Neuro-Oncology Working Group 01 trial of nimustine plus teniposide versus nimustine plus cytarabine chemotherapy in addition to involved-field radiotherapy in the first-line treatment of malignant glioma. J Clin Oncol 21(17):3276–3284 Wentworth P, Datta A, Blakey D, Boyle T, Partridge LJ, Blackburn GM (1996) Toward antibody-directed “abzyme” prodrug therapy, ADAPT: carbamate prodrug activation by a catalytic antibody and its in vitro application to human tumor cell killing. Proc Natl Acad Sci USA 93(2):799–803 Wolf M, Maasberg M, Pfab R, Havemann K (1991) Combined chemo- and radiosensitivity testing with

4

Alkylating Agents

ifosfamide and ACNU in human lung cancer cell lines. J Cancer Res Clin Oncol 117(Suppl 4):S187–S192 194. Yeager AM, Shinn C, Farmer ER, Wingard JR, Yeager MJ (1992) Growth retardation and depigmentation of hair after high-dose busulfan and congenic hematopoietic cell transplantation in mice. Bone Marrow Transplant 9(3):199–204 195. Zon G, Ludeman SM, Brandt JA, Boyd VL, Ozkan G, Egan W et al (1984) NMR spectroscopic studies of intermediary metabolites of cyclophosphamide.

85 A comprehensive kinetic analysis of the interconversion of cis- and trans-4-hydroxycyclophosphamide with aldophosphamide and the concomitant partitioning of aldophosphamide between irreversible fragmentation and reversible conjugation pathways. J Med Chem 27(4):466–485 196. Zytkovicz TH, Moses HL, Spelsberg TC (1977) The binding of benzo(alpha)pyrene and N-methyl-N -nitro-Nnitrosoguanidine to subnuclear fractions of AKR mouse embryo cells in culture. Int J Cancer 20(3):408–417

Chapter 5

Anthracyclines and Anthracenediones Nicole Coufal and Lauge Farnaes

5.1 Introduction Daunorubicin was the first anthracycline isolated, a natural product isolated from the actinobacteria Streptomyces peucetius. It was identified in 1963 by both Italian and French groups [7, 38]. The Italian group focused on natural product analogues, and isolated doxorubicin from the S. peucetius caesius variant, and the French group produced semi-synthetic derivates [6]. Although a vast number of analogues were synthesized after these initial discoveries, only two other anthracyclines ever made it to market in most western countries and Japan, idarubicin and epirubicin. Several liposomal formulations have also been marketed. Doxorubicin is the most widely used anthracycline, and therefore the standard by which all new derivatives are evaluated. After years of debate, it is generally accepted that the mechanism of action of the anthracyclines is by targeting the nuclear enzyme DNA topoisomerase II (topo II) and through formation of free radials, although they also exhibit a wide array of other cellular effects. These off-target effects may contribute to their efficacy, however they doubtlessly also play a role in their toxicity. In the pursuit for new anthracycline analogs with chemotherapeutic activity, a variety of multi-ringed structures with the potential to intercalate between the bases of DNA have been identified. Through

N. Coufal () UCSD Department of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA e-mail: [email protected]

this process the anthracenediones were identified as a class of compounds related to anthracyclines which exhibited promising leukemic properties [101]. Mitoxantrone is the only compound in this class currently marketed, with efficacy against a narrower range of tumors than the anthracyclines, but with the benefit of greatly reduced risk of cardiotoxicity.

5.2 Chemistry Anthracyclines are composed of an anthraquinone (a planar polyaromatic ring system with a quinone moiety) linked to an amino sugar. The central anthraquinone is an intense chromophore that absorbs light in both the UV (at 254 nm) and the visible spectrum (at 480 nm). This chromophore gives the compounds their characteristic orange-red color and intense fluorescence. The compounds lose their fluorescence when intercalated in DNA. Although many structural variations have been made to the basic anthracycline structure only four are currently in clinical use. These vary in only three places in the molecule. Idarubicin differs from the other three anthracyclines by not having a methyl ester at carbon 4 of the central chromophore (Fig. 5.1). Another structural difference between the four anthracyclines is that doxorubicin and epirubicin have a hydroxyl moiety at carbon 14 while daunorubicin and idarubicin are missing this hydroxyl group. The final structural variation is found at carbon 4 on the amino sugar where epirubicin has the opposite stereochemical configuration at this carbon from doxorubicin and idarubicin. The anthraquinone head is quite lipophilic and aids anthracyclines binding to targets molecules through

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_5, © Springer Science+Business Media B.V. 2011

87

88 Fig. 5.1 The structures of anthracyclines in current clinical use and the anthracenedione mitoxatrone. The anthracyclines vary in structure at the carbons marked 4, 14, and 4 on doxorubicin

N. Coufal and L. Farnaes

1

4 O

O

OH

O

O

OH

13 14 OH O

OH OH

OH O

O

O

OH O

O

O

HO NH2

HO NH2

Daunorubicin

Doxorubicin

4'

O

OH

O

O

O

OH

O

OH OH O

O HO

OH

OH O

O

OH O

O

O

NH2

HO NH2

Epirubicin

Idarurubicin

OH O HN

OH O HN

H N

N H

OH

OH

Mitoxantrone

hydrophobic interactions. The amino sugar helps to make the molecules soluble in water. All the anthracyclines are currently marketed as hydrochloric acid salt since this formulation is soluble in both water and polar organic solvents. The anthracyclines have different lipophilicities with idarubicin being the most lipophilic, followed by daunorubicin, epirubicin, and doxorubicin. Metabolic transformations can include reduction of the ketone on carbon 13 (Fig. 5.1) to yield the respective 13-dihydro derivatives, which are usually named by adding the –ol suffix to the parent compound (i.e. doxorubicinol). Another structural variation that is observed in metabolites is compounds where the sugar has been eliminated to yield either 7-deoxy or 7-hydroxy aglycones. In order to reduce the anthracycline to the 7-deoxyaglycone a stepwise reaction with flavin containing enzymes must occur. This has been used as evidence to support the existence of an anthracycline redox cycle. The 7-hydroxyaglycones result from the hydrolysis of the sugar-anthraquinone bond. Therefore the 7-hydroxyaglycones can arise

as artifacts in the handling or processing of the drug. American Cyanamid Laboratories synthesized a class of compounds similar to the anthracyclines in the late 1970s [101]. This resulted in the anthracenediones class of molecules, of which the most active is mitoxantrone. Mitoxantrone has a dihydroxyanthraquinone central chromophore with two symmetrical aminoalkyl side chains. These side chains may undergo oxidation to yield the mono- and dicarboxylic acids of the anthracenedione.

5.3 Mechanism of Action It was rapidly realized that the anthracyclines have a profound inhibitory effect on nucleic acid synthesis [6]. There has been some controversy over the exact mechanism of the anthracyclines. It is possible that the anthracyclines have a few potential mechanisms of action and which of these is most important may

5

Anthracyclines and Anthracenediones

depend on the cellular and extracellular environment in which they are acting. It seems most likely that the anthracyclines act by interaction with topoisomerase II and/or by the creation of oxygen free radicals, which can subsequently lead to the creation of the hydroxyl radical, a very destructive chemical entity. It has also been noted that the anthracyclines may have effects on signal transduction and effects at the cellular membrane [26]. Anthracyclines intercalate into DNA but it is unclear if this process is important in the cytotoxic effects of these drugs when used in the same concentrations as seen in vivo. Topoisomerase II (Topo II) is a nuclear enzyme that is responsible for the tertiary structure of DNA. One of the main roles for topo II is to control the amount of positive and negative supercoiling of DNA. In order to create alterations in the tertiary structure of the DNA, topo II binds to specific recognition sites and cleaves one phosphodiester bond on each strand of DNA. The broken strands are stabilized by topo II in a “cleavable complex.” While both strands of the DNA chain are broken another DNA chain can pass through the break before the two broken chains are relegated. This allows DNA to be knotted and unknotted. Investigations have shown that anthracyclines may work to stabilize this cleavable complex. If the cleavable complex is stabilized for too long then topo II may not be able to adequately religate the phosphodiester bonds. This leads to topo II associated DNA cleavage, which can be demonstrated at concentrations (10−8 ) that are well below the dissociation constant for the intercalation of anthracyclines in DNA [113]. It is also possible that the anthracyclines may work to not only stabilize the cleavable complex but also inactivate the catalytic activity of the enzyme. When the anthracyclines interact with topo II they act as chemically inert compounds, however the anthracyclines are chemically reactive compounds with complex redox chemistry [1]. One-electron reduction of the anthracyclines was initially described in in vitro systems [10] and was later shown to play a role in the cardiotoxicity that is seen with anthracyclines administration [44, 102]. It has also been suggested that the reduction of the anthracyclines may be responsible for some of the anti-neoplastic effects of the anthracyclines [43, 129]. Anthracyclines are able to undergo one and two electron reduction to create reactive compounds that can cause widespread damage to cellular components [25, 64, 114]. In the presence of

89

NADH or NADPH, flavoproteins can induce a oneelectron reduction of the anthracyclines, generating a reduced semi-quinone radical form. Oxygen allows this semiquinone to generate a superoxide anion [74]. This superoxide anion can then form hydrogen peroxide with another oxygen radical, leading to the creation of the hydroxyl radical in the presence of metal ions such as the iron found in myoglobin (Fig. 5.2). The hydroxyl radical is one of the most destructive chemical entities known. Doxorubicin has been shown to oxidize bases in chromatin which may provide a cytotoxic action for the drugs when they interact directly with DNA [2, 100]. Hydrogen peroxide and hence the hydroxyl free radical may also be created in normal tissue so there are cellular defenses against these species. The cardiotoxicity of the anthracyclines may partially be due to the lower levels of catalase in the heart as compared with other tissue. Anthracycline exposure causes changes in cardiac biochemistry which eventually leads to cumulative cardiotoxicity. These changes include alterations in calcium handling characterized by inhibition of calcium sequestration by the sarcoplasmic reticulum. Damage to the sarcoplasmic reticulum is postulated to be secondary to drug-induced free radical damage. Free radical damage is increased by inhibition of the cardiac tissues’ ability to detoxify free radicals by

Fig. 5.2 The reduction of doxorubicin to the semi-quinone and the subsequent oxidation back to doxorubicin creates the superoxide anion which can in turn react with hydrogen peroxide to create the oxygen free radical which can have broad destructive cellular effects

90

glutathione peroxidase, which is inhibited by anthracyclines [104]. It has been found that doxorubicin resistance in neoplastic cells is associated with increased glutathione (a sulfur containing short peptide that acts to inactivate free radicals) concentrations [120] which could potentially be reversed by decreasing the ability of the cells to neutralized free radicals. It has also been noted that transfection of cells with glutathione peroxidase induces doxorubicin resistance while antisense expression sensitizes the cells to doxorubicin [42, 143]. In addition to one-electron reductions two-electron reductions of the anthracyclines also exist. In these two electron reductions the sugar is lost and the deoxyaglycone, a non-cytotoxicly active metabolite is formed [1].

5.4 Pharmacokinetics Isolation and characterization of anthracyclines and their metabolites is greatly aided by their fluorescence and UV/visible absorption of the compounds allowing detection levels as low as 1 ng/ml. High Performance Liquid Chromatography (HPLC) can usually achieve separation using reversed phase columns and a solvent made with acetonitrile or methanol and an aqueous buffer at pH2–4 [71]. Anthracycline accumulation in cells can be measured using fluorescent microscopy or flow cytometry [90]. Since the fluorescence of the anthracyclines is quenched when the molecules intercalate in DNA it is possible to directly measure uptake in a cell suspension, as the fluorescence decreases in direct proportion to the amount of compound that is taken up [142]. The anthracyclines are usually administered intravenously, although intraperitoneal or intra-arterial routes may also be utilized for doxorubicin. The only anthracycline that is given orally is idarubicin. After oral administration of idarubicin, the amount of intact drug is higher under non-fasting conditions. The pharmacokinetics of idarubicinol (the 13-dihydro derivative of idarubicin) is not affected by food intake [49]. The extensive binding of these drugs to DNA and proteins, therefore the free drug pool, represents a fraction of the drug measured in both plasma and cells. Therefore, 75% of the drug in plasma is protein bound [61]. Although there is a high amount of

N. Coufal and L. Farnaes

protein binding, tissue plasma ratios of 10:1–500:1 are regularly observed due to the higher DNA content in tissue [137]. Doxorubicin and daunorubicin appear to cross the plasma membrane of cells through free diffusion of the non-ionized drug [110]. This becomes an issue because anthracyclines have pKa’s in the physiological range. Acidosis can therefore trap drug either in the intracellular or extracellular space depending on where the acidosis is concomitantly present. It has been noted that the pH can have a significant effect on the activity of the anthracyclines [54, 109]. Many solid tumors may create an internal acidic environment with a pH as low as 6 [150]. This would function to withhold anthracyclines from the cells, thereby maintain a more alkaline internal environment than the acidic extracellular fluid in the tumors [115]. In addition, the acidification of internal organelles may work to sequester the anthracyclines away from their targets within the cells [5]. The cytotoxic effect of the anthracyclines has been found to correlate with the area under the curve (AUC), not the peak drug levels. The myelosuppression that is often seen with the administration of the anthracyclines is also correlated with the area under the curve, but cardiotoxicity is correlated with peak drug levels. Since cytotoxic effect of the drug is determined by AUC there has been an interest in prolonging the infusion to reduce the incidence of cardiotoxicity. One study was able to limit the cardiotoxicity of doxorubicin by administering a prolonged 96 h infusion [81]. Nausea and vomiting were also greatly reduced through the use of this prolonged infusion. Doxorubicin disappears from the plasma in triexponential decay after bolus administration. The decay is characterized by three successive half lives of 3–5 min, 1–2 h, and 24–36 h [72, 97, 119, 146]. Idarubicin’s decay after an intravenous injection is best described by a biexponential model with two successive half lives of 20 min and 15–20 h [21, 139]. The pharmacokinetics of these drugs is dominated by its tissue binding. In the early distributive phase the drug levels fall rapidly as the drug gains access to all tissues except the brain. Generally, anthracyclines do not cross the blood brain barrier, however it has been reported that idarubicinol may be able to cross the blood brain barrier [118] but the CSF concentrations are very low (0.5 ng/ml). The majority of the drug bind to DNA throughout the body and therefore has a tissue

5

Anthracyclines and Anthracenediones

distribution profile that is consistent with tissue DNA content [144]. There is substantial interpatient variability and also significant intergender variability in drug metabolism. Studies have shown that men with normal hepatic function have approximately twice the clearance of doxorubicin (when given as a bolus) as women. This increased clearance was associated with a greater conversion of drug into its alcohol derivatives [40, 41]. The total plasma clearance of doxorubicin is approximately 30 l/h/m2 and its total volume of distribution at steady state is 800 l/m2 [119]. The total plasma clearance and volume of distribution for doxorubicin are the lowest for any of the anthracyclines, such that epirubicin has a total plasma clearance of 43.1 l/h/m2 and a volume of distribution of 1272 l/m2 , daunorubicin has a value of 95.0 l/h/m2 and 1334 l/m2 respectively, and idarubicin has respective values of 56 l/h/m2 and 1138 l/m2 [22, 116, 139]. Mitoxantrone, an anthracenedione, has a pharmacokinetic profile that is also characterized a triexponential decay with three successive half lives of 10 min, 1.6 h, and 23–42 h. This drug also distributes in high concentrations into tissue with the highest concentrations being found in the liver and bone marrow [3]. One of the most prevalent biotransformations of anthracyclines is reduction of the ketone at C-13 to yield 13-dihydro derivatives. The enzyme responsible for this reduction is a ubiquitous aldoketoreductase located in the cytoplasm of all cells and tissues with an especially high concentration in the liver, kidney, and RBC’s [52]. In vitro, the 13-dihydro derivatives are much less cytotoxic than their parent compounds with the exception of idarubicinol which is as active metabolite [125]. The majority of daunorubicin that is found in the plasma a few hours after a bolus injection is the alcohol metabolite daunorubinicol. Daunorubinicol has a longer half life than it’s parent drug and therefore may be responsible for the majority of the effect of this drug [57, 68]. It is possible that the 13-dihydro derivatives may be responsible for the largest part of the cardiotoxicity as well [57]. The aglycones (anthracyclines which have lost their sugar residue) are a cytotoxicly inactive metabolite that has been shown to be produced under anaerobic conditions in vitro using microsomal enzymes [8]. The deoxyglycones and their 13-dihydroderivatives are sometimes observed in the urine and plasma of patients, however their appearance is usually transient and unpredictable. Epirubicin can also form a β-O-glucuronide conjugate

91

in a metabolic pathway unique to humans [154]. The side chains of mitoxantrone undergo oxidation to yield the mono- and dicarboxylic acid form of the compound. Neither of these two forms have any cytotoxic activity [29]. Elimination of the anthracyclines occurs mainly through the biliary tract with urinary excretion barely exceeding 10% of the injected dose [141]. All of the blood metabolites that are commonly detected are also found in feces and in urine. Urine discoloration is possible due to the anthracycline chromophore. It has been noted that altered liver function can have profound effects on the elimination of both doxorubicin and epirubicin [23, 111]. Dose adjustments are suggested for both doxorubicin and epirubicin according to total bilirubin plasma levels with a reduction of 50% when bilirubinemia reaches 25 μM, and 100% when bilirubinemia reaches 50 μM [147]. Renal elimination is more important for idarubicin than for other anthracyclines and therefore a dose reduction is also recommended for patients with renal dysfunction [21]. Less than 10% of mitoxantrone is found in the urine of patients and only 20% can be accounted for in the stool. It is likely that the hepato-biliary system plays a role in the metabolism of this drug as several people have noted an extended half life in patients with compromised liver function [122, 131].

5.5 Clinical Uses Doxorubicin is widely used in the treatment of adult solid tumors of many types. It is the most broadly useful of the anthracyclines, having exhibited efficacy against carcincomas of the breast, ovary, bladder, stomach, and thyroid, as well as small-cell lung cancer, soft-tissue and osteogenous sarcoma, and numerous pediatric solid tumors. It also has proven useful in the treatment of hematopoietic malignancies such as leukemias, lymphomas (Hodgekin’s and nonHodgekin’s), and multiple myeloma [26]. Epirubicin has similar properties to doxorubicin, but its use is limited primarily to the treatment of solid tumors. Epirubicin has significantly less cardiotoxicity, but is also relatively less potent. Thus epirubicin is of limited utility, as there are currently other methods of lessening anthracycline induced cardiotoxicity without sacrificing efficacy. Daunorubicin and idarubicin

92

N. Coufal and L. Farnaes

are used primarily for the treatment of adult and childhood leukemias, although also useful for the treatment of lymphoma and breast cancer. Daunorubicin is routinely used for treatment of acute myelogenous leukemia (AML) and acute lymphocytic leukemia (ALL). Liposomal formulation of doxo- and daunorubicin have been utilized for treatment of Kaposi’s sarcoma. Key features of the anthracyclines are summarized in Table 5.1. Doxorubicin and daunorubicin are active over a wide range of doses and administration regimes, varying from monthly boli to weekly injections, to prolonged infusions [80, 81]. Additionally, the anthracyclines do not have any apparent negative interactions with other chemotherapeutic agents. While the clinically significant toxicities include myelosuppression, alopecia, and mucositis, by far the most significant and potentially dangerous toxicity of the anthracyclines is a cumulative cardiotoxicity. Once the mechanism of cardiotoxicity was revealed, an ironchelating agent with moderate antineoplastic activity was identified, dexrazoxane (ICRF-187), which has been shown to block this drug-induced cardiotoxicity in clinical trials. Myelosuppression has also

been ameliorated by co-administration of colonystimulating factors combined with peripheral blood progenitors. Altogether this has allowed for lesser dosing intervals, and greater dose intensity and duration [20, 95, 133]. The anthracyclines are generally administered intravenously, and are mostly sold as lyophilized powders or ready formulations of 2 mg/ml. Formulations vary from 10 to 200 mg for doxorubicin and epirubicin, and are marketed as 20 mg daunorubicin and 5 or 10 mg idarubicin product. Idarubicin can be administered orally as well, as 1, 5, 10, or 20 mg of drug. Generally in all situations these medications are further diluted in 5% glucose before administration to patients [26]. Although administration dosing regimes do not affect antitumor efficacy, it does alter normal tissue toxicity. Several alternative routes of administration have been investigated. Intraperitoneal administration of anthracyclines can also be valuable for the treatment of peritoneal ovarian metastases, as it targets the malignancy directly without extensive systemic effects [106]. Fluid exchange between the peritoneal fluid and plasma is low, on the order of 2–25 ml/min, such that doxorubicin has a half life in the peritoneal fluid of

Table 5.1 Key features of the anthracyclines Doxorubicin Epirubicin

Daunorubicin

Family Mechanism of action Standard Dose (mg/m2 )

Route of administration

Metabolism to 13-dihydro derivatives Elimination Terminal half-life (h) Principal Toxicity

Idarubicin

Mitoxantrone

Anthracycline Anthracycline Anthracycline Anthracycline Anthracenedione (1) Inhibit the nuclear enzyme DNA topoisomerase II by intercalating between the DNA bases and stabilizing the DNA-TopoII cleavage complex. (2) generate reactive oxygen intermediates (3) stimulate apoptosis 35–70 every Up to 120 every 30–45 per day, 8–15 per day, 12–14 every 3 weeks 3 weeks 3–5 days 3–5 days IV or 3 weeks or 12 30–50 per week ever 3 days for orally AML Intravenous mainly, Intravenous only Intravenous only Intravenous or oral Intravenous, also intraperitoneal intraperitoneal and intra-arterial Low Low High High N/A

Hepatic and 10% renal 20–30

Hepatic and 10% renal 18–24

Hepatic and 10% renal 15–18

Cardiomyopathy, Neutropenia, mucositis, alopecia

Cardiomyopathy, Neutropenia, mucositis, alopecia

Neutropenia, mucositis, alopecia, cardiomyopathy

80% in urine 12–16 Neutropenia, mucositis, alopecia, cardiomyopathy (less than doxorubicin)

Partially hepatic, partially renal 9 Less toxic than anthracyclines, especially less cardiotoxicity

5

Anthracyclines and Anthracenediones

approximately 2 h [36]. For the treatment of bladder cancer, intravesical anthracycline treatments have been well tolerated, with little systemic leakage [28, 98]. In addition, loco-regional administration of anthracyclines has been investigated, in order to increase intra-tumoral concentrations, and theoretically reduce the amount of systemic toxicity, especially cardiotoxicity. This route of administration is most effective for drugs which have high uptake in the target organ, and high total body clearance, so is best suited for doxorubicin. Intra-arterial administration has been utilized for head and neck cancer, limb sarcoma, bladder cancer, and breast carcinoma. However, these have not shown significant improvement over systemic administration [37]. In addition to novel routes of administration, numerous carriers for anthracyclines have been tested, endeavoring to increase the positive targeting of the drug to the tumor, or decrease inadvertent targeting of other organs, such as the heart. Liposomal formulations of the less lipophilic anthracyclines are currently marketed. These liposomes of duano- and doxorubicin are formulated as administration-ready formulations of 50 mg dauno- or 10 mg doxorubicin at 2 mg/mL. Research has shown decreased cardiotoxicity with liposomal administration of doxorubicin [149]. The current main use for liposomal formulations is in the treatment of AIDS related Kaposi’s sarcoma, although other uses are being investigated. In order to increase the dose of drug specifically to the tumor, lipiodol suspensions have also been employed. Lipiodol undergoes embolization in the tumor vasculature and reduces the arteriolar flow rate, such that drug accumulation is enhanced within the tumor [117]. A number of other conjugates are currently in early clinical trials. This notably includes doxorubicin-N-(2hydroxypropyl) methacrylamide copolymers of high molecular weight where the drug is bound to a polymer via an aminosugar. In preclinical testing this formulation cannot diffuse through cellular membranes until it is activated by proteolytic extracellular degradation on the tumor, thereby showing a high degree of tumor specificity, and reduced cardiotoxicity [47, 126]. Anthracycline dose modifications should be considered for some patients. Alterations in renal function do not appear to modify the pharmacokinetics of most anthracyclines, other than idarubicin. Patients with renal dysfunction (creatinine clearance <60 l/h) should received modified doses [21]. Liver

93

dysfunction, whether due to liver malignancies or not, often affects anthracycline elimination, especially of doxorubicin and epirubicin [21, 111]. Patients with significantly increased bilirubin should have 50 or 25% dose reductions. The anthracenedione mitoxantrone has exhibited efficacy towards breast and prostate cancer, as well as leukemias and lymphomas. It has a significantly reduced toxicity profile, making it preferable to the anthracyclines whenever possible. Decreased cardiotoxicity, nausea, vomiting, and extravasation injuries are noted [26]. However it is efficacious only towards a much narrower range of tumor types than the anthracyclines. Mitoxantrone is especially successful in the treatment of P388 leukemia, towards which is has yielded a 500% increase in life span and a significant number of cures [73]. Because of its reduced toxicity profile, mitoxantrone is preferable for use in an elderly population, such as in the treatment of hormone-refractory prostate cancer in a palliative setting [17, 94]. However, due to its decreased efficacy as compared to the anthracyclines, mitoxantrone is mainly useful in palliative situations and as part of a combination therapy for hematological malignancies.

5.6 Mechanism of Resistance Drug resistance to the anthracyclines develops through a plethora of different pathways, as varied as enhanced drug efflux, alterations to topoisomerase II, and changes in apoptotic signaling. The overexpression of multidrug resistance transporters is a common mechanism of resistance to a wide range of chemotherapeutic agents. Multidrug resistance is mediated by members of the ATP-binding cassette (ABC) transporter family, a large and varied family of transmembrane transporters which efflux large compounds from cells in an ATP dependent fashion. MDR (multidrug resistance protein, also known as P-gycloprotein) is a major component of anthracycline resistance [60, 63, 75], and mediates the cross-resistance phenotype which exists between the anthracyclines, vinca alkaloids, epipodophyllotoxins, and taxanes, among others [51]. The more lipophilic anthracyclines, such as idarubicin, are less susceptible to this cross resistance, almost certainly due to their more rapid cell reentry rather than any change

94

in cell extrusion characteristics [99]. There is clinical evidence that MDR mediates resistance in hematological and pediatric malignancies [89]. Increased expression of MDR can arise through multiple mechanisms, including gene amplification, and mutations allowing for increased MDR transcription [83, 105]. In most in vivo situations, increased RNA expression levels are detected, but it is unclear what mechanism has allowed for upregulation [51]. There are some tissues which endogenously exhibit high baseline levels of MDR expression, such as colonic mucosa, endothelial cells forming the blood-brain barrier, adrenal tissue, and bone marrow cells. Tumors derived from these tissues, such as renal, colon, and adrenal carcinomas, frequently exhibit high MDR expression as a result [26]. High level expression of MDR in AML or ALL patients is associated with an unfavorable prognosis [58, 91]. Although not necessarily true for all solid tumors, posttreatment upregulation of MDR expression is detected in patients who fail primary anthracycline therapy for leukemia and lymphoma [27, 62]. A second related family of transmembrane transporters, called MDR-related proteins (MRP), are postulated to also function in mediating anthracycline resistance. These proteins, which share approximately 15% homology with the MDR family, extrude foreign compounds after conjugation with glutathione [31]. Overexpression of MRP has been demonstrated in multiple tumor cell systems [48, 95]. Export of doxorubicin by MRP is as efficient as that by MDR [88]. One caveat is that no glutathione conjugate of doxorubicin has yet been identified. However, present research indicates there is intracellular sequestration of doxorubicin after glutathione conjugation, preventing its interaction with DNA in the nucleus [132]. There is some clinical evidence that MRP and MDR can function jointly in producing resistance in leukemia patients [82, 123]. Several other ATP-binding cassette transporters have also been implicated in resistance, such as breast cancer resistance protein (BCRP) [9, 112]. A second mechanism for anthracycline resistance in tumor cells involves alterations in topoisomerase II (topo II). Doxorubicin resistance in P388 and L1210 cells, as well as multiple other lung cancer and melanoma cell lines, is mediated by decreases in topo II activity [35, 134]. Alterations in topo II activity in vitro are demonstrated in tumor cultures treated with MDR and MRP inhibitors, usually a cyclosporine A

N. Coufal and L. Farnaes

analog. Although similar mechanisms have not yet been shown to mediate resistance in vivo, mechanisms for modifying topo II activity in culture occur by multiple pathways. One means of evading anthracycline induced apoptosis is downregulation of mRNA expression of topo II [107]. A second means of eluding anthracyclines is through point mutations in topo II which either decrease the binding affinity of the anthracyclines or prevent stabilization of the topo II – DNA cleavage complex [12]. Decreases in topo II gene copy number have also been documented [156]. A lowered level of free-radical formation and lipid peroxidation has been noted in numerous doxorubicinresistant cell lines, however current research indicates this is not a likely mechanism for cell resistance. There are considerable, often tissue-specific variations in the ability of cells to counter free-radical damage [24]. Rather, researchers postulate response to free radicals represents a generalized non-specific response to noxious compounds [13]. Lastly, since cells treated with anthracyclines ultimately die as a result of apoptosis, alterations in apoptotic signaling can lead to anthracycline resistance. Previously, overexpression of bcl-2 has been shown to mediate resistance, as do mutations in p53 [78, 79, 157]. Drug resistance to the anthracenediones, mitoxantrone, occurs via the same pathways as resistance towards the vinca alkaloids and the anthracyclines [15, 34, 70]. This is unsurprising considering their similarity as large bulky planar xenobiotics. Thus, MDR, MRP, and BCRP drug efflux channels figure prominently in mitoxantrone resistance, as do mutations in topo II function [76, 103, 121, 124].

5.7 Toxicity The common toxicities associated with anthracyclines and anthracenediones include myelosuppression, mucositis, cardiotoxicity, and extravasation injuries. Dose limitation is typically due to myelosuppression, whereas the length of treatment is limited by cumulative cardiotoxicity. Myelosuppression, alopecia, and mucositis occur frequently with a number of cytotoxic chemotherapeutic agents. This toxicity occurs as a result of the death of rapidly cycling cells, such as those of

5

Anthracyclines and Anthracenediones

the hair follicle, digestive mucosa, and bone marrow progenitors. Normally toxicity follows an acute course beginning 3–5 days after treatment, with maximal toxicity 7–10 days post treatment, and resolving rapidly thereafter. Doxorubicin causes mucositis more frequently than the other anthracyclines, such that mucositis can become the dose limiting toxicity in some patients. Nausea and vomiting are also frequent side effects of all anthracyclines, although are reportedly less frequent with liposomal formulations [4]. However, liposomal formulations are associated with increased rates of palmar-plantar erythrodysesthesia syndrome (PPES) as compared to traditional doxorubicin and daunorubicin. PPES is a painful skin toxicity also known as hand-foot syndrome. This syndrome is usually self-limited and resolves within a few weeks without medical intervention [69]. Extravasation injury results from local leakage of anthracyclines in the vicinity of the intravenous injection site, and is characterized by severe local injury that progresses over the course of weeks to months [26]. The drug binds to local tissues and can be detected for an extensive time post-injury, and makes the injury extremely difficult to treat [45, 135]. Tissue grafting is only feasible with extensive debridement, which should be undertaken with great care to prevent any infection in myelosuppressed patients [66]. Several courses of treatment have been employed, including ice, steroids, DMSO, bicarbonate, and recently a combination of dexrazoxane and subcutaneous granulocyte-macrophage colony-stimulating factor to promote wound healing [14, 39, 50]. Although the major dose limiting toxicity for the anthracyclines is usually bone marrow suppression, mucositis, or tumor drug-resistance, it can transpire that a patient’s exhibits cardiotoxicity while their tumor is still responsive to anthracycline treatment. This effect is most prominent with the treatment of breast cancer using doxorubicin. Children exhibit increased vulnerability to anthracycline cardiotoxicity,

95

limiting the use of doxorubicin in pediatric oncology [77]. Furthermore, increased cardiotoxicity is seen in combined therapy with the monoclonal antibody trastuzamab, which exhibits synergistic cardiotoxicity when combined with doxorubicin [130]. Trastuzamab is a monoclonal antibody directed against the HER2/neu oncoprotein, which is active in advanced breast cancer [30]. Cardiac toxicity is generally observed in patients administered a bolus dose of 45–60 mg/m2 every 21–28 days or a cumulative body dose greater than 450 mg/m2 doxorubicin or 900 mg/m2 daunorubicin [26]. Doxorubicin doses above 450 mg/m2 carry a risk of congestive heart failure of approximately 5%, varying from 1 to 10% [81]. Cumulative doses below 300 mg/m2 doxorubicin or 600 mg/m2 daunorubicin rarely exhibit cardiotoxicity, although it is possible to induce cardiotoxicity with only a single dose of either drug [152, 153]. Doses above 250 mg/m2 doxorubicin suggest subclinical reductions in ejection fraction which can still be easily identified clinically [32, 108]. Endocardial biopsy is the benchmark for describing cardiotoxicity, as biopsy’s exhibit characteristic features which correlate the pathology to the clinical cardiac toxicity [16, 18, 26] (Table 5.2). These studies show that damage is cumulative, and increases with each subsequent dose of anthracycline. Increasing drug administrations correlates with increased number of abnormal cardiac cells, and once high grade cardiomyopathy develops extensive diffuse myocardial fibrosis is also noted. Measurement of ejection fraction or electrocardiogram-gated radioisotopic cardiac pool can also be an accurate measure of cardiotoxicity and contractility [46]. It has been shown that changing from a bolus administration to a 96 h infusion or adding bexrazoxane will allow for additional anthracycline therapy with a decreased risk of cardiotoxicity [140]. A regime including higher than recommended cumulative doses should only be used in patients with

Table 5.2 Criteria for grading anthracycline cardiomyopathy Grade Criteria 0 Normal tissue 1 Scattered cells with myofibrillar loss and/or distended sarcoplasmic reticulum 2 Clusters of cells with myofibrillar loss and/or cytoplasmic vacuolization 3 Diffuse cell damage with total loss of contractile elements, nuclear degeneration, loss of mitochondria and organelles. Adapted from Chabner and Longo [26]

96

anthracycline responsive tumors who have exhausted other treatment options. Many patients who exhibit cardiotoxicity can be cared for using standard measures and stabilized at somewhat lower levels of cardiac function [96]. However, patients are still at increased risk of mortality due to congestive heart failure, which can manifest significantly after the conclusion of treatment. Subsequent illness can trigger congestive heart failure, and in the case of children treated with anthracyclines congestive heart failure can develop decades after treatment. This remains true even in patients managed with long term angiotensin-converting enzyme inhibitors (ACE inhibitors) [84, 96]. Although cardiotoxicity is usually cumulative, it can also occur acutely in response to doxorubicin therapy. Acute syndromes typically present as arrhythmias, including heart block. More rarely they can manifest as a potentially lethal pericarditis-myocarditis syndrome characterized by fever, pericarditis, and congestive heart failure [19]. Treatment with H1 and H2 blockers might be advantageous, although clinical trials have not been conducted due to the rarity of their presentation [19]. In order to minimize cumulative cardiotoxicity, atrisk patients need to be identified and monitored, and the cardioprotective agent dexrazoxane can be administered. Risk factors which greatly increase the risk for patients to develop cardiac toxicity are pre-existing hypertension, concomitant cardiac disease, or cardiac/mediastinal radiation. Contrary to efficacy, which is a function of area under the curve (the total amount of anthracycline exposure), cardiac toxicity is a function of peak levels of anthracycline. Therefore, administering the drug weekly or as a continuous infusion rather than a monthly bolus significantly decreases the rate of cardiac toxicity [80, 145]. Dexrazoxane has been shown to be safe, effective, and does not decrease the efficacy of the co-administered anthracycline. In clinical trials dexrazoxane decreases the risk of multiple markers of cardiac disease, including increased injection fraction and decreased abnormal cardiac pathology, and leads to a higher tolerance of cumulative doses of anthracycline [138, 140]. This effect was observed for doxorubicin, and also epirubicin and daunorubicin [151]. Pediatric cases greatly benefit from the use of the cardioprotective agent dexrazoxane, as do cases of breast cancer when combined with prolonged infusion schedules [85].

N. Coufal and L. Farnaes

The primary advantage of the anthracenedione, mitoxantrone, is the reduced incidence of cardiotoxicity, as well as decreased rates of alopecia, nausea, and vomiting in comparison with the anthracyclines. Other toxicities include leucopenia similar to that of anthracyclines. Those patients who exhibit cardiotoxicity have often undergone a primary unsuccessful treatment with doxorubicin [148]. Patients who also suffer from multiple sclerosis have an increased risk of developing mitoxantrone-induced cardiotoxicity, such that 5% of patients receiving > 100 mg/m2 develop decreases in LV ejection fraction [55, 59]. Patients with prior chest irradiation, prior cardiac disease, or prior anthracycline exposure are at increased risk [65, 127]. A minor side effect of mitoxantrone is a blue discoloration of the sclera, fingernails, and urine [136].

5.8 Drug Interactions Only a few medications are known to interact with the anthracyclines. The anthracyclines interact with some chemotherapeutic agents, for instance coadministration of doxorubicin and etoposide has been shown to decrease doxorubicin clearance at least twofold [33]. Additionally, concomitant administration of paclitaxel and doxorubicin leads to non-linear disposition of both drugs, likely as a result of competition for biliary secretion [56]. Doxorubicin, daunorubicin, and the anthracenediones mitoxantrone can cause radiosensitization of normal tissues. This is significant in cases of mediastinal or chest wall radiation therapy for breast cancer or Hodgekin’s lymphoma. A dose of 2,000 cGy given in 200 cGy/day fractions results in a two fold increase in cardiotoxicity. In such situations only half the dose of doxorubicin should be administered. Daunorubicin binds to heparin leading to aggregate formation, such that co-administration can lead to an increase in the rate of daunorubicin clearance [26]. There is evidence that mitoxantrone acts synergistically with arabinosylcytosine, and is therefore frequently used in combination to treat acute nonlymphocytic leukemia [65]. Combining doxorubicin or epirubicin with the cardioprotectant dexrazoxane (ICRF-187) does not seem to alter their pharmacokinetics [67]. Numerous pharmaceuticals have been shown to reverse MDR associated resistance, such as

5

Anthracyclines and Anthracenediones

cyclosporine A, verapamil, and quinine [53, 92]. Clinical trials investigating the efficacy and feasibility of these medications in reversal of MDR resistance have had mixed results [11, 87, 93, 155]. These studies have shown that MDR reversal strategies are most effective for leukemias and lymphomas, but are generally hampered by associated toxicity of the reversal agent at therapeutic doses. The pharmacokinetics of the reversal agent can alter clearance of the anthracyclines, such that concomitant administration of cyclosporine with either doxorubicin or daunorubicin decreases clearance of either. Despite these caveats, a large randomized study of AML patients established that cyclosporine A combined with daunorubicin as part of a standard daunorubicin and cytosine arabinoside regimen significantly improved overall survival and relapse rates in patients [86]. The changes in anthracycline clearance which occur with MDR reversal agents indicates a different administration strategy should be considered. Sikic et al. [128] has proposed that instead of administering standard anthracycline doses combined with an increasing dose of reversal agent, instead it would be wise to administer the maximally tolerated reversal agent dose, and then gradually increase anthracycline doses to predetermined tolerance levels (e.g., myelosuppression tolerance limits).

References 1. Abdella BR, Fisher J (1985) A chemical perspective on the anthracycline antitumor antibiotics. Environ Health Perspect 64:4–18 2. Akman SA, Doroshow JH, Burke TG, Dizdaroglu M (1992) DNA base modifications induced in isolated human chromatin by NADH dehydrogenasecatalyzed reduction of doxorubicin. Biochemistry 31(13): 3500–3506 3. Alberts DS, Goldman R, Xu MJ, Dorr RT, Quinn J, Welch K et al (1996) Disposition and metabolism of topically administered alpha-tocopherol acetate: a common ingredient of commercially available sunscreens and cosmetics. Nutr Cancer 26(2):193–201 4. Alexopoulos A, Karamouzis MV, Stavrinides H, Ardavanis A, Kandilis K, Stavrakakis J et al (2004) Phase II study of pegylated liposomal doxorubicin (Caelyx) and docetaxel as first-line treatment in metastatic breast cancer. Ann Oncol 15(6):891–895 5. Altan N, Chen Y, Schindler M, Simon SM (1998) Defective acidification in human breast tumor cells and implications for chemotherapy. J Exp Med 187(10): 1583–1598

97 6. Arcamone F (1981) Doxorubicin: anticancer antibiotics. Academic, New York 7. Arcamone F, Cassinelli G, Fantini G, Grein A, Orezzi P, Pol C et al (1969) Adriamycin 14-hydroxydaunomycin, a new antitumor antibiotic from S. peucetius var. caesius. Biotechnol Bioeng 11(6):1101–1110 8. Asbell MA, Schwartzbach E, Bullock FJ, Yesair DW (1972) Daunomycin and adriamycin metabolism via reductive glycosidic cleavage. J Pharmacol Exp Ther 182(1):63–69 9. Awasthi S, Singhal SS, Srivastava SK, Zimniak P, Bajpai KK, Saxena M et al (1994) Adenosine triphosphatedependent transport of doxorubicin, daunomycin, and vinblastine in human tissues by a mechanism distinct from the P-glycoprotein. J Clin Invest 93(3): 958–965 10. Bachur NR, Gordon SL, Gee MV (1978) A general mechanism for microsomal activation of quinone anticancer agents to free radicals. Cancer Res 38(6):1745–1750 11. Bassan R, Lerede T, Borleri G, Chiodini B, Rossi A, Buelli M et al (2002) Phase I trial with escalating doses of idarubicin and multidrug resistance reversal by short-course cyclosporin A, sequential high-dose cytosine arabinoside, and granulocyte colony-stimulating factor for adult patients with refractory acute leukemia. Haematologica 87(3):257–263 12. Beck WT, Danks MK, Wolverton JS, Chen M, Granzen B, Kim R et al (1994) Resistance of mammalian tumor cells to inhibitors of DNA topoisomerase II. Adv Pharmacol 29B:145–169 13. Benchekroun MN, Pourquier P, Schott B, Robert J (1993) Doxorubicin-induced lipid peroxidation and glutathione peroxidase activity in tumor cell lines selected for resistance to doxorubicin. Eur J Biochem 211(1–2): 141–146 14. Bertelli G, Gozza A, Forno GB, Vidili MG, Silvestro S, Venturini M et al (1995) Topical dimethylsulfoxide for the prevention of soft tissue injury after extravasation of vesicant cytotoxic drugs: a prospective clinical study. J Clin Oncol 13(11):2851–2855 15. Bhalla K, Hindenburg A, Taub RN, Grant S (1985) Isolation and characterization of an anthracyclineresistant human leukemic cell line. Cancer Res 45(8): 3657–3662 16. Billingham ME, Mason JW, Bristow MR, Daniels JR (1978) Anthracycline cardiomyopathy monitored by morphologic changes. Cancer Treat Rep 62(6):865–872 17. Bloomfield DJ, Krahn MD, Neogi T, Panzarella T, Smith TJ, Warde P et al (1998) Economic evaluation of chemotherapy with mitoxantrone plus prednisone for symptomatic hormone-resistant prostate cancer: based on a Canadian randomized trial with palliative end points. J Clin Oncol 16(6):2272–2279 18. Bristow MR, Minobe WA, Billingham ME, Marmor JB, Johnson GA, Ishimoto BM et al (1981) Anthracyclineassociated cardiac and renal damage in rabbits. Evidence for mediation by vasoactive substances. Lab Invest 45(2):157–168 19. Bristow MR, Thompson PD, Martin RP, Mason JW, Billingham ME, Harrison DC (1978) Early anthracycline cardiotoxicity. Am J Med 65(5):823–832

98 20. Bronchud MH, Howell A, Crowther D, Hopwood P, Souza L, Dexter TM (1989) The use of granulocyte colony-stimulating factor to increase the intensity of treatment with doxorubicin in patients with advanced breast and ovarian cancer. Br J Cancer 60(1):121–125 21. Camaggi CM, Comparsi R, Strocchi E, Testoni F, Angelelli B, Pannuti F (1988) Epirubicin and doxorubicin comparative metabolism and pharmacokinetics. A crossover study. Cancer Chemother Pharmacol 21(3):221–228 22. Camaggi CM, Strocchi E, Carisi P, Martoni A, Tononi A, Guaraldi M et al (1992) Idarubicin metabolism and pharmacokinetics after intravenous and oral administration in cancer patients: a crossover study. Cancer Chemother Pharmacol 30(4):307–316 23. Camaggi CM, Strocchi E, Martoni A, Angelelli B, Comparsi R, Pannuti F (1985) Epirubicin plasma and blood pharmacokinetics after single i.v. bolus in advanced cancer patients. Drugs Exp Clin Res 11(4):285–294 24. Capranico G, Babudri N, Casciarri G, Dolzani L, Gambetta RA, Longoni E et al (1986) Lack of effect of glutathione depletion on cytotoxicity, mutagenicity and DNA damage produced by doxorubicin in cultured cells. Chem Biol Interact 57(2):189–201 25. Carmichael AJ, Riesz P (1985) Photoinduced reactions of anthraquinone antitumor agents with peptides and nucleic acid bases: an electron spin resonance and spin trapping study. Arch Biochem Biophys 237(2):433–444 26. Chabner B, Longo DL (2006) Cancer chemotherapy and biotherapy: principles and practice, 4th edn. Lippincott Williams & Wilkins, Philadelphia 27. Chabner BA, Fojo A (1989) Multidrug resistance: P-glycoprotein and its allies–the elusive foes. J Natl Cancer Inst 81(12):910–913 28. Chai M, Wientjes MG, Badalament RA, Burgers JK, Au JL (1994) Pharmacokinetics of intravesical doxorubicin in superficial bladder cancer patients. J Urol 152(2 Pt 1): 374–378 29. Chiccarelli FS, Morrison JA, Cosulich DB, Perkinson NA, Ridge DN, Sum FW et al (1986) Identification of human urinary mitoxantrone metabolites. Cancer Res 46(9):4858–4861 30. Cobleigh MA (1998) Hormone replacement therapy and nonhormonal control of menopausal symptoms in breast cancer survivors. Cancer Treat Res 94:209–230 31. Cole SP, Bhardwaj G, Gerlach JH, Mackie JE, Grant CE, Almquist KC et al (1992) Overexpression of a transporter gene in a multidrug-resistant human lung cancer cell line. Science 258(5088):1650–1654 32. Cottin Y, Touzery C, Dalloz F, Coudert B, Toubeau M, Riedinger A et al (1998) Comparison of epirubicin and doxorubicin cardiotoxicity induced by low doses: evolution of the diastolic and systolic parameters studied by radionuclide angiography. Clin Cardiol 21(9):665–670 33. Cummings J, Forrest GJ, Cunningham D, Gilchrist NL, Soukop M (1986) Influence of polysorbate 80 (Tween 80) and etoposide (VP-16–213) on the pharmacokinetics and urinary excretion of adriamycin and its metabolites in cancer patients. Cancer Chemother Pharmacol 17(1): 80–84 34. Dalton WS, Cress AE, Alberts DS, Trent JM (1988) Cytogenetic and phenotypic analysis of a human colon

N. Coufal and L. Farnaes

35.

36.

37.

38.

39.

40.

41.

42. 43.

44.

45.

46.

47.

48.

49.

carcinoma cell line resistant to mitoxantrone. Cancer Res 48(7):1882–1888 Deffie AM, Batra JK, Goldenberg GJ (1989) Direct correlation between DNA topoisomerase II activity and cytotoxicity in adriamycin-sensitive and -resistant P388 leukemia cell lines. Cancer Res 49(1):58–62 Demicheli R, Bonciarelli G, Jirillo A, Foroni R, Petrosino L, Targa L et al (1985) Pharmacologic data and technical feasibility of intraperitoneal doxorubicin administration. Tumori 71(1):63–68 Didolkar MS, Kanter PM, Baffi RR, Schwartz HS, Lopez R (1978) Comparison of regional versus systemic chemotherapy with adriamycin. Ann Surg 187(3): 332–336 Dimarco A, Gaetani M, Orezzi P, Scarpinato BM, Silvestrini R, Soldati M et al (1964) ‘Daunomycin’, a new antibiotic of the rhodomycin group. Nature 201: 706–707 Disa JJ, Chang RR, Mucci SJ, Goldberg NH (1998) Prevention of adriamycin-induced full-thickness skin loss using hyaluronidase infiltration. Plast Reconstr Surg 101(2):370–374 Dobbs NA, Twelves CJ (1998) What is the effect of adjusting epirubicin doses for body surface area? Br J Cancer 78(5):662–666 Dobbs NA, Twelves CJ, Gillies H, James CA, Harper PG, Rubens RD (1995) Gender affects doxorubicin pharmacokinetics in patients with normal liver biochemistry. Cancer Chemother Pharmacol 36(6):473–476 Doroshow J, Esworthy R, Chu F (1993) Structure and function of glutathione transferases. CRC, Boca Raton Doroshow JH (1986) Role of hydrogen peroxide and hydroxyl radical formation in the killing of Ehrlich tumor cells by anticancer quinones. Proc Natl Acad Sci USA 83(12):4514–4518 Doroshow JH, Locker GY, Myers CE (1980) Enzymatic defenses of the mouse heart against reactive oxygen metabolites: alterations produced by doxorubicin. J Clin Invest 65(1):128–135 Dorr RT, Dordal MS, Koenig LM, Taylor CW, McCloskey TM (1989) High levels of doxorubicin in the tissues of a patient experiencing extravasation during a 4-day infusion. Cancer 64(12):2462–2464 Dresdale A, Bonow RO, Wesley R, Palmeri ST, Barr L, Mathison D et al (1983) Prospective evaluation of doxorubicin-induced cardiomyopathy resulting from postsurgical adjuvant treatment of patients with soft tissue sarcomas. Cancer 52(1):51–60 Duncan R (2007) Designing polymer conjugates as lysosomotropic nanomedicines. Biochem Soc Trans 35(Pt 1): 56–60 Eijdems EW, Zaman GJ, de Haas M, Versantvoort CH, Flens MJ, Scheper RJ et al (1995) Altered MRP is associated with multidrug resistance and reduced drug accumulation in human SW-1573 cells. Br J Cancer 72(2):298–306 Eksborg S, Soderberg M, Nilsson B, Antila K (1990) Plasma pharmacokinetics of Idarubicin and its 13-hydroxymetabolite after intravenous and oral administration under fasting and non-fasting conditions. Acta Oncol 29(7):921–925

5

Anthracyclines and Anthracenediones 50. El-Saghir N, Otrock Z, Mufarrij A, Abou-Mourad Y, Salem Z, Shamseddine A et al (2004) Dexrazoxane for anthracycline extravasation and GM-CSF for skin ulceration and wound healing. Lancet Oncol 5(5):320–321 51. Endicott JA, Ling V (1989) The biochemistry of Pglycoprotein-mediated multidrug resistance. Annu Rev Biochem 58:137–171 52. Felsted RL, Richter DR, Bachur NR (1977) Rat liver aldehyde reductase. Biochem Pharmacol 26(12):1117–1124 53. Georges E, Sharom FJ, Ling V (1990) Multidrug resistance and chemosensitization: therapeutic implications for cancer chemotherapy. Adv Pharmacol 21:185–220 54. Gerweck LE, Kozin SV, Stocks SJ (1999) The pH partition theory predicts the accumulation and toxicity of doxorubicin in normal and low-pH-adapted cells. Br J Cancer 79(5–6):838–842 55. Ghalie RG, Edan G, Laurent M, Mauch E, Eisenman S, Hartung HP et al (2002) Cardiac adverse effects associated with mitoxantrone (Novantrone) therapy in patients with MS. Neurology 59(6):909–913 56. Gianni L, Vigano L, Locatelli A, Capri G, Giani A, Tarenzi E et al (1997) Human pharmacokinetic characterization and in vitro study of the interaction between doxorubicin and paclitaxel in patients with breast cancer. J Clin Oncol 15(5):1906–1915 57. Gil P, Favre R, Durand A, Iliadis A, Cano JP, Carcassonne Y (1983) Time dependency of adriamycin and adriamycinol kinetics. Cancer Chemother Pharmacol 10(2): 120–124 58. Goasguen JE, Dossot JM, Fardel O, Le Mee F, Le Gall E, Leblay R et al (1993) Expression of the multidrug resistance-associated P-glycoprotein (P-170) in 59 cases of de novo acute lymphoblastic leukemia: prognostic implications. Blood 81(9):2394–2398 59. Gonsette RE (2003) Mitoxantrone in progressive multiple sclerosis: when and how to treat? J Neurol Sci 206(2):203–208 60. Gottesman MM, Pastan I (1993) Biochemistry of multidrug resistance mediated by the multidrug transporter. Annu Rev Biochem 62:385–427 61. Greene RF, Collins JM, Jenkins JF, Speyer JL, Myers CE (1983) Plasma pharmacokinetics of adriamycin and adriamycinol: implications for the design of in vitro experiments and treatment protocols. Cancer Res 43(7): 3417–3421 62. Grogan TM, Spier CM, Salmon SE, Matzner M, Rybski J, Weinstein RS et al (1993) P-glycoprotein expression in human plasma cell myeloma: correlation with prior chemotherapy. Blood 81(2):490–495 63. Gros P, Ben Neriah YB, Croop JM, Housman DE (1986) Isolation and expression of a complementary DNA that confers multidrug resistance. Nature 323(6090): 728–731 64. Harris RN, Doroshow JH (1985) Effect of doxorubicinenhanced hydrogen peroxide and hydroxyl radical formation on calcium sequestration by cardiac sarcoplasmic reticulum. Biochem Biophys Res Commun 130(2): 739–745 65. Heinemann V, Murray D, Walters R, Meyn RE, Plunkett W (1988) Mitoxantrone-induced DNA damage in leukemia cells is enhanced by treatment

99

66.

67.

68.

69.

70.

71.

72.

73.

74.

75.

76.

77. 78.

79.

80.

with high-dose arabinosylcytosine. Cancer Chemother Pharmacol 22(3):205–210 Heitmann C, Durmus C, Ingianni G (1998) Surgical management after doxorubicin and epirubicin extravasation. J Hand Surg [Br] 23(5):666–668 Hochster H, Liebes L, Wadler S, Oratz R, Wernz JC, Meyers M et al (1992) Pharmacokinetics of the cardioprotector ADR-529 (ICRF-187) in escalating doses combined with fixed-dose doxorubicin. J Natl Cancer Inst 84(22):1725–1730 Huffman DH, Bachur NR (1972) Daunorubicin metabolism in acute myelocytic leukemia. Blood 39(5): 637–643 Hui YF, Cortes JE (2000) Palmar-plantar erythrodysesthesia syndrome associated with liposomal daunorubicin. Pharmacotherapy 20(10):1221–1223 Inaba M, Nagashima K, Sakurai Y (1984) Crossresistance of vincristine-resistant sublines of P388 leukemia to mitoxantrone with special emphasis on the relationship between in vitro and in vivo cross-resistance. Gann 75(7):625–630 Israel M, Pegg WJ, Wilkinson PM (1978) Urinary anthracycline metabolites from mice treated with adriamycin and N-trifluoroacetyladriamycin-14-valerate. J Pharmacol Exp Ther 204(3):696–701 Jacquet JM, Bressolle F, Galtier M, Bourrier M, Donadio D, Jourdan J et al (1990) Doxorubicin and doxorubicinol: intra- and inter-individual variations of pharmacokinetic parameters. Cancer Chemother Pharmacol 27(3):219–225 Johnson RK, Zee-Cheng RK, Lee WW, Acton EM, Henry DW, Cheng CC (1979) Experimental antitumor activity of aminoanthraquinones. Cancer Treat Rep 63(3): 425–439 Kalyanaraman B, Morehouse KM, Mason RP (1991) An electron paramagnetic resonance study of the interactions between the adriamycin semiquinone, hydrogen peroxide, iron-chelators, and radical scavengers. Arch Biochem Biophys 286(1):164–170 Kartner N, Riordan JR, Ling V (1983) Cell surface P-glycoprotein associated with multidrug resistance in mammalian cell lines. Science 221(4617):1285–1288 Kozin SV, Gerweck LE (1998) Cytotoxicity of weak electrolytes after the adaptation of cells to low pH: role of the transmembrane pH gradient. Br J Cancer 77(10): 1580–1585 Kremer LC, Caron HN (2004) Anthracycline cardiotoxicity in children. N Engl J Med 351(2):120–121 Kuhl JS, Krajewski S, Duran GE, Reed JC, Sikic BI (1997) Spontaneous overexpression of the long form of the Bcl-X protein in a highly resistant P388 leukaemia. Br J Cancer 75(2):268–274 Lavie Y, Cao H, Volner A, Lucci A, Han TY, Geffen V et al (1997) Agents that reverse multidrug resistance, tamoxifen, verapamil, and cyclosporin A, block glycosphingolipid metabolism by inhibiting ceramide glycosylation in human cancer cells. J Biol Chem 272(3):1682–1687 Legha SS, Benjamin RS, Mackay B, Ewer M, Wallace S, Valdivieso M et al (1982) Reduction of doxorubicin cardiotoxicity by prolonged continuous intravenous infusion. Ann Intern Med 96(2):133–139

100 81. Legha SS, Benjamin RS, Mackay B, Yap HY, Wallace S, Ewer M et al (1982) Adriamycin therapy by continuous intravenous infusion in patients with metastatic breast cancer. Cancer 49(9):1762–1766 82. Legrand O, Simonin G, Beauchamp-Nicoud A, Zittoun R, Marie JP (1999) Simultaneous activity of MRP1 and Pgp is correlated with in vitro resistance to daunorubicin and with in vivo resistance in adult acute myeloid leukemia. Blood 94(3):1046–1056 83. Lemontt JF, Azzaria M, Gros P (1988) Increased mdr gene expression and decreased drug accumulation in multidrug-resistant human melanoma cells. Cancer Res 48(22):6348–6353 84. Lipshultz SE, Lipsitz SR, Sallan SE, Simbre VC 2nd, Shaikh SL, Mone SM et al (2002) Long-term enalapril therapy for left ventricular dysfunction in doxorubicintreated survivors of childhood cancer. J Clin Oncol 20(23):4517–4522 85. Lipshultz SE, Rifai N, Dalton VM, Levy DE, Silverman LB, Lipsitz SR et al (2004) The effect of dexrazoxane on myocardial injury in doxorubicin-treated children with acute lymphoblastic leukemia. N Engl J Med 351(2): 145–153 86. List AF, Kopecky KJ, Willman CL, Head DR, Persons DL, Slovak ML et al (2001) Benefit of cyclosporine modulation of drug resistance in patients with poor-risk acute myeloid leukemia: a Southwest Oncology Group study. Blood 98(12):3212–3220 87. Lum BL, Fisher GA, Brophy NA, Yahanda AM, Adler KM, Kaubisch S et al (1993) Clinical trials of modulation of multidrug resistance. Pharmacokinetic and pharmacodynamic considerations. Cancer 72(11 Suppl):3502–3514 88. Marbeuf-Gueye C, Broxterman HJ, Dubru F, Priebe W, Garnier-Suillerot A (1998) Kinetics of anthracycline efflux from multidrug resistance protein-expressing cancer cells compared with P-glycoprotein-expressing cancer cells. Mol Pharmacol 53(1):141–147 89. Marie JP (1995) P-glycoprotein in adult hematologic malignancies. Hematol Oncol Clin North Am 9(2): 239–249 90. Marie JP, Faussat-Suberville AM, Zhou D, Zittoun R (1993) Daunorubicin uptake by leukemic cells: correlations with treatment outcome and mdr1 expression. Leukemia 7(6):825–831 91. Marie JP, Zittoun R, Sikic BI (1991) Multidrug resistance (mdr1) gene expression in adult acute leukemias: correlations with treatment outcome and in vitro drug sensitivity. Blood 78(3):586–592 92. Merlin JL, Guerci A, Marchal S, Missoum N, Ramacci C, Humbert JC et al (1994) Comparative evaluation of S9788, verapamil, and cyclosporine A in K562 human leukemia cell lines and in P-glycoprotein-expressing samples from patients with hematologic malignancies. Blood 84(1):262–269 93. Miller TP, Grogan TM, Dalton WS, Spier CM, Scheper RJ, Salmon SE (1991) P-glycoprotein expression in malignant lymphoma and reversal of clinical drug resistance with chemotherapy plus high-dose verapamil. J Clin Oncol 9(1):17–24 94. Moore MJ, Osoba D, Murphy K, Tannock IF, Armitage A, Findlay B et al (1994) Use of palliative end points

N. Coufal and L. Farnaes

95.

96.

97.

98.

99.

100.

101.

102.

103.

104.

105.

106.

107.

to evaluate the effects of mitoxantrone and low-dose prednisone in patients with hormonally resistant prostate cancer. J Clin Oncol 12(4):689–694 Moran E, Cleary I, Larkin AM, Amhlaoibh RN, Masterson A, Scheper RJ et al (1997) Co-expression of MDR-associated markers, including P-170, MRP and LRP and cytoskeletal proteins, in three resistant variants of the human ovarian carcinoma cell line OAW42. Eur J Cancer 33(4):652–660 Moreb JS, Oblon DJ (1992) Outcome of clinical congestive heart failure induced by anthracycline chemotherapy. Cancer 70(11):2637–2641 Mross K, Maessen P, van der Vijgh WJ, Bogdanowicz JF, Kurth KH, Pinedo HM (1987) Absorption of epidoxorubicin after intravesical administration in patients with in situ transitional cell carcinoma of the bladder. Eur J Cancer Clin Oncol 23(5):505–508 Mross K, Maessen P, van der Vijgh WJ, Gall H, Boven E, Pinedo HM (1988) Pharmacokinetics and metabolism of epidoxorubicin and doxorubicin in humans. J Clin Oncol 6(3):517–526 Mulder HS, Dekker H, Pinedo HM, Lankelma J (1995) The P-glycoprotein-mediated relative decrease in cytosolic free drug concentration is similar for several anthracyclines with varying lipophilicity. Biochem Pharmacol 50(7):967–974 Muller I, Jenner A, Bruchelt G, Niethammer D, Halliwell B (1997) Effect of concentration on the cytotoxic mechanism of doxorubicin – apoptosis and oxidative DNA damage. Biochem Biophys Res Commun 230(2):254–257 Murdock KC, Child RG, Fabio PF, Angier RB, Wallace RE, Durr FE et al (1979) Antitumor agents. 1. 1,4Bis[(aminoalkyl)amino]-9,10-anthracenediones. J Med Chem 22(9):1024–1030 Myers CE, McGuire WP, Liss RH, Ifrim I, Grotzinger K, Young RC (1977) Adriamycin: the role of lipid peroxidation in cardiac toxicity and tumor response. Science 197(4299):165–167 Nakagawa M, Schneider E, Dixon KH, Horton J, Kelley K, Morrow C et al (1992) Reduced intracellular drug accumulation in the absence of P-glycoprotein (mdr1) overexpression in mitoxantrone-resistant human MCF-7 breast cancer cells. Cancer Res 52(22):6175–6181 Nakano E, Takeshige K, Toshima Y, Tokunaga K, Minakami S (1989) Oxidative damage in selenium deficient hearts on perfusion with adriamycin: protective role of glutathione peroxidase system. Cardiovasc Res 23(6):498–504 Noonan KE, Beck C, Holzmayer TA, Chin JE, Wunder JS, Andrulis IL et al (1990) Quantitative analysis of MDR1 (multidrug resistance) gene expression in human tumors by polymerase chain reaction. Proc Natl Acad Sci USA 87(18):7160–7164 Ozols RF, Young RC, Speyer JL, Sugarbaker PH, Greene R, Jenkins J et al (1982) Phase I and pharmacological studies of adriamycin administered intraperitoneally to patients with ovarian cancer. Cancer Res 42(10): 4265–4269 Patel S, Sprung AU, Keller BA, Heaton VJ, Fisher LM (1997) Identification of yeast DNA topoisomerase II mutants resistant to the antitumor drug doxorubicin:

5

Anthracyclines and Anthracenediones

108.

109.

110.

111.

112.

113.

114.

115.

116.

117.

118.

119.

120.

121.

implications for the mechanisms of doxorubicin action and cytotoxicity. Mol Pharmacol 52(4):658–666 Perez EA, Suman VJ, Davidson NE, Kaufman PA, Martino S, Dakhil SR et al (2004) Effect of doxorubicin plus cyclophosphamide on left ventricular ejection fraction in patients with breast cancer in the North Central Cancer Treatment Group N9831 Intergroup Adjuvant Trial. J Clin Oncol 22(18):3700–3704 Peterson C, Baurain R, Trouet A (1980) The mechanism for cellular uptake, storage and release of daunorubicin. Studies on fibroblasts in culture. Biochem Pharmacol 29(12):1687–1692 Peterson C, Trouet A (1978) Transport and storage of daunorubicin and doxorubicin in cultured fibroblasts. Cancer Res 38(12):4645–4649 Piscitelli SC, Rodvold KA, Rushing DA, Tewksbury DA (1993) Pharmacokinetics and pharmacodynamics of doxorubicin in patients with small cell lung cancer. Clin Pharmacol Ther 53(5):555–561 Plasschaert SL, van der Kolk DM, de Bont ES, Kamps WA, Morisaki K, Bates SE et al (2003) The role of breast cancer resistance protein in acute lymphoblastic leukemia. Clin Cancer Res 9(14):5171–5177 Potmesil M, Kirschenbaum S, Israel M, Levin M, Khetarpal VK, Silber R (1983) Relationship of adriamycin concentrations to the DNA lesions induced in hypoxic and euoxic L1210 cells. Cancer Res 43(8):3528–3533 Praet M, Laghmiche M, Pollakis G, Goormaghtigh E, Ruysschaert JM (1986) In vivo and in vitro modifications of the mitochondrial membrane induced by 4 Epi-adriamycin. Biochem Pharmacol 35(17): 2923–2928 Raghunand N, He X, van Sluis R, Mahoney B, Baggett B, Taylor CW et al (1999) Enhancement of chemotherapy by manipulation of tumour pH. Br J Cancer 80(7):1005–1011 Rahman A, Goodman A, Foo W, Harvey J, Smith FP, Schein PS (1984) Clinical pharmacology of daunorubicin in phase I patients with solid tumors: development of an analytical methodology for daunorubicin and its metabolites. Semin Oncol 11(4 Suppl 3):36–44 Raoul JL, Heresbach D, Bretagne JF, Ferrer DB, Duvauferrier R, Bourguet P et al (1992) Chemoembolization of hepatocellular carcinomas. A study of the biodistribution and pharmacokinetics of doxorubicin. Cancer 70(3):585–590 Reid JM, Pendergrass TW, Krailo MD, Hammond GD, Ames MM (1990) Plasma pharmacokinetics and cerebrospinal fluid concentrations of idarubicin and idarubicinol in pediatric leukemia patients: a Childrens Cancer Study Group report. Cancer Res 50(20):6525–6528 Robert J, Bui NB, Vrignaud P (1987) Pharmacokinetics of doxorubicin in sarcoma patients. Eur J Clin Pharmacol 31(6):695–699 Samuels BL, Murray JL, Cohen MB, Safa AR, Sinha BK, Townsend AJ et al (1991) Increased glutathione peroxidase activity in a human sarcoma cell line with inherent doxorubicin resistance. Cancer Res 51(2):521–527 Satake S, Sugawara I, Watanabe M, Takami H (1997) Lack of a point mutation of human DNA topoisomerase II in multidrug-resistant anaplastic thyroid carcinoma cell lines. Cancer Lett 116(1):33–39

101 122. Savaraj N, Lu K, Manuel V, Loo TL (1982) Pharmacology of mitoxantrone in cancer patients. Cancer Chemother Pharmacol 8(1):113–117 123. Schneider E, Cowan KH, Bader H, Toomey S, Schwartz GN, Karp JE et al (1995) Increased expression of the multidrug resistance-associated protein gene in relapsed acute leukemia. Blood 85(1):186–193 124. Schneider E, Horton JK, Yang CH, Nakagawa M, Cowan KH (1994) Multidrug resistance-associated protein gene overexpression and reduced drug sensitivity of topoisomerase II in a human breast carcinoma MCF7 cell line selected for etoposide resistance. Cancer Res 54(1): 152–158 125. Schott B, Robert J (1989) Comparative activity of anthracycline 13-dihydrometabolites against rat glioblastoma cells in culture. Biochem Pharmacol 38(22):4069–4074 126. Seymour LW, Ulbrich K, Strohalm J, Kopecek J, Duncan R (1990) The pharmacokinetics of polymerbound adriamycin. Biochem Pharmacol 39(6):1125–1131 127. Shenkenberg TD, Von Hoff DD (1986) Mitoxantrone: a new anticancer drug with significant clinical activity. Ann Intern Med 105(1):67–81 128. Sikic BI, Fisher GA, Lum BL, Halsey J, BeketicOreskovic L, Chen G (1997) Modulation and prevention of multidrug resistance by inhibitors of P-glycoprotein. Cancer Chemother Pharmacol 40 Suppl S13–19 129. Sinha BK, Katki AG, Batist G, Cowan KH, Myers CE (1987) Differential formation of hydroxyl radicals by adriamycin in sensitive and resistant MCF-7 human breast tumor cells: implications for the mechanism of action. Biochemistry 26(13):3776–3781 130. Slamon D, Leyland-Jones B, Shak S (1998) Addition of Herceptin (humanized anti-HER2 antibody) to first line chemotherapy for markedly increased anticancer activity: a randomized, multinational controlled phase III trial. Proc Amer Soc Clin Oncol 17:98a 131. Smyth JF, Macpherson JS, Warrington PS, Leonard RC, Wolf CR (1986) The clinical pharmacology of mitozantrone. Cancer Chemother Pharmacol 17(2): 149–152 132. Sognier MA, Zhang Y, Eberle RL, Sweet KM, Altenberg GA, Belli JA (1994) Sequestration of doxorubicin in vesicles in a multidrug-resistant cell line (LZ-100). Biochem Pharmacol 48(2):391–401 133. Somlo G, Doroshow JH, Forman SJ, Leong LA, Margolin KA, Morgan RJ Jr et al (1994) High-dose doxorubicin, etoposide, and cyclophosphamide with stem cell reinfusion in patients with metastatic or high-risk primary breast cancer. City of hope bone marrow oncology team. Cancer 73(6):1678–1685 134. Son YS, Suh JM, Ahn SH, Kim JC, Yi JY, Hur KC et al (1998) Reduced activity of topoisomerase II in an Adriamycin-resistant human stomach-adenocarcinoma cell line. Cancer Chemother Pharmacol 41(5):353–360 135. Sonneveld P, Wassenaar HA, Nooter K (1984) Long persistence of doxorubicin in human skin after extravasation. Cancer Treat Rep 68(6):895–896 136. Speechly-Dick ME, Owen ER (1988) Mitozantroneinduced onycholysis. Lancet 1(8577):113 137. Speth PA, Linssen PC, Holdrinet RS, Haanen C (1987) Plasma and cellular adriamycin concentrations in patients

102

138.

139.

140.

141.

142.

143.

144.

145.

146.

147.

N. Coufal and L. Farnaes with myeloma treated with ninety-six-hour continuous infusion. Clin Pharmacol Ther 41(6):661–665 Speyer JL, Green MD, Kramer E, Rey M, Sanger J, Ward C et al (1988) Protective effect of the bispiperazinedione ICRF-187 against doxorubicin-induced cardiac toxicity in women with advanced breast cancer. N Engl J Med 319(12):745–752 Stewart DJ, Grewaal D, Green RM, Verma S, Maroun JA, Redmond D et al (1991) Bioavailability and pharmacology of oral idarubicin. Cancer Chemother Pharmacol 27(4):308–314 Swain SM, Whaley FS, Gerber MC, Weisberg S, York M, Spicer D et al (1997) Cardioprotection with dexrazoxane for doxorubicin-containing therapy in advanced breast cancer. J Clin Oncol 15(4):1318–1332 Takanashi S, Bachur NR (1976) Adriamycin metabolism in man. Evidence from urinary metabolites. Drug Metab Dispos 4(1):79–87 Tarasiuk J, Garnier-Suillerot A (1992) Kinetic parameters for the uptake of anthracycline by drug-resistant and drugsensitive K562 cells. Eur J Biochem 204(2):693–698 Taylor SD, Davenport LD, Speranza MJ, Mullenbach GT, Lynch RE (1993) Glutathione peroxidase protects cultured mammalian cells from the toxicity of adriamycin and paraquat. Arch Biochem Biophys 305(2):600–605 Terasaki T, Iga T, Sugiyama Y, Hanano M (1982) Experimental evidence of characteristic tissue distribution of adriamycin. Tissue DNA concentration as a determinant. J Pharm Pharmacol 34(9):597–600 Torti FM, Bristow MR, Howes AE, Aston D, Stockdale FE, Carter SK et al (1983) Reduced cardiotoxicity of doxorubicin delivered on a weekly schedule. Assessment by endomyocardial biopsy. Ann Intern Med 99(6): 745–749 Twelves CJ, Dobbs NA, Aldhous M, Harper PG, Rubens RD, Richards MA (1991) Comparative pharmacokinetics of doxorubicin given by three different schedules with equal dose intensity in patients with breast cancer. Cancer Chemother Pharmacol 28(4):302–307 Twelves CJ, Dobbs NA, Michael Y, Summers LA, Gregory W, Harper PG et al (1992) Clinical pharmacokinetics of epirubicin: the importance of liver biochemistry tests. Br J Cancer 66(4):765–769

148. Unverferth DV, Unverferth BJ, Balcerzak SP, Bashore TA, Neidhart JA (1983) Cardiac evaluation of mitoxantrone. Cancer Treat Rep 67(4):343–350 149. van Dalen EC, Michiels EM, Caron HN, Kremer LC (2006) Different anthracycline derivates for reducing cardiotoxicity in cancer patients. Cochrane Database Syst Rev(4):CD005006 150. Vaupel PW, Frinak S, Bicher HI (1981) Heterogeneous oxygen partial pressure and pH distribution in C3H mouse mammary adenocarcinoma. Cancer Res 41(5):2008–2013 151. Venturini M, Michelotti A, Del Mastro L, Gallo L, Carnino F, Garrone O et al (1996) Multicenter randomized controlled clinical trial to evaluate cardioprotection of dexrazoxane versus no cardioprotection in women receiving epirubicin chemotherapy for advanced breast cancer. J Clin Oncol 14(12):3112–3120 152. Von Hoff DD, Layard MW, Basa P, Davis HL Jr, Von Hoff AL, Rozencweig M et al (1979) Risk factors for doxorubicin-induced congestive heart failure. Ann Intern Med 91(5):710–717 153. Von Hoff DD, Rozencweig M, Layard M, Slavik M, Muggia FM (1977) Daunomycin-induced cardiotoxicity in children and adults. A review of 110 cases. Am J Med 62(2):200–208 154. Weenen H, van Maanen JM, de Planque MM, McVie JG, Pinedo HM (1984) Metabolism of 4 -modified analogs of doxorubicin. unique glucuronidation pathway for 4 epidoxorubicin. Eur J Cancer Clin Oncol 20(7):919–926 155. Wishart GC, Bissett D, Paul J, Jodrell D, Harnett A, Habeshaw T et al (1994) Quinidine as a resistance modulator of epirubicin in advanced breast cancer: mature results of a placebo-controlled randomized trial. J Clin Oncol 12(9):1771–1777 156. Withoff S, Keith WN, Knol AJ, Coutts JC, Hoare SF, Mulder NH et al (1996) Selection of a subpopulation with fewer DNA topoisomerase II alpha gene copies in a doxorubicin-resistant cell line panel. Br J Cancer 74(4):502–507 157. Yamamoto M, Maehara Y, Oda S, Ichiyoshi Y, Kusumoto T, Sugimachi K (1999) The p53 tumor suppressor gene in anticancer agent-induced apoptosis and chemosensitivity of human gastrointestinal cancer cell lines. Cancer Chemother Pharmacol 43(1):43–49

Chapter 6

Topoisomerase I Inhibitors – The Camptothecins Michael Newton, Gene Wetzstein, and Daniel Sullivan

6.1 Introduction

6.2 Chemistry

The camptothecins are a class of antineoplastic agents that inhibit the enzyme DNA topoisomerase I and have established activity in the treatment of various human malignancies. Camptothecin (CPT) was originally isolated in 1966 from the bark and stem of the native Chinese tree, Campotheca acuminate [155]. Although camptothecin demonstrated promising antitumor effects in animal systems , its utility was compromised in the clinical setting because of erratic absorption, insolubility, and severe toxicities. However, interest was renewed in the mid-1980s when the topoisomerase enzyme was identified as the cellular target of camptothecin. This led to the development of more soluble and less toxic camptothecin analogs with even greater preclinical anticancer activity, including the two FDA approved agents, irinotecan and topotecan. There are several other campothecin analogs in various stages of clinical investigation including SN-38, 9-aminocamptothecin (9-AC), 9-Nitrocamptothecin (9-NC), lurtotecan (GI-47211), rubitecan, OSI-211, exatecan mesylate (DX8951f), diflomotecan (BN80915), gimatecan (ST1481), CKD602, DB-67, and karenitecin (BNP1350). The advancement of these agents and further development within the class may further signify the importance of topoisomerase I inhibition as a major target for cancer chemotherapy [105].

The characteristic structural features of the camptothecins include a five-ring backbone in which a quinolone moiety on one end is attached to an α-hydroxy-δ-lactone ring at position C-20 (Fig. 6.1). The naturally occurring 20S-isomer of camptothecin inhibits purified topoisomerase I 10–100 times more potently than the 20R-isomer [157]. The electrophilic center and chemical reactivity of the lactone ring is essential for the camptothecins biological activity. Substitution at positions C-7, C-9, C-10 and C-11 of the aromatic A ring of the quinolone moiety can have positive effects on CPT potency and physical properties (Fig. 6.2) [75, 163]. At the same time, the lactone ring is also vulnerable to reversible hydrolysis to a less active carboxylate species at neutral and alkaline pH [36]. This reaction is reversible, pH dependent, and influenced by solution composition (Fig. 6.3).

D. Sullivan () Experimental Therapeutics Program and Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA e-mail: [email protected]

Fig. 6.1 Camptothecin backbone structure

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_6, © Springer Science+Business Media B.V. 2011

103

104

M. Newton et al.

Fig. 6.2 Modification of camptothecin structure

Analogue

R1

R2

Topotecan

-H

CH2N(CH3)2 -OH

H

Irinotecan

CH2CH3

H

H

DB 67

BNP 1350

CH2CH2Si(CH3)3

R3

R4

H

OH

H

H

H

H

CH3

F

H

H

NH2

Exatecan

Lurtotecan

H

ST 1481

CH NOC(CH3)3

CKD 602

CH2CH2NHCH(CH3)2

H

H

H

H

6

Topoisomerase I Inhibitors – The Camptothecins

105

Fig. 6.3 Camptothecin lactone and carboxylate equilibrium

6.3 Mechanisms of Action Topoisomerase enzymes are found in all organisms. Their primary function is to alter DNA topology, which plays a critical role in facilitating replication, transcription, recombination and repair. DNA is packaged in cells in a highly compact, supercoiled state. DNA metabolism requires that the strands of the double helix be separated into their individual strands so that they can serve as templates for transcription and replication complexes. The separation of the individual strands results in torsional stress, both upstream and downstream on the double helix. Type I topoisomerases introduce a single stranded break in DNA, and then form a covalent intermediate with the 3’ end of the strand, resulting in the “cleavable complex” [156]. The cleaved strand is then able to swivel around the intact strand, resulting in DNA relaxation [19]. This releases the topographic constraints of supercoiled DNA and relieves torsional stress. Religation of the strand then occurs and topoisomerase I releases itself from the complex. The camptothecins form a complex with topoisomerase I, which stabilizes the normally transient bond between topoisomerase I and DNA. This reversible stabilization of the cleavable complex prevents the religation step. Irreversible double strand breaks occur when a replication fork collides with the cleavable complex, which is still bound. This leads to cell cycle arrest and cell death [64]. Topoisomerase I inhibitors exert these effects primarily during DNA or RNA synthesis, and are thus considered to be S-phase specific. The camptothecins also seem to inhibit angiogenesis [21]. Inhibition of hypoxia inducible factor 1 (HIF-1) accumulation is achieved by topotecan through a mechanism that is independent of replication mediated DNA damage [111]. HIF-1 is a major regulator of vascular endothelial growth factor (VEGF). In an in vitro study of neuroblastoma cell lines, topotecan

blocked insulin-like growth factor-1 induced HIF-1α, which resulted in a decrease in VEGF expression [4]. The precise mechanism through which topotecan inhibits HIF-1α remains to be determined; however it appears to be through a novel pathway involving topoisomerase I and independent of PI3k-Akt-mTOR pathway or HIF-1 degradation. Unlike the cytotoxic mechanism of the topoisomerase I inhibitors, this effect is cell cycle independent, and may guide future investigation in solid tumors with HIF-1 dependent responses.

6.4 Clinical Use 6.4.1 Irinotecan Irinotecan has exhibited activity in a number of solid tumors. It gained initial approval in the United States in 1996 for the treatment of metastatic carcinoma of the colon or rectum that has progressed during or after first-line chemotherapy with 5-fluorouracil. It was the first novel, effective treatment for colon cancer in decades. In 2000, irinotecan gained FDA indication as a component of first line therapy in combination with 5-FU and leucovorin for patients with metastatic carcinoma of the colon or rectum. Irinotecan has also been studied in several other tumor types, including other gastrointestinal malignancies, gliomas, sarcoma [7], breast cancer [103], lymphomas [133], and MDS [114]. Several phase II trials examining irinotecan’s activity as a second line agent in metastatic colon cancer revealed response rates ranging from 9 to 23%. Median response duration was 6–8 months and median overall survival was 8–13 months [2, 39, 147, 120, 121, 124]. Most of these studies utilized the dosing strategy of either 350 mg/m2 every 3 weeks or 125 mg/m2

106

weekly for 4 weeks followed by two weeks of rest. In one of the studies an alternate dose of 100 mg/m2 substituted for the 125 mg/m2 dose resulted in suboptimal response rates without a reduction in toxicity [120]. Irinotecan’s clinical utility in second line treatment of metastatic colon cancer was confirmed by two subsequent phase III trials. The first trial randomized patients who had progressed on standard 5-FU therapy within 6 months to either receive best supportive care (BSC) or irinotecan 350 mg/m2 (300 mg/m2 in patients age 70 or older or with performance status of 2) every 3 weeks. Median survival was 9.2 months for the irinotecan group and 6.5 months for the BSC group (p = 0.0001). One year overall survival was 36.2% in the irinotecan group vs. 13.8% in the BSC group. Quality of life analysis favored the irinotecan group in all scores except diarrhea [27]. The second trial compared irinotecan to regimens that utilized a continuous infusion of 5-FU. The three 5-FU control regimens utilized in this trial were widely considered equivalent to one another at the time in Europe, and the regimen selected was left to the discretion of the individual physician. Median survival was 10.8 months for the group treated with an irinotecan containing regimen and 8.5 months for the 5-FU group (p = 0.035). There was not a statistically significant difference in survival between the different 5-FU groups. Progression free (4.2 months vs. 2.9 months) and one year survival (45% vs. 32%) also favored irinotecan. Quality of life scores were similar for both regimens [125]. Two international phase III trials led to the approval of irinotecan in first line therapy of metastatic colorectal cancer. The first trial compared irinotecan 125 mg/m2 combined with a bolus regimen of 5-FU + leucovorin weekly for 4 of 6 weeks with the “Mayo Clinic” 5-FU + leucovorin regimen, which consisted of 5-FU 425 mg/m2 per day combined with leucovorin 20 mg/m2 daily for 5 consecutive days every 4 weeks. A third arm received irinotecan alone. Overall median survival was found to be significantly longer in the irinotecan combination arm vs. 5-FU/leucovorin arm (14.8 vs. 12.6 months, p = 0.04). Response rates and progression free survival were also longer in the irinotecan combination arm. The single agent irinotecan arm had similar response and survival rates as the 5-FU + leucovorin arm [129]. The second trial utilized irinotecan in combination with 2 different infusional combinations of 5-FU/leucovorin. Comparator groups consisted of

M. Newton et al.

infusional 5-FU/leucovorin alone. Doses of irinotecan were based on the 5-FU infusional regimen selected. Once again, overall median survival was higher in the irinotecan arm (median 17.4 vs. 14.1 months, p = 0.031). Overall response was 41% vs. 23% in favor of the irinotecan group, and time to progression was also significantly in favor of the irinotecan group [33]. Neither of the first line trials showed that use of irinotecan contributed to a negative impact on quality of life. Irinotecan is widely used in combination with two recently introduced biologic agents for metastatic colon cancer. Cetuximab, a monoclonal antibody that inhibits the epidermal growth factor receptor (EGFR), exhibited a 23% partial response rate with 4.1 month time to progression when combined with irinotecan in those patients that had failed a previous irinotecanbased therapy [26]. Another monoclonal antibody, bevacizumab, which targets the vascular endothelial growth factor receptor ligand, has resulted in increased median survival for metastatic colon cancer patients to over 20 months when it is combined with an irinotecan and 5-FU containing regimen [65]. Unfortunately, irinotecan’s benefit in the metastatic setting has not translated to the adjuvant setting when added to 5-FU/leucovorin in high risk stage II and stage III colon cancer patients [130]. Irinotecan has demonstrated activity in solid tumor types other than colorectal cancer. A Japanese phase II trial found irinotecan to have high response rates in small cell lung cancer [78]. This led to a phase III trial in Japan that investigated irinotecan combined with cisplatin in comparison to etoposide and cisplatin in metastatic small cell lung cancer patients. Enrollment was terminated early as an interim analysis found a statistically significant increase in median survival in the irinotecan containing arm (12.8 vs. 9.4 months, p = 0.002) [98]. Notably, only 80.4% of planned dose intensity of irinotecan was delivered in this study due to toxicity. A confirmatory study was initiated in the United States, Canada and Australia utilizing the same combinations as the Japanese study with some dose modification intended to improve delivery and reduce toxicity; however, this study failed to demonstrate a statistically significant difference in response, time to progression or survival [55]. The failure of this study could be attributed to either the dosing differences between the studies or pharmacogenomic differences between North American and

6

Topoisomerase I Inhibitors – The Camptothecins

Japanese patient populations. In advanced non-small cell lung cancer (NSCLC), irinotecan has been shown to be a viable agent when used in combination with cisplatin, and is considered noninferior to other commonly used platinum based doublets in this patient population [101]. Irinotecan has also shown activity in pancreatic cancer in phase II trials, and a phase III trial utilizing irinotecan combined with gemcitabine showed increased response rates but no improvement in survival [117]. In Phase I/II trials, irinotecan has shown modest response rates between 6 and 15% in recurrent malignant glioma [3, 18, 22, 37, 107]. Many of these studies utilized dose-escalation strategies for patients receiving enzyme-inducing anti-epileptic drugs (EIAEDs) or corticosteroids as these agents alter the metabolism and elimination of irinotecan [51] (see Section 6.6). A phase II trial combining irinotecan with bevacizumab in recurrent glioblastoma showed compelling results, including an overall response rate of 57% and 6 month progression free survival (PFS) rate of 46% [153]. This resulted in wide adoption of the combination of bevacizumab and irinotecan as the regimen of choice for recurrent glioblastoma. The activity of this combination was confirmed recently in a phase II non-comparative trial that examined bevacizumab combined with irinotecan vs. bevacizumab alone [38]. In this study, the combination resulted in a response rate of 38% and a 6 month progression free survival of 50%. It should be noted that in the bevacizumab alone arm, response rate and 6 month PFS were 43 and 29% respectively. Since the study was not comparative, it is not possible to draw a conclusion as to whether irinotecan truly adds a significant benefit when combined with bevacizumab in recurrent gliomas.

6.4.2 Topotecan Topotecan has received regulatory approval in the United States for second line treatment of ovarian cancer, relapsed small cell lung cancer, and most recently, late stage or recurrent cervical cancer in combination with cisplatin. Topotecan has shown varying degrees of response in several other tumor types, including non-small cell lung cancer [69, 110], pediatric medulloblastoma [140], myelodysplastic syndrome [5] and multiple myeloma [76].

107

In a phase II trial, topotecan was administered to patients diagnosed with stage III or IV ovarian cancer that failed to respond to first line therapy with a platinum-containing regimen. Patients who received topotecan 1.5 mg/m2 daily × 5 days per 3 week cycle had an overall response rate of 16.3%. In subgroups of cisplatin refractory, resistant and sensitive patients, the response rates were 5.9, 17.8, and 26.7% respectively [23]. A separate study found that topotecan 1.5 mg/m2 daily × 5 days every 3 weeks resulted in a 33% overall response rate when used upon relapse in platinum sensitive ovarian cancer patients [88]. A phase III trial compared the same topotecan regimen to paclitaxel 175 mg/m2 every 3 weeks in stage III or IV ovarian cancer patients who had progressed on a platinum containing regimen. The overall response rates for the intent to treat populations were 20.5% for the topotecan group and 13.2% for the paclitaxel group (p = 0.138). Time to progression was 23.1 weeks for topotecan and 14 weeks for paclitaxel (p = 0.002). There were no differences in overall survival [145]. Analysis of subsequent crossover between the two study groups upon progression demonstrated a degree of non-cross resistance between topotecan and paclitaxel [46]. A phase III study compared topotecan 1.5 mg/m2 daily × 5 to CAV (cyclophosphamide 1000 mg/m2 , doxorubicin 45 mg/m2 and vincristine 2 mg) every 21 days in small cell lung cancer (SCLC) patients who relapsed at least 60 days after standard first line therapy. Response rates, time to progression and median survival were not statistically different between the groups. Patients in the topotecan arm experienced greater symptom improvement and less grade 4 neutropenia [152]. Topotecan has also been shown to be a well tolerated and reasonable treatment choice in poorer performance status (ECOG PS 2) SCLC patients [146]. Topotecan has traditionally been available exclusively in an intravenous formulation. However, an oral formulation has been investigated, and recently received regulatory approval in the United States. A phase II trial compared an oral formulation of topotecan to intravenous topotecan in relapsed SCLC. This study found similar efficacy, less neutropenia, and greater convenience of administration for the oral formulation [151]. A subsequent phase III trial compared oral topotecan combined with cisplatin vs. etoposide and cisplatin in previously untreated

108

extensive-disease SCLC patients. This study showed similar response rates, survival and tolerability for both regimens. There was a slight statistical advantage to the etoposide/cisplatin arm in time to progression and symptom improvement scores but these differences may not be clinically significant [34]. Oral topotecan has also shown activity similar to docetaxel in second line treatment of advanced non-small cell lung cancer [110]. Topotecan’s activity in advanced cervical cancer was identified in a phase II study that showed an objective response rate of 18.6% [94]. The dose of topotecan in this trial was 1.5 mg/m2 daily × 5 days every 4 weeks. A phase III study compared topotecan 0.75 mg/m2 /day × 3 days combined with cisplatin 50 mg/m2 against the standard single agent cisplatin 50 mg/m2 in this patient population. Doses were repeated in each arm every 3 weeks. A third arm utilizing the MVAC regimen (a combination of methotrexate, vinblastine, doxorucibin, and cisplatin) was closed due to deaths secondary to neutropenic sepsis in this group. The combination of topotecan and cisplatin had statistically superior outcomes, including overall survival (9.4 vs. 6.5 months, p = 0.017), and response rates (27% vs. 13%, p = 0.04) [81]. This trial led to FDA approval of topotecan in combination with cisplatin for the treatment of advanced or recurrent cervical cancer in the United States. Although its place in therapy remains an area requiring further research, topotecan has shown promise in hematologic malignancies. In relapsed or resistant multiple myeloma, topotecan exhibited an overall response rate of 16%, with a median survival of 28 months [76]. As a single agent, topotecan has shown a CR rate of 37% in myelodysplastic syndrome (MDS), often resulting in the disappearance of abnormal karyotypes [6]. When utilized in combination with cytarabine as an induction regimen in high risk MDS, topotecan resulted in complete response rates of 50–60%, including in those with poor-prognosis karyotypes and secondary MDS [5]. A retrospective analysis conducted at the MD Anderson Cancer Center showed similar CR and long term survival rates for induction therapy in MDS patients receiving topotecan combined with cytarabine compared with those receiving idarubicin and cytarabine. This analysis associated lower induction mortality rates with the topotecan regimen and suggests this combination may be an appropriate alternative for patients with contraindications to

M. Newton et al.

anthracyclines [70]. Topotecan has also been shown to be an active agent when combined with fludarabine and cytarabine in refractory AML [45].

6.5 Mechanisms of Resistance Mechanisms of resistance to camptothecins are not well understood and have been characterized mostly in preclinical studies. However, there appear to be several mechanisms by which resistance to camptothecins occur. Inadequate accumulation of drug in the tumor cells, alteration in the structure of topoisomerase I, or alterations in the cellular response to the topoisomerase 1-camptothecin complex are the primary general mechanisms by which clinically significant resistance occur [112]. Inadequate accumulation of active drug in the tumor cells can result from reduced uptake, increased efflux, or altered cellular metabolism. Cellular uptake of camptothecins occurs through both active and passive transport [48]. Active transport appears to be required for the influx of topotecan into ovarian cells [83]. It is unclear if alterations in cellular uptake contribute significantly to clinically relevant resistance to camptothecins. Cellular efflux however is likely to play a large role. As with many chemotherapy agents, membrane proteins belonging to the ATP-binding cassette superfamily (ABC) participate in active efflux of camptothecin derivatives. These transporters are widely studied due to their impact on a wide variety of agents. Over expression of P-glycoprotein is associated with resistance to many classes of cytotoxic compounds, including camptothecins [20]. Several members of the multi-drug resistance protein (MRP) family are also implicated in camptothecin resistance. The over expression of MRP4 appears to confer resistance to both topotecan and irinotecan [143, 144]. Breast Cancer Resistance Protein (BCRP) over expression may also play a role in resistance to some camptothecins [71, 109]. Alterations in the structure and expression of the topoisomerase I enzyme may also have an impact on camptothecin resistance. Cellular topoisomerase I levels exhibit a direct correlation with sensitivity to camptothecins [89]. Topoisomerase I levels vary widely between and within tumor types, and decreased topoisomerase I content is associated with low level

6

Topoisomerase I Inhibitors – The Camptothecins

resistance [137]. Mutations in the structure of topoisomerase I may play a more significant role in resistance to agents that target the enzyme. Structural mutations may or may not affect the enzyme’s activity, but can impact the targeting agent’s ability to bind and stabilize the Top1-DNA complex. Cellular processes that alter response or occur downstream of the camptothecin-TopI-DNA complex may also be important in resistance. DNA replication, damage checkpoint, and damage repair proteins appear to play a role. For example, the topoisomerase I/drug/DNA complexes can be removed and repaired by tyrosyl DNA phosphodiesterase (Tdp1) and polynucleotide kinase phosphatase (PNKP) [106]. Modifications in pro- and anti-apoptotic pathways occur that also may influence resistance to topoisomerase I targeting agents. Up-regulation of inhibitors of apoptosis bcl-2 and p21Waf1/Cip1 has been associated with resistance to camptothecins [162]. Treatment with camptothecins is followed by the downstream activation of the anti-apoptotic factor nuclear factor kappa B (NF-kB). Inhibition of this pathway could augment irinotecan-induced apoptosis [13].

6.6 Pharmacokinetics 6.6.1 Irinotecan The pharmacokinetic profile of irinotecan is complex, involving several metabolic pathways and genetic variability. Peak plasma concentrations of irinotecan occur immediately after short intravenous infusions of 30–90 min. Peak concentration is dose proportional, as is area under the curve (AUC), indicating linear pharmacokinetics (reviewed in [85]). Cleavage of its dipiperidino side chain via carboxylesterases forms the active metabolite 7-ethyl-10-hydroxycamptothecin (SN-38). Peak concentrations of SN-38 occur approximately 1–2 h after infusion of irinotecan. SN-38 levels are approximately 100-fold lower than corresponding irinotecan concentrations, however SN-38 is between 100 and 1000 times more potent in topoisomerase I inhibition than the parent compound [17, 72]. SN-38 also has a longer terminal half life ranging from 6 to 47 h, vs. irinotecan’s 5 to 27 h. Most pharmacokinetic analyses of these compounds assume a two or three compartment model (Table 6.1).

109 Table 6.1 Pharmacokinetic parameters of Irinotecan and SN-38 Parameter Irinotecan (plasma) SN-38 (plasma) Tmax (hrs) 1.5 (90 min infusion) 1534 ± 143 Cmax (ng/ml) AUC (ng · h/ml) 8808 ± 2215 Vd (l/m2 ) 297 ± 119 14.6 (5–27)a t1/2 (h) CL (l/h/m2 ) 12.4 a Denotes range variation published in other studies Adapted from Slatter et al. [135]

2.32 27.1 ± 11.6 400 ± 242 28.5 (6–47)a pharmacokinetic

Irinotecan and SN-38 undergo pH dependent hydrolysis of the lactone ring, resulting in an open carboxylate form (Fig. 6.4). The carboxylate form is not able to passively diffuse across cell membranes, thus only the lactone form is able to function as an inhibitor of topoisomerase I. In comparison to irinotecan, the equilibrium for SN-38 is shifted more towards the active lactone form in the presence of human albumin. The lactone form of SN-38 accounts for a mean of approximately 64% of its total AUC, while irinotecan lactone accounts for 34–44% of total irinotecan AUC [85]. Protein binding of irinotecan is approximately 65% and does not differ significantly between the lactone and carboxylate forms [17]. SN-38 is 95% bound to plasma proteins, with the lactone form binding more potently than the carboxylate. Irinotecan’s volume of distribution at steady state is large, with reported values ranging from 76 to 297 l/m2 . The large volume of distribution is suggestive of extensive tissue penetration, but the specificity of penetration has not been published extensively. In a nonhuman primate model, cerebrospinal fluid concentrations of irinotecan were found to have an AUC(CSF):AUC(plasma) ratio of approximately 14%, while SN-38 carboxylate and lactone were not detectable [11]. A clinical trial conducted in Japan examining the combination of cisplatin and irinotecan in pleural mesothelioma patients found high concentrations of irinotecan and SN-38 in pleural fluid. The maximum concentrations of irinotecan and SN-38 in the pleural fluid were 36.5 and 75.8%, respectively, of the corresponding plasma values [96]. No clear evidence exists of excess accumulation or toxicity in patients with ascites or pleural effusion. Irinotecan is extensively metabolized into both active and inactive forms by various classes of

110

M. Newton et al.

Fig. 6.4 Conversion between lactone and carboxylate forms of irinotecan and SN-38 (modified from Tallman et al. [142])

enzymes, including carboxylesterases (CE), UDP glucuronosyl transferases (UGTs), Cytochrome P-450 3A isozymes (CYP3A), and ß-glucuronidases (Fig. 6.5). As mentioned previously, carboxylesterases are responsible for the conversion of irinotecan to the highly active metabolite SN-38. Carboxylesterases are present in the liver and intestine of humans, with human isotype CE-2 being predominantly responsible for conversion of irinotecan to SN-38 [132]. Intratumoral concentrations of CE-2 have large interindividual variation, but it remains unclear if this contributes to variation in therapeutic outcomes or toxicities [131]. Conversion velocity of irinotecan to SN-38 was found to be twofold higher for irinotecan lactone than carboxylate. This may be partially responsible for the predominance of SN-38 in its lactone form in plasma [53]. The cytochrome P-450 enzyme system has also been identified as a pathway of irinotecan metabolism. CYP3A4 mediated oxidation of the distal piperidine group at C10 of irinotecan forms the metabolite APC [52]. APC has little cytotoxic activity, and is a poor substrate for conversion to SN-38 by carboxylesterases. It also does not appear to contribute significantly to clinical toxicities [115]. NPC, another clinically important metabolite, is formed via CYP3A4 mediated cleavage of the distal piperidine ring of irinotecan [51]. Although this metabolite has very little inherent anti-tumor activity, it is a substrate of CE-2, which results in conversion to SN-38, and thus NPC may contribute the activity and toxicity of irinotecan [32]. Although other metabolites generated through CYP3A microsomes have been partially identified,

their exact chemical structure and clinical importance are not yet known. As a substrate for CYP3A4, irinotecan has the potential for serious drug interactions (see Section 6.10). Significant inhibition of the formation of NPC and APC has been observed with known CYP3A4 inhibitors such as ketoconazole [51]. Increased clearance of irinotecan was observed in malignant glioma patients receiving enzyme-inducing anti-epileptic drugs (EIAEDs) and steroids [37]. Concurrent use of EIAEDs with irinotecan increases the role of CYP3A4/5, shifting metabolism more toward APC and NPC rather than the highly active SN-38. This finding is clinically significant and resulted in a number of studies utilizing larger doses of irinotecan in those receiving EIAEDs. SN-38 undergoes glucuronidation in the liver to the inactive SN-38 glucuronide (SN-38G) [116]. The uridine-diphosphate glucuronosyltransferase isozyme 1A1 (UGT1A1) is thought to be the primary mediator of this inactivation [68], but UGT1A9 and extrahepatic UGT 1A7 [40] also play an important role. Patients with impaired ability to conjugate bilirubin (Gilbert syndrome, Crigler-Najjar syndrome) may not effectively conjugate SN-38 and are at increased risk of toxicities such as severe diarrhea [47]. Variation of UGT1A1 activity in patients receiving irinotecan has also been found to be responsible for excessive myelosuppression [66]. One genetic variant occurs in the TATA promoter region consisting of variable repeats of thymine-adenine (TA). The UGT1A1∗ 28 gene polymorphism, involving two alleles with seven TA repeats, has been identified as possibly having

6

Topoisomerase I Inhibitors – The Camptothecins

111

Fig. 6.5 Metabolic pathways of irinotecan (CPT-11) [85]

predictive value for lower SN-38 glucuronidation and greater susceptibility to irinotecan toxicity [67]. Approximately 10% of North Americans are homozygous (7 TA repeats on each allele, also abbreviated “7/7”) for this genotype [90]. These findings compelled the FDA in 2005 to include a warning on irinotecan’s package insert indicating that patients with the UGT1A1∗ 28 genotype were at increased risk for neutropenia and that a reduced initial irinotecan dosage should be considered. The FDA also approved a molecular assay that tests for the presence of the UGT1A1∗ 28 variant, but predictive power of the test is uncertain and specific dosage reduction recommendations are not available. Inconsistencies also exist in published data examining toxicity in patients with UGT1A1 mutations. For example, pediatric patients homozygous for the UGT1A1∗ 28

genotype who received low-dose irinotecan (15– 75 mg/m2 daily for 5 days for 2 consecutive weeks) did not experience increased toxicity despite higher SN-38 AUC values [141]. After glucuronidation of SN-38, SN-38G is secreted into the intestinal lumen via biliary excretion. Betaglucuronidase enzymes produced by intestinal flora result in intralumenal reactivation of SN-38. This mechanism likely contributes to mucosal damage and the severe late diarrhea associated with irinotecan treatment. In a small case-series, reduction in ß-glucuronidase activity via administration of neomycin resulted in reduced fecal concentrations of SN-38 and diarrhea, without affecting plasma exposure of irinotecan or its metabolites [74]. However, follow-up clinical trials have not produced evidence compelling enough to employ this strategy in clinical practice [29].

112

Elimination of irinotecan also occurs via urinary and fecal excretion. The mean 24-h urinary excretion of irinotecan represents 17–25% of the dose, while SN-38 and SN-38 glucuronide account for 1–3% of the dose [17]. Cumulative biliary excretion of irinotecan and its metabolites ranges from 25 to 50% of the dose in 48 h [80]. Fecal excretion accounted for 24.4 ± 13.3% of the total dose [139]. Cyclosporin A has been shown to modulate the biliary excretion of irinotecan [49]. One small clinical trial in humans showed a reduction in irinotecan associated diarrhea when modulated with cyclosporine [31] but the potential impact on efficacy is not known.

6.6.1.1 Topotecan Topotecan undergoes rapid pH dependent, reversible hydrolysis of its lactone ring to an open ring carboxylate form. At physiological pH, the inactive carboxylate form predominates [58]. The ratio of topotecan lactone to total topotecan AUC is approximately 35%. Peak topotecan concentrations occur at the end of a 30 min infusion, with its major N-desmethyl metabolite peaking approximately 2 h later [86]. Topotecan exhibits linear two compartment kinetics at most common dosages [58]. The half life of topotecan is about 3 h, and its metabolite is 8.8 h. Protein binding is <50% and volume of distribution can range from 25 to 75 l/m2 after a 30 min infusion. Pharmacokinetic parameters of topotecan are subject to a large amount of interpatient variability. Population pharmacokinetic analyses have correlated weight, height, renal function, sex, and performance status to topotecan AUC, and give some ability to predict its clearance in an individual patient [42, 93]. Topotecan is most commonly administered intravenously; however an oral form has been available in some countries and was recently FDA approved in the United States. Bioavailability of the oral form ranges from 21 to 45% vs. the same dose administered intravenously, with no difference in lactone to carboxylate ratio [134]. Food does not affect the amount of drug absorbed [57]. Using a dose of oral topotecan that was adjusted to account for decreased bioavailability, oral topotecan had similar efficacy and toxicity to the IV form in small cell lung cancer patients [35]. The absorption of oral topotecan is affected by the presence of a efflux pumps such as p-glycoprotein

M. Newton et al.

(p-gp) [77]. BCRP (Breast Cancer Resistance Protein) is also present in the small intestine and plays a major role in the efflux of topoisomerase I inhibitors [84]. Co-administration of the p-glycoprotein inhibitor GF120918 (elacridar) increased bioavailability of oral topotecan to 97.1% [77]. However, it is unclear if this translates into clinical benefit. Topotecan has been investigated for administration via other routes. A phase I trial showed benefit in six of 23 patients administered topotecan intrathecally. The mean tolerated dose was 0.4 mg [10]. The modest toxicity and possible utility of this dose of intrathecal topotecan was echoed in a small retrospective report [43]. A phase I study examined the intraperitoneal administration of topotecan. A dose of 20 mg/m2 instilled intraperitoneally was able to achieve therapeutic plasma levels of topotecan and a peritoneal to plasma AUC ratio of 54 ± 34. Toxicities included hypotension, chills, fever, and mild myelosuppression and abdominal pain [62]. Another phase I trial utilized the same intraperitoneal dose of topotecan in combination with intravenous paclitaxel and carboplatin, and exhibited pharmacokinetics similar to the previous study [12]. Topotecan has been found to substantially distribute into third spaces; however, it does not appear to accumulate in these compartments and can be safely administered to patients with ascites and pleural effusion. The mean AUC of topotecan in pleural and ascitic fluid was 55% of plasma AUC [44]. These levels peaked at approximately 6 h after dosing, and declined more slowly than in plasma. Cerebrospinal fluid penetration is also significant, with CSF concentrations approximately 32% of plasma concentrations [9]. Preliminary data have indicated that increasing the infusion time of topotecan from 30 min to 4 h may result in increased CSF exposure [161, 160]. Topotecan is minimally metabolized via hepatic CYP3A enzymatic mediated conversion to N-desmethyl topotecan. Concentrations of this metabolite in plasma and urine appear to be low [118]. This metabolite exists in both lactone and carboxylate form. Topotecan and N-desmethyl topotecan may undergo further metabolism via UGTmediated glucuronidation [119]. Transformation into topotecan-O-glucuronide and N-desmethyl-topotecanO-glucuronide is reversible through ß-glucuronidase. Dose modification of topotecan does not appear

6

Topoisomerase I Inhibitors – The Camptothecins

113

to be necessary in patients with impaired hepatic function [99]. Elimination of topotecan primarily occurs via renal excretion. Approximately 40–49% of the drug is excreted unchanged in urine, and 18% of intravenous dose and 33% of the oral dose excreted unchanged in the feces [59]. Only small amounts of N-desmethyltopotecan were found in urine and feces. Dose adjustments are necessary for patients with moderate to severe renal dysfunction [100].

6.7 Doses and Schedules The topoisomerase I inhibitors are given primarily by intravenous infusion. Only experienced oncology personnel should administer these agents. As with many other chemotherapy agents, the dosing of topotecan and irinotecan are based on body surface area (BSA). This dosing strategy unfortunately has limitations with the camptothecins due to significant interpatient variability in the pharmacokinetics of topotecan and irinotecan (reviewed in Section 6.6). Irinotecan doses are based largely on dosing interval and whether it is being used as a single agent or in combination with other agents. Most commonly, it is administered as a 90 min infusion, with intervals generally ranging from weekly to every three weeks depending on the protocol. Dosage reductions based on toxicity are most often due to neutropenia or diarrhea. Adjustment of irinotecan dosing based on pharmacogenetics and concurrent use of CYP450 enzyme inducing drugs is becoming more common as our understanding of the impact of

these factors increase [54, 107]. It is recommended that dosage reductions be instituted for patients with the UGT1A1∗ 28 genetic polymorphism or Gilbert Syndrome; however, the extent of dosage reduction is not yet determined [66]. More specific dosage adjustment recommendations have been published for patients concurrently receiving enzyme inducing antiepileptic drugs (EIAED) such as phenytoin and carbamazepine. Patients receiving EIAEDs have required increased doses of irinotecan to elicit the same effects as more traditional doses in patients not receiving these drugs. Doses as high as 340 mg/m2 every 2 weeks [154] or 600 to 750 mg/m2 every 3 weeks [18] have been safely administered to glioma patients receiving EIAEDs. Emerging data is also examining lower-dose, daily irinotecan schedules in order to take advantage of cell cycle phase specificity of the agent. Irinotecan at a dose of 20 mg/m2 /day 5 days a week for 2 weeks has shown reasonable response rates and toxicity in sarcoma patients [7]. The most commonly utilized, US Food and Drug Administration approved doses in colorectal cancer are outlined in Table 6.2. Topotecan is most often administered as an intravenous infusion over 30 min, at a dose of 0.75– 1.5 mg/m2 daily for 3–5 days depending on the regimen. The most commonly utilized, FDA approved doses/regimens are outlined in Table 6.3. Other notable dosing strategies for topotecan have been adopted in clinical practice. A weekly dose of single agent topotecan at 4 mg/m2 in recurrent ovarian cancer has demonstrated similar response and toxicity to the FDA approved dose, with the addition of a convenience factor that is more attractive to some practitioners and patients [63, 92, 128, 138]. In this case, topotecan

Table 6.2 Commonly used doses of irinotecan in colorectal cancer Dose Interval Regimen mg/m2

125 180 mg/m2 350 mg/m2

Weekly ×4; 2 weeks off Every 14 days Every 21 days

Single agent or IFL; combination with MoAbs FolFIRI Single Agent

Table 6.3 Current FDA approved doses of topotecan Cancer site FDA approved dose/interval Ovarian, small cell lung Cancer Small Cell Lung Cancer Cervical Cancer

1.5 IV × 5 days every 21 days 2.3 mg/m2 /day PO × 5 days 0.75 mg/m2 /day IV × 3 days (with cisplatin 50 mg/m2 on day 1) every 21 days mg/m2 /day

References [26, 121, 129] [33] [27]

References [145, 152] [34] [81]

114

M. Newton et al.

is given weekly for 3 doses, with one week of rest. Dose reductions are necessary for renal insufficiency or hematologic toxicity. Topotecan’s S-phase specificity has made it an attractive agent for use as a continuous infusion. In an AML salvage regimen combining topotecan with fludarabine and cytarabine, topotecan was dosed at 1.25 mg/m2 /day × 5 days and given as a continuous infusion [45]. Longer protracted infusions of topotecan have also been studied in solid tumors with doses of 0.3–0.4 mg/m2 /day × 14 to 21 days [30, 56, 60, 61]. These strategies have shown a trend toward increased hematological toxicities. High doses of topotecan have also been studied alone and in combination as preparative regimens for stem cell transplant, with mean tolerated doses up to 9 mg/m2 /day × 5 days [82]. Doses of this magnitude are still under early investigation, and are followed by stem cell rescue.

6.8 Dose Adjustments 6.8.1 Topotecan Dosage adjustments are required in individuals with impaired renal function. The clearance of total topotecan is decreased by 33 and 75% in those with estimated creatinine clearances (CrCL) of 40–59 mL/min and 20–39 mL/min, respectively [100]. There is insufficient data available in patients with severe renal insufficiency. The following dosing adjustments have been recommended (Prod Info 2007) (Table 6.4). No dosage adjustment is required for treating patients with impaired hepatic function (plasma bilirubin >1.5 to <10 mg/dL). Dosage reduction may be necessary for subsequent courses if patient experienced grade IV hematologic toxicity. Therapy should not be initiated until ANC

Table 6.4 Dose adjustment recommendations for topotecan in renal dysfunction Creatinine clearance (mL/min) Adjusted dose 40–60 20–39 <20

No change Decrease dose by 50% Insufficient data

Table 6.5 Dose adjustment of topotecan for hematologic toxicity Previous cycle toxicity Action Grade IV neutropenia > 7 days or Febrile neutropenia Platelets < 25,000/mm3

Reduce dose by 0.25 mg/m2 or Use granulocyte growth factor with next cycle Reduce dose by 0.25 mg/m2

> 1500 cells/mm3 and platelets > 100,000 cells/mm3 (Prod Info Hycamtin 2007) (Table 6.5).

6.8.2 Irinotecan No dosage adjustments for patients with renal insufficiency or failure are recommended. No specific dosage adjustments exist in patients with hepatic insufficiency. Dosing for patients with bilirubin > 2 mg/dL, or transaminase > 3 times upper limit of normal (ULN) with no liver metastasis, or transaminase > 5 times ULN with liver metastasis, cannot be recommended as there is insufficient information in this patient population. Patients with deficient glucuronidation of bilirubin, such as those with Gilbert’s syndrome, may be at greater risk of myelosuppression (Prod Info Camptosar 2007). Extreme caution should be taken when administering irinotecan to patients with impaired hepatic function and increased bilirubin, and a 43% reduction in dose has been recommended in individuals whose bilirubin is 1.5–3 times ULN [113, 150]. When administered in combination with other agents, or as a single agent, initial dose reductions should be considered in patients with any of the following conditions: age > 65 years, prior pelvic/abdominal radiotherapy, performance status of 2, increased bilirubin levels, or in patients known to be homozygous for the UGT1A1∗ 28 allele [123] (Prod Info Camptosar 2007). Subsequent dosing modifications should be based on worst preceding toxicities. Patients must be closely monitored for toxicity and assessed prior to each treatment. Subsequent dosing should be modified based upon individual tolerance to treatment regimen (see Tables 6.6 and 6.7). A new cycle of therapy should not be initiated until the toxicity has recovered to NCI grade I or less. Treatment may be delayed 1–2 weeks

6

Topoisomerase I Inhibitors – The Camptothecins

115

Table 6.6 Dose adjustment of irinotecan based on hematologic and nonhematologic toxicities when used in combination with fluorouracil and leucovorin CAMPTOSAR/5-Fluorouracil (5-FU)/Leucovorin (LV) Combination Schedules Patients should return to pre-treatment bowel function without requiring antidiarrhea medications for at least 24 h before the next chemotherapy administration. A new cycle of therapy should not begin until the granulocyte count has recovered to ≥l500 mm3, and the platelet count has recovered to ≥100,000 mm3 , and treatment-related diarrhea is fully resolved. Treatment should be delayed 1–2 weeks to allow for recovery from treatment-related toxicities. If the pa dent has not recovered after a 2-week delay, consideration should be given to discontinuing therapy

Toxicity NCI CTC gradea (value)

During a cycle of therapy

At the start of subsequent cycles of Therapy of therapyb

No toxicity

Maintain dose level

Maintain dose level

Neutropenia 1 (1500–1999 mm3 ) 2 (1000–1499 mm3 ) 3 (500–999 mm3 ) 4 (<500 mm3 )

Maintain dose level ↓ 1 dose level Omit dose until resolved to ≤ grade 2, then ↓ 1 dose level Omit dose until resolved to ≤ grade 2, then ↓ 2 dose levels

Maintain dose level Maintain dose level ↓ 1 dose level ↓ 2 dose levels

Neutropenic fever

Omit dose until resolved, then ↓ 2 dose levels

Other hematologic toxicities

Dose modifications for leukopenia or thrombocytopenia during a cycle of therapy and at the start of subsequent cycles of therapy ace also based on NCI toxicity criteria and are the same as recommended for neutropenia above.

Diarrhea 1 (2–3 stools/day> pretxc ) 2 (4–6 stools/day> pretx) 3 (7–9 stools/day> pretx) 4 (≥10 stools/day> pretx)

Delay dove until resolved to baseline, then give same dose Omit dose until resolved to baseline, then ↓ 1 dose level Omit dose until resolved to baseline, then ↓ 1 dose level Omit dose until resolved to baseline, then ↓ 2 dose levels

Maintain dose level Maintain dose level ↓ dose level ↓ 2 dose levels

Other nonhematologic toxicitiesd 1 2 3 4

Maintain dose level Omit dose until resolved to ≤ grade 1, then ↓ 1 dose level Omit dose until resolved to ≤ grade 2, then ↓ 1 dose level Omit dose until resolved to ≤ grade 2, then ↓ 2 dose levels

Maintain dose level Maintain dose level ↓ 1 dose level ↓ 2 dose levels

For mucositis/stomatitis decrease only 5-FU, not CAMPTOSAR

For mucositis/stomatitis decrease only 5-FU, not CAMPTOSAR

a National

Cancer Institute Common Toxicity Criteria (version 1.0) to the starting dose used in the previous cycle c Pretreatment d Excludes alopecia, anorexia, asthenia b Relative

for recovery from treatment-related toxicity (Prod Info Camptosar 2007).

6.9 Toxicity 6.9.1 Topotecan Myelosuppression, primarily neutropenia, is the dose limiting toxicity (DLT) for all administration schedules of topotecan in solid tumor patients [15, 24, 25, 60,

79, 104, 126, 149]. It is dose related, reversible, and non-cumulative over time. The incidence of Grade IV neutropenia for the approved dosing regimen was 60% during the first course of treatment (Prod Info Hycamtin 2007). The nadir neutrophil count occurred at a median of 12 days with median duration being one week. Febrile neutropenia occurred in 23% of patients. Severe grade IV thrombocytopenia occurred in nearly 30% with a median duration of 5 days reaching its nadir at day 15. The degree of myelotoxicity appears to be related to administration schedule.

116

M. Newton et al.

Table 6.7 Dose modification of irinotecan when given as a single agent A new cycle of therapy should not begin until the granulocyte count has recovered to ≥1500 mm3 , and the platelet count has recovered to ≥100,000 mm3 , and treatment-related diarrhea is fully revolved. Treatment should be delayed 1–2 weeks to allow for recovery from treatment-related toxicities. If the patient has not recovered after a 2-week delay, consideration should be given to discontinuing CAMPTOSAR. Werst toxicity NCI gradeb (value)

During a cycle of therapy

At the start of the next cycles of therapy (after adequate recovery). compared with the starring dose in the previous cyclea

Weekly

Weekly

Once every 3 weeks

Maintain dose level

up to a ↑ 25 maximum dose of 150 mg/m2

Maintain dose level

mg/m2

No toxicity Neutropenia 1 (1500–1999 mm3 ) 2 (1000–1499 mm3 ) 3 (500–999 mm3 )

4 (<500 mm3 )

Neutropenic fever

Other hematologic toxicities Diarrhea 1 (2–3 stools/day > pretxc ) 2 (4–6 stools/day > pretx) 3 (7–9 stools/day > pretx)

4 (≥10 stools/day > pretx)

Maintain dose level Maintain dose level Maintain dose level ↓ 25 mg/m2 Maintain dose level Maintain dose level Omit dose until revolved to ↓ 25 mg/m2 ↓ 50 mg/m2 ≤ grade 2, then ↓ 25 mg/m2 Omit dose until revolved to ↓ 50 mg/m2 ↓ 50 mg/m2 ≤ grade 2, then ↓ 50 mg/m2 Omit dose until revolved, ↓ 50 mg/m2 ↓ 50 mg/m2 then v 50 nig in” when resolved Dose modifications for leucopenia, thrombocytopenia, and anemia during a cycle of therapy and at the start of subsequent cycles of therapy are also based on NCI toxicity criteria and are the same as recommended for neutropenia above. Maintain dose level ↓ 25 mg/m2 Omit dose until revolved to ≤ grade 2, then ↓ 25 mg/m2 Omit dose until revolved to ≤ grade 2, then ↓ 50 mg/m2

Other nonhematologicd toxicities 1 2 3

Maintain dose level Maintain dose level ↓ 25 mg/m2

Maintain dose level Maintain dose level ↓ 50 mg/m2

↓ 50 mg/m2

↓ 50 mg/m2

Maintain dose level Maintain dose level ↓ 25 mg/m2 ↓ 25 mg/m2 Omit dose until revolved to ↓ 25 mg/m2 ≤ grade 2, then ↓ 25 mg/m2 4 Omit dose until revolved to ↓ 50 mg/m2 ≤ grade 2, then ↓ 50 mg/m2 a All dose modifications should be based on the worst preceding toxicity b National Cancel Institute Common Toxicity Criteria (version 1.0) c Pretreatment d Excludes alopecia, anorexia, asthenia

In comparison to the standard dosing regimen, continuous infusion regimens have been associated with dose-limiting thrombocytopenia and anemia in addition to severe neutropenia [8, 24, 60, 108, 148].

Maintain dose level ↓ 50 mg/m2 ↓ 50 mg/m2 ↓ 50 mg/m2

At increased dosages of up to 4.5 mg/m2 in the acute leukemia setting, severe mucositis emerged as a complicating feature as well [127]. In addition, the dose-limiting toxicities were an unexpected

6

Topoisomerase I Inhibitors – The Camptothecins

constellation of adverse events, consisting of high fevers, chills and rigors, sudden decreases in hematocrit, and hyperbilirubinemia. The precise etiology of these effects is unknown; however, high doses of topotecan may induce acute hemolytic reactions in this patient population. Myelosuppression with topotecan has tended to be more severe in patients that have received extensive prior therapy [14, 24] and those receiving concurrent cisplatin chemotherapy [91]. Non-hematologic toxicities are usually mild and self-limiting including nausea and vomiting, fatigue, stomatitis, headache, alopecia, fever, pain, and rash.

6.9.2 Irinotecan The DLT’s for all dosing regimens are severe lateonset diarrhea and neutropenia [85, 97, 122] (Prod Info R ). The incidence of grade III or IV Camptosar 2007 diarrhea was reported in up to 37% of patients in phase I clinical trials. The onset is typically between days 5 and 12 dependent upon dosing regimen and schedule with severe diarrhea lasting 5–7 days. It can be potentially life-threatening so patients should be carefully monitored for dehydration and supported with fluid and electrolyte replacement as needed. Management of diarrhea should include prompt treatment with high dose loperamide [1]. Neutropenia is dose-related, generally brief, and non-cumulative in nature. The frequency of severe neutropenia has been reported in 14– 47% of patients receiving the every 3 week schedule and to a lesser extent, 12–19%, with weekly administration [28, 120, 124, 125]. Patients who have had prior pelvic or abdominal irradiation or those with elevated bilirubin levels have significantly greater likelihood of severe neutropenia (Prod Info Camptosar 2007). Given Table 6.8 Topotecan interactions Agent Effect Phenytoin (Zamboni et al. [159]

Docetaxel (Zamboni et al. [158]

Neupogen (Slichenmyer et al. [136])

Increased topotecan Clearance

117

the brief duration of severe neutropenia, the incidence of febrile neutropenia is low with an incidence of 3%. Early-onset diarrhea can occur during or within 24 h of administration. It is usually transient and is felt to be secondary to a cholinergic syndrome resulting from inhibition of acetyl cholinesterase activity. Symptoms may include: rhinitis, increased salivation, miosis, lacrimation, diaphoresis, flushing, and intestinal hyperperistalsis that can cause abdominal cramping and early-onset diarrhea. These effects are usually short-lasting and respond to atropine 0.5–1 mg IV or subcutaneous as needed. Prophylactic atropine may be considered for subsequent treatments [16]. Other non-hematologic adverse events that have been reported include: nausea and vomiting, abdominal pain, fatigue, alopecia, stomatitis, asthenia, fever, liver transaminase elevation, rash, flushing, and bradycardia. All are highly manageable and self-limiting.

6.10 Drug Interactions 6.10.1 Topotecan Pharmacokinetic studies of the interaction of topotecan with concomitantly administered medications have not been formally investigated. In vitro inhibition studies utilizing marker substrates known to be metabolized by human cytochrome P450 enzymes (CYP1A2, CYP2A6, CYP2C8/9, CYP2C19, CYP2D6, CYP2E, CYP3A, CYP4A), or dihydropyridine dehydrogenase indicated no alteration in enzyme activity by topotecan (Prod Info Hycamtin 2007). However, there have been reports of altered clearance in patients receiving concurrent treatment with agents that affect P-450 enzymes (see Table 6.8). These findings are consistent with a potential interaction at the CYP3A level, however, additional study is warranted to better define.

Proposed mechanism Induction of hepatic metabolism

Clinical management

Avoid concurrent therapy if possible; consider increasing dose of topotecan Docetaxel clearance decreased CYP3A4 inhibition altering Change administration by 50% when given on day 4 docetaxel metabolism schedule-administer of topotecan therapy docetaxel on day 1 Increased myelosuppression Increased precursors entering Initiated at least 24 h post S-phase topotecan administration

118

M. Newton et al.

Table 6.9 Irinotecan interactions Agent Effect Ketoconazole [73]

St John’s Wort [87]

Enzyme-inducing anti-epileptic May decrease antineoplastic drugs i.e. phenytoin, activity carbamazepine, phenobarbital, valproic acid [41, 50, 54, 95, 107] Dexamethasone chronic May decrease antineoplastic dosing [37] activity

Bevacizumab (Bevacizumab Presribing Info 2006, Genentech) Atazanavir [102]

Proposed mechanism

SN-38 AUC increased by CYP3A4 inhibition 109% while APC was reduced by 87% SN-38 AUC decreased by 42% CYP3A4 induction

Concurrent utilization is contraindicated Induction of hepatic May need to increase irinotecan metabolization via CYP3A4 dose for therapeutic effect or or glucuronidation utilization of a non-enzyme inducing anti-epileptic Induction of hepatic metabolism and increased clearance

SN-38 increased by 33%

Unknown

May increase risk of toxicity

UGT1A1 inhibition

6.10.2 Irinotecan As previously described (see Section 6.6), the metabolism of irinotecan is complex (Fig. 6.5) involving several enzyme systems, including carboxyl esterase isoenzymes, glucuronidation, and CYP3A4mediated oxidation. As a result, the potential for multiple drug interactions exist. The extent and clinical impact of the interaction is dependent upon the enzyme system affected (Table 6.9). Concurrent administration of ketoconazole and St Johns Wort with irinotecan is contraindicated (Product Info Camptosar 2007). And although limited data exists with drug-drug interactions, clinicians must be conscientious of the potential effects when prescribing agents that may interfere with the metabolism of irinotecan as the consequences may be significant.

3.

References

8.

1. Abigerges D, Armand JP, Chabot GG et al (1994) Irinotecan (CPT-11) high-dose escalation using intensive high-dose loperamide to control diarrhea. J Natl Cancer Inst 86(6):446–449 2. Anton A, Aranda E (1998) Phase II study of irinotecan (cpt-11) in the treatment of patients with advanced colorectal cancer (acrc) resistant to 5-fluoracil (5-fu) based

Clinical management Concurrent utilization is contraindicated

4.

5.

6.

7.

9.

10.

May need to increase irinotecan dose for therapeutic effect; effect of single-dose dexamethasone is unknown but clinical interventions appear unnecessary Monitor for severe diarrhea and neutropenia and adjust dose as indicated Combination should be avoided if possible

chemotherapy the experience of TTD Spanish cooperative group (meeting abstract). Proc Am Soc Clin Oncol 17:278a Batchelor TT, Gilbert MR, Supko JG et al (2004) Phase 2 study of weekly irinotecan in adults with recurrent malignant glioma: final report of nabtt 97–11. Neuro Oncol 6:21–27 Beppu K, Nakamura K, Linehan WM, Rapisarda A, Thiele C (2005) Topotecan blocks hypoxia-inducible factor-1α and vascular endothelial growth factor expression induced by insulin-like growth factor-1 in neuroblastoma cells. Cancer Res 65(11):4775–4781 Beran M, Estey E, O’Brien SM et al (1998) Results of topotecan single-agent therapy in patients with myelodysplastic syndromes and chronic myelomonocytic leukemia. Leuk Lymphoma 31:521–531 Beran M, Estey E, O’Brien S et al (2006) Topotecan and cytarabine is an active combination regimen in myelodysplastic syndromes and chronic myelomonocytic leukemia. J Clin Oncol 17:2819–2830 Bisogno G, Riccardi R, Ruggiero A et al (2006) Phase II study of a protracted irinotecan schedule in children with refractory or recurrent soft tissue sarcoma. Cancer 106:703–707 Blaney SM, Balis FM, Cole DE et al (1993) Pediatric phase I trial and pharmacokinetic study of topotecan administered as a 24-hour continuous infusion. Cancer Res 53:1032–1036 Blaney SM, Cole DE, Balis FM et al (1993) Plasma and cerebrospinal fluid pharmacokinetic study of topotecan in nonhuman primates. Cancer Res 53:725–727 Blaney SM, Heideman R, Berg S et al (2003) Phase i clinical trial of intrathecal topotecan in patients with neoplastic meningitis. J Clin Oncol 21:143–147

6

Topoisomerase I Inhibitors – The Camptothecins 11. Blaney SM, Takimoto C, Murry DJ et al (1998) Plasma and cerebrospinal fluid pharmacokinetics of 9-aminocamptothecin (9-ac), irinotecan (cpt-11), and sn38 in nonhuman primates. Cancer Chemother Pharmacol 41:464–468 12. Bos AME, De Vos FYFL, de Vries EGE et al (2005) A phase I study of intraperitoneal topotecan in combination with intravenous carboplatin and paclitaxel in advanced ovarian cancer. Eur J Cancer 41:539–548 13. Bottero V, Busuttil V, Loubat A et al (2001) Acitvation of nuclear factor kappaB through the IKK complex by the topoisomerase poisons SN38 and doxorubicin: a brake to apoptosis in HeLa human carcinoma cells. Cancer Res 61:7785–7791 14. Brogden RN, Wiseman LR (1998) Topotecan. A Review of its potential in advanced ovarian cancer. Drugs 56: 709–723 15. Burris HA, Rothenberg ML, Kuhn JG et al (1992) Clinical trials with the topoisomerase inhibitors. Semin Oncol 19:663–669 16. Cersosimo RJ (1998) Irinotecan: a new antineoplastic agent for the management of colorectal cancer. Ann Pharmacother 32(12):1324–1333 17. Chabot GG (1997) Clinical pharmacokinetics of irinotecan. Clin Pharmacokinet 33:245–259 18. Chamberlain MC (2002) Salvage chemotherapy with cpt-11 for recurrent oligodendrogliomas J Neurooncol 59:157–163 19. Champoux JJ (2001) DNA topoisomerases: structure, function, and mechanism. Annu Rev Biochem 70: 369–413 20. Chu XY, Suzuki H, Ueda K et al (1999) Active efflux of CPT-11 and its metabolites in human KB-derived cell lines. J Pharmacol Exp Ther 288:735–741 21. Clements MK, Jones CB, Cumming M, Daoud SS (1999) Antiangiogenic potential of camptothecin and topotecan. Cancer Chemother Pharmacol 44:411–416 22. Cloughesy TF, Filka E, Kuhn J et al (2003) Two studies evaluating irinotecan treatment for recurrent malignant glioma using an every-3-week regimen. Cancer 97: 2381–2386 23. Creemers GJ, Bolis G, Gore M et al (1996) Topotecan, an active drug in the second-line treatment of epithelial ovarian cancer: results of a large european phase II study. J Clin Oncol 14:3056–3061 24. Creemers GJ, Lund B, Verweijt J (1994) Topoisomerase I inhibitors: topotecan and irinotecan. Cancer Treat Rev 20:73–96 25. Creemers GJ, Wanders J, Gamucci T et al (1995) Topotecan in colorectal cancer: a phase II study of the EORTC early clinical trials group. Ann Oncol 6(suppl):844–846 26. Cunningham D, Humblet Y, Siena S et al (2004) Cetuximab monotherapy and cetuximab plus irinotecan in irinotecan-refractory metastatic colorectal cancer. N Engl J Med 351:337–345 27. Cunningham D, Pyrhönen S, James RD et al (1998) Randomised trial of irinotecan plus supportive care versus supportive care alone after fluorouracil failure for patients with metastatic colorectal cancer. Lancet 352: 1413–1418

119 28. Cunningham D, Glimelius B (1999) A phase III study of irinotecan (CPT-11) versus best supportive care in patients with metastatic colorectal cancer who have failed 5-fluorouracil therapy. V301 study group. Semin Oncol 26:6–12 29. de Jong FA, Kehrer DFS, Mathijssen RHJ et al (2006) Prophylaxis of irinotecan-induced diarrhea with neomycin and potential role for ugt1a1∗ 28 genotype screening: a double-blind, randomized, placebo-controlled study. Oncologist 11:944–954 30. Denschlag D, Watermann D, Hörig K et al (2004) Topotecan as a continuous infusion over 14 days in recurrent ovarian cancer patients. Anticancer Res 24: 1267–1269 31. Desai AA, Kindler HL, Taber D et al (2005) Modulation of irinotecan with cyclosporine: a phase II trial in advanced colorectal cancer. Cancer Chemother Pharmacol 56:421–426 32. Dodds HM, Haaz MC, Riou JF et al (1998) Identification of a new metabolite of cpt-11 (irinotecan): pharmacological properties and activation to sn-38. J Pharmacol Exp Ther 286:578–583 33. Douillard JY, Cunningham D, Roth AD et al (2000) Irinotecan combined with fluorouracil compared with fluorouracil alone as first-line treatment for metastatic colorectal cancer: a multicentre randomised trial. Lancet 355:1041–1047 34. Eckardt JR, von Pawel J, Papai Z et al (2006) Open-label, multicenter, randomized, phase iii study comparing oral topotecan/cisplatin versus etoposide/cisplatin as treatment for chemotherapy-naive patients with extensive-disease small-cell lung cancer. J Clin Oncol 24:2044–2051 35. Eckardt JR, von Pawel J, Pujol J et al (2007) Phase III study of oral compared with intravenous topotecan as second-line therapy in small-cell lung cancer. J Clin Oncol 25:2086–2092 36. Fassberg J, Stella VJ (1992) A kinetic and mechanistic study of the hydrolysis of camptothecin and some analogues. J Pharm Sci 81:676–684 37. Friedman HS, Petros WP, Friedman AH et al (1999) Irinotecan therapy in adults with recurrent or progressive malignant glioma J Clin Oncol 17:1516–1525 38. Friedman HS, Prados MD, Wen PY et al (2009) Bevacizumab alone and in combination with irinotecan in recurrent glioblastoma. J Clin Oncol 27:4733–4740 39. Frontini L, Labianca R, Sobrero A, Rosso R, Turci D, Pergola M, Frassineti GL, D’Aprile M, Cascinu S, Nobile MT, Aschele C, Pessi A, Martignoni G, Lionetto R, Comis S, Bruzzi P, Luporini G (1999) Irinotecan (cpt-11) is effective as second-line chemotherapy in advanced colorectal cancer (acc): a phase II trial of giscad (italian group for the study of gastrointestinal cancer) (meeting abstract). Proc Am Soc Clin Oncol 18:260a 40. Gagné J, Montminy V, Belanger P et al (2002) Common human ugt1a polymorphisms and the altered metabolism of irinotecan active metabolite 7-ethyl10-hydroxycamptothecin (sn-38). Mol Pharmacol 62: 608–617 41. Gajjar A, Radomski K, Bowers D et al (2000) Pharmacokinetics of irinotecan (IRN) and metabolites in pediatric high-grade glioma patients with and without

120

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

M. Newton et al. co-administration of enzyme inducing anticonvulsants. ASCO 2000 (abstract 626) Gallo JM, Laub PB, Rowinsky EK et al (2000) Population pharmacokinetic model for topotecan derived from phase I clinical trials. J Clin Oncol 18:2459–2467 Gammon DC, Bhatt MS, Tran L et al (2006) Intrathecal topotecan in adult patients with neoplastic meningitis. Am J Health Syst Pharm 63:2083–2086 Gelderblom H, Loos WJ, Verweij J et al (2000) Topotecan lacks third space sequestration. Clin Cancer Res 6: 1288–1292 Giles FJ, Cortes JE, Kantarjian HM et al (2004) A fludarabine, topotecan, and cytarabine regimen is active in patients with refractory acute myelogenous leukemia. Leuk Res 28:353–357 Gore M, ten Bokkel Huinink W, Carmichael J et al (2001) Clinical evidence for topotecan-paclitaxel non– cross-resistance in ovarian cancer. J Clin Oncol 19: 1893–1900 Gupta E, Lestingi TM, Mick R et al (1994) Metabolic fate of irinotecan in humans: correlation of glucuronidation with diarrhea. Cancer Res 54:3723–3725 Gupta E, Luo F, Lallo A et al (2000) The intestinal absorption of camptothecin, an highly lipophilic drug, across Caco-2 cells is mediated by active transporter(s). Anticancer Res 20:1013–1016 Gupta E, Safa AR, Wang X et al (1996) Pharmacokinetic modulation of irinotecan and metabolites by cyclosporin a. Cancer Res 56:1309–1314 Gupta E, Wang X, Ramirez J et al (1997) Modulation of glucuronidation of SN-38, the active metabolite of irinotecan, by valproic acid and Phenobarbital. Cancer Chemother Pharmacol 39:498–504 Haaz MC, Riché C, Rivory LP et al (1998) Biosynthesis of an aminopiperidino metabolite of irinotecan [7-ethyl10-[4-(1-piperidino)-1-piperidino]carbonyloxycamptothe cine] by human hepatic microsomes. Drug Metab Dispos 26:769–774 Haaz MC, Rivory L, Riché C et al (1998) Metabolism of irinotecan (cpt-11) by human hepatic microsomes: participation of cytochrome p-450 3a and drug interactions. Cancer Res 58:468–472 Haaz MC, Rivory LP, Riché C et al (1997) The transformation of irinotecan (cpt-11) to its active metabolite sn-38 by human liver microsomes. differential hydrolysis for the lactone and carboxylate forms. Naunyn Schmiedebergs Arch Pharmacol 356:257–262 Hahn KK, Wolff JJ, Kolesar JM (2006) Pharmacogenetics and irinotecan therapy. Am J Health Syst Pharm 63: 2211–2217 Hanna N, Bunn PAJ, Langer C et al (2006) Randomized phase iii trial comparing irinotecan/cisplatin with etoposide/cisplatin in patients with previously untreated extensive-stage disease small-cell lung cancer J Clin Oncol 24:2038–2043 Hawkins DS, Bradfield S, Whitlock JA et al (2006) Topotecan by 21-day continuous infusion in children with relapsed or refractory solid tumors: a children’s oncology group study. Pediatr Blood Cancer 47:790–794 Herben VM, Rosing H, ten Bokkel Huinink WW et al (1999) Oral topotecan: bioavailablity and effect of food co-administration. Br J Cancer 80:1380–1386

58. Herben VM, ten Bokkel Huinink WW, Beijnen JH (1996) Clinical pharmacokinetics of topotecan. Clin Pharmacokinet 31:85–102 59. Herben VMM, Schoemaker NE, Rosing H et al (2002) Urinary and fecal excretion of topotecan in patients with malignant solid tumours. Cancer Chemother Pharmacol 50:59–64 60. Hochster H, Liebes L, Speyer J et al (1994) Phase I trial of low-dose continous topotecan infusion in patients with cancer: an active and well-tolerated regimen. J Clin Oncol 12: 553–559 61. Hochster HS, Plimack ER, Mandeli J et al (2006) Prolonged topotecan infusion with cisplatin in the firstline treatment of ovarian cancer: an nygog and ecog study. Gynecol Oncol 100:324–329 62. Hofstra LS, Bos AM, de Vries EG et al (2001) A phase I and pharmacokinetic study of intraperitoneal topotecan. Br J Cancer 85:1627–1633 63. Homesley HD, Hall DJ, Martin DA et al (2001) A dose-escalating study of weekly bolus topotecan in previously treated ovarian cancer patients. Gynecol Oncol 83: 394–399 64. Hsiang YH, Lihou MG, Liu LF (1989) Arrest of replication forks by drug-stabilized topoisomerase I dna cleavable complexes as a mechanism of cell killing by camptothecin. Cancer Res 49:5077–5082 65. Hurwitz H, Fehrenbacher L, Novotny W et al (2004) Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med 350: 2335–2342 66. Innocenti F, Undevia SD, Iyer L et al (2004) Genetic variants in the udp-glucuronosyltransferase 1a1 gene predict the risk of severe neutropenia of irinotecan J Clin Oncol 22:1382–1388 67. Iyer L, Das S, Janisch L et al (2002) Ugt1a1∗ 28 polymorphism as a determinant of irinotecan disposition and toxicity. Pharmacogenomics J 2:43–47 68. Iyer L, King CD, Whitington PF et al (1998) Genetic predisposition to the metabolism of irinotecan (cpt-11). role of uridine diphosphate glucuronosyltransferase isoform 1a1 in the glucuronidation of its active metabolite (sn-38) in human liver microsomes. J Clin Invest 101: 847–854 69. Joppert MG, Garfield DH, Gregurich MA et al (2003) A phase II multicenter study of combined topotecan and gemcitabine as first line chemotherapy for advanced nonsmall cell lung cancer. Lung Cancer 39:215–219 70. Kantarjian H, Beran M, Cortes J et al (2006) Long-term follow-up results of the combination of topotecan and cytarabine and other intensive chemotherapy regimens in myelodysplastic syndrome. Cancer 106:1099–1109 71. Kawabata S, Oka M, Shiozawa K et al (2001) Breast cancer resistance protein directly confers SN-38 resistance of lung cancer cells. Biochem Biophys Res Commun 280:1216–1223 72. Kawato Y, Aonuma M, Hirota Y et al (1991) Intracellular roles of sn-38, a metabolite of the camptothecin derivative cpt-11, in the antitumor effect of cpt-11. Cancer Res 51:4187–4191 73. Kehrer DFS, Mathijssen RHJ, Verweij, J et al (2002) Modulation of irinotecan metabolism by ketoconazole. J Clin Oncol 20:3122–3129

6

Topoisomerase I Inhibitors – The Camptothecins 74. Kehrer DF, Sparreboom A, Verweij J et al (2001) Modulation of irinotecan-induced diarrhea by cotreatment with neomycin in cancer patients. Clin Cancer Res 7:1136–1141 75. Kingsbury WD, Boehm JC, Jakas DR et al (1991) Synthesis of water-soluble (aminoalkyl) camptothecin analogues: inhibition of topoisomerase I and antimtumor activity. J Med Chem 34:98–107 76. Kraut EH, Crowley JJ, Wade JL et al (1998) Evaluation of topotecan in resistant and relapsing multiple myeloma: a southwest oncology group study. J Clin Oncol 16: 589–592 77. Kruijtzer CMF, Beijnen JH, Rosing H et al (2002) Increased oral bioavailability of topotecan in combination with the breast cancer resistance protein and p-glycoprotein inhibitor gf120918. J Clin Oncol 20: 2943–2950 78. Kudoh S, Fujiwara Y, Takada Y et al (1998) Phase ii study of irinotecan combined with cisplatin in patients with previously untreated small-cell lung cancer. west japan lung cancer group. J Clin Oncol 16:1068–1074 79. Law TM, Iison DH, Motzer RJ (1994) Phase II trial of topotecan in patients with advanced renal cell carcinoma. Invest New Drugs 12:143–145 80. Lokiec F, Canal P, Gay C et al (1995) Pharmacokinetics of irinotecan and its metabolites in human blood, bile, and urine. Cancer Chemother Pharmacol 36:79–82 81. Long HJ, Bundy BN, Grendys ECJ et al (2005) Randomized phase III trial of cisplatin with or without topotecan in carcinoma of the uterine cervix: a gynecologic oncology group study. J Clin Oncol 23: 4626–4633 82. Lotz J, Pautier P, Selle F et al (2006) Phase I study of high-dose topotecan with haematopoietic stem cell support in the treatment of ovarian carcinomas: the ITOV 01 protocol. Bone Marrow Transplant 37:669–675 83. Ma J, Maliepaard M, Nooter K et al (1998) Reduced cellular accumulation of topotecan: a novel mechanism of resistance in human ovarian cancer cell line. Br J Cancer 77:1645–1652 84. Maliepaard M, van Gastelen MA, de Jong LA et al (1999) Overexpression of the bcrp/mxr/abcp gene in a topotecan-selected ovarian tumor cell line. Cancer Res 59:4559–4563 85. Mathijssen RH, van Alphen RJ, Verweij J et al (2001) Clinical pharmacokinetics and metabolism of irinotecan (cpt-11). Clin Cancer Res 7:2182–2194 86. Mathijssen RHJ, Loos WJ, Verweij J et al (2002) Pharmacology of topoisomerase I inhibitors irinotecan (cpt-11) and topotecan. Curr Cancer Drug Targets 2: 103–123 87. Mathijssen RHJ, Verweij, J, de Bruijn P et al (2002) Effects of St John’s wort on irinotecan metabolism. J Natl Cancer Inst 94: 1247–1249 88. McGuire WP, Blessing JA, Bookman MA et al (2000) Topotecan has substantial antitumor activity as first-line salvage therapy in platinum-sensitive epithelial ovarian carcinoma: a gynecologic oncology group study. J Clin Oncol 18:1062–1067 89. McLeod HL, Keith WN (1996) Variation in topoisomerase I gene copy number as a mechanism for intrinsic drug sensitivity. Br J Cancer 74:508–512

121 90. McLeod HL, Watters JW (2004) Irinotecan pharmacogenetics: is it time to intervene? J Clin Oncol 22:1356–1359 91. Miller AA, Lilenbaum RC, Lynch TJ et al (1996) Treatment-related fatal sepsis from topotecan/cisplatin and topotecan/paclitaxel. J Clin Oncol 14:1964–1965 92. Morris RT (2003) Weekly topotecan in the management of ovarian cancer. Gynecol Oncol 90:S34–S38 93. Mould DR, Holford NHG, Schellens JHM et al (2002) Population pharmacokinetic and adverse event analysis of topotecan in patients with solid tumors. Clin Pharmacol Ther 71:334–348 94. Muderspach LI, Blessing JA, Levenback C et al (2001) A phase ii study of topotecan in patients with squamous cell carcinoma of the cervix: a gynecologic oncology group study. Gynecol Oncol 81:213–215 95. Murry DJ, Cherrick I, Salama V et al (2002) Influence of phenytoin on the disposition of irinotecan: a case report. J Pediatr Hematol Oncol 24:130–133 96. Nakano T, Chahinian AP, Shinjo M et al (1999) Cisplatin in combination with irinotecan in the treatment of patients with malignant pleural mesothelioma: a pilot phase ii clinical trial and pharmacokinetic profile. Cancer 85: 2375–2384 97. Negoro S, Fukuoka M, Masuda N et al (1991) Phase I study of weekly intravenous infusions of CPT-11, a new derivative of camptothecin, in the treatment of advanced non-small-cell lung cancer. J Natl Cancer Inst 83: 1164–1168 98. Noda K, Nishiwaki Y, Kawahara M et al (2002) Irinotecan plus cisplatin compared with etoposide plus cisplatin for extensive small-cell lung cancer N Engl J Med 346: 85–91 99. O’Reilly S, Rowinsky E, Slichenmyer W et al (1996) Phase I and pharmacologic studies of topotecan in patients with impaired hepatic function. J Natl Cancer Inst 88: 817–824 100. O’Reilly S, Rowinsky EK, Slichenmyer W et al (1996) Phase I and pharmacologic study of topotecan in patients with impaired renal function. J Clin Oncol 14:3062–3073 101. Ohe Y, Ohashi Y, Kubota K et al (2007) Randomized phase III study of cisplatin plus irinotecan versus carboplatin plus paclitaxel, cisplatin plus gemcitabine, and cisplatin plus vinorelbine for advanced non-small-cell lung cancer: four-arm cooperative study in Japan. Ann Oncol 18:317–323 102. Orrick JJ, Steinhart CR (2004) Atazanavir. Ann Pharmacother 38:1664–1674 103. Perez EA, Hillman DW, Mailliard JA et al (2004) Randomized phase II study of two irinotecan schedules for patients with metastatic breast cancer refractory to an anthracycline, a taxane, or both. J Clin Oncol 22: 2849–2855 104. Perez-Soler R, Glisson BS, Lee JS et al (1996) Treatment of patients with small-cell lung cancer refractory to teniposide and cisplatin with the topoisomerase I poison topotecan. J Clin Oncol 14:2785–2790 105. Pizzolato JF, Saltz LB (2003) The camptothecins. Lancet 361:2235–2242 106. Plo I, Liao ZY, Barcelo JM et al (2003) Association of XRCC1 and tyrosyl DNA phosphodiesterase (Tdp1) for the repair of topoisomerase I-mediated DNA lesions. DNA Repair 2:1087–1100

122 107. Prados MD, Lamborn K, Yung WKA et al (2006) A phase 2 trial of irinotecan (cpt-11) in patients with recurrent malignant glioma: a North American brain tumor consortium study Neuro Oncol 8:189–193 108. Pratt CB, Steward C, Santana VM et al (1994) Phase I study of topotecan for pediatric patients with malignant solid tumors. J Clin Oncol 12:539–543 109. Rajendra R, Gounder MK, Saleem A et al (2003) Differential effects of the breast cancer resistance protein on the cellular accumulation and cytotoxicity of 9-aminocamptothecin and 9-nitrocamptothecin. Cancer Res 63:3228–3233 110. Ramlau R, Gervais R, Krzakowski M et al (2006) Phase III study comparing oral topotecan to intravenous docetaxel in patients with pretreated advanced non-small-cell lung cancer. J Clin Oncol 24:2800–2807 111. Rapisarda A, Uranchimeg B, Sordet O, Pommier Y, Shoemaker RH, Melillo G (2004) Topoisomerase I mediated inhibition of hypoxia inducible factor 1: mechanism and therapeutic inplications. Cancer Res 64: 1475–1482 112. Rasheed ZA, Rubin EH (2003) Mechanisms of resistance to topoisomerase I-targeting drugs. Oncogene 22: 7296–7304 113. Raymond E, Boige V, Faivre S et al (2002) Dosage adjustment and pharmacokinetic profile of irinotecan in cancer patients with hepatic dysfunction. J Clin Oncol 20:4303–4312 114. Ribrag V, Suzan F, Ravoet C et al (2003) Phase II trial of cpt-11 in myelodysplastic syndromes with excess of marrow blasts. Leukemia 17:319–322 115. Rivory LP, Riou JF, Haaz MC et al (1996) Identification and properties of a major plasma metabolite of irinotecan (cpt-11) isolated from the plasma of patients. Cancer Res 56:3689–3694 116. Rivory LP, Robert J (1995) Identification and kinetics of a beta-glucuronide metabolite of sn-38 in human plasma after administration of the camptothecin derivative irinotecan. Cancer Chemother Pharmacol 36:176–179 117. Rocha Lima CM, Green MR, Rotche R et al (2004) Irinotecan plus gemcitabine results in no survival advantage compared with gemcitabine monotherapy in patients with locally advanced or metastatic pancreatic cancer despite increased tumor response rate. J Clin Oncol 22:3776–3783 118. Rosing H, Herben VM, van Gortel-van Zomeren DM et al (1997) Isolation and structural confirmation of n-desmethyl topotecan, a metabolite of topotecan. Cancer Chemother Pharmacol 39:498–504 119. Rosing H, van Zomeren DM, Doyle E et al (1998) O-glucuronidation, a newly identified metabolic pathway for topotecan and n-desmethyl topotecan. Anticancer Drugs 9:587–592 120. Rothenberg ML, Cox JV, DeVore RF et al (1999) A multicenter, phase II trial of weekly irinotecan (cpt-11) in patients with previously treated colorectal carcinoma. Cancer 85:786–795 121. Rothenberg ML, Eckardt JR, Kuhn JG et al (1996) Phase II trial of irinotecan in patients with progressive or rapidly recurrent colorectal cancer. J Clin Oncol 14: 1128–1135

M. Newton et al. 122. Rothenberg M, Kuhn J, Burris H et al (1993) Phase I and pharmacokinetic trial of weekly CPT-11. J Clin Oncol 11:2194–2204 123. Rougier P, Bugat R (1996) CPT-11 in the treatment of colorectal cancer: clinical efficacy and safety profile. Semin Oncol 23: 34–41 124. Rougier P, Bugat R, Douillard JY et al (1997) Phase II study of irinotecan in the treatment of advanced colorectal cancer in chemotherapy-naive patients and patients pretreated with fluorouracil-based chemotherapy. J Clin Oncol 15:251–260 125. Rougier P, Van Cutsem E, Bajetta E et al (1998) Randomised trial of irinotecan versus fluorouracil by continuous infusion after fluorouracil failure in patients with metastatic colorectal cancer. Lancet 352:1407–1412 126. Rowinski EK, Grochow LB, Hendricks CB et al (1992) Phase I and pharmacologic study of topotecan: a novel topoisomerase I inhibitor. J Clin Oncol 10:647–656 127. Rowinski EK, Kaufmann SH, Baker SD et al (1996) A Phase I and pharmacological study of topotecan infused over 30 minutes for five days in patients with refractory acute leukemia. Clin Cancer Res 2:1921–1930 128. Safra T, Menczer J, Bernstein R et al (2007) Efficacy and toxicity of weekly topotecan in recurrent epithelial ovarian and primary peritoneal cancer. Gynecol Oncol 105: 205–210 129. Saltz LB, Cox JV, Blanke C et al (2000) Irinotecan plus fluorouracil and leucovorin for metastatic colorectal cancer. Irinotecan study group. N Engl J Med 343:905–914 130. Saltz LB, Niedzwiecki D, Hollis D et al (2007) Irinotecan fluorouracil plus leucovorin is not superior to fluorouracil plus leucovorin alone as adjuvant treatment for stage iii colon cancer: results of calgb 89803. J Clin Oncol 25:3456–3461 131. Sanghani SP, Quinney SK, Fredenburg TB et al (2003) Carboxylesterases expressed in human colon tumor tissue and their role in cpt-11 hydrolysis. Clin Cancer Res 9:4983–4991 132. Sanghani SP, Quinney SK, Fredenburg TB et al (2004) Hydrolysis of irinotecan and its oxidative metabolites, 7-ethyl-10-[4-n-(5-aminopentanoic acid)-1piperidino] carbonyloxycamptothecin and 7-ethyl-10[4-(1-piperidino)-1-amino]-carbonyloxycamptothecin, by human carboxylesterases ces1a1, ces2, and a newly expressed carboxylesterase isoenzyme, ces3. Drug Metab Dispos 32:505–511 133. Sarris AH, Phan A, Goy A et al (2002) Irinotecan in relapsed or refractory non-hodgkin’s lymphomas. indications of activity in a phase ii trial. Oncology (Williston Park) 16:27–31 134. Schellens JH, Creemers GJ, Beijnen JH et al (1996) Bioavailability and pharmacokinetics of oral topotecan: a new topoisomerase i inhibitor. Br J Cancer 73:1268–1271 135. Slatter JG, Schaaf LJ, Sams JP et al (2000) Pharmacokinetics, metabolism, and excretion of irinotecan (cpt-11) following i.v. infusion of [(14)c]cpt-11 in cancer patients. Drug Metab Dispos 28:423–433 136. Slichenmyer WJ, Rowinsky EK, Donehower RC, Kaufmann SH (1993) The current status of camptothecin analogues as antitumor agents. J Natl Cancer Inst 85:271–291

6

Topoisomerase I Inhibitors – The Camptothecins

137. Sorensen M, Sehested M, Jensen PB (1995) Characterisation of a human small-cell lung cancer cell line resistant to the DNA topoisomerase I-directed drug topotecan. Br J Cancer 72:399–404 138. Spannuth WA, Leath CA3, Huh WK et al (2007) A phase II trial of weekly topotecan for patients with secondary platinum-resistant recurrent epithelial ovarian carcinoma following the failure of second-line therapy. Gynecol Oncol 104:591–595 139. Sparreboom A, de Jonge MJ, de Bruijn P et al (1998) Irinotecan (cpt-11) metabolism and disposition in cancer patients. Clin Cancer Res 4:2747–2754 140. Stewart CF, Iacono LC, Chintagumpala M et al (2004) Results of a phase II upfront window of pharmacokinetically guided topotecan in high-risk medulloblastoma and supratentorial primitive neuroectodermal tumor. J Clin Oncol 22:3357–3365 141. Stewart CF, Panetta JC, O’Shaughnessy MA et al (2007) UGT1A1 promoter genotype correlates with sn-38 pharmacokinetics, but not severe toxicity in patients receiving low-dose irinotecan J Clin Oncol 25:2594–2600 142. Tallman MN, Ritter JK, Smith PC (2005) Differential rates of glucuronidation for 7-ethyl-10-hydroxycamptothecin (sn-38) lactone and carboxylate in human and rat microsomes and recombinant udpglucuronosyltransferase isoforms. Drug Metab Dispos 33: 977–983 143. Tian Q, Zhang J, Chan Sy et al (2006) Topotecan is a substrate for multidrug resistance associated protein 4. Curr Drug Metab 7:105–118 144. Tian Q, Zhang J, Tan TM et al (2005) Human multidrug resistance associated protein 4 confers resistance to camptothecins. Pharm Res 22:1837–1853 145. ten Bokkel Huinink W, Gore M, Carmichael J et al (1997) Topotecan versus paclitaxel for the treatment of recurrent epithelial ovarian cancer. J Clin Oncol 15:2183–2193 146. Treat J, Huang CH, Lane SR et al (2004) Topotecan in the treatment of relapsed small cell lung cancer patients with poor performance status. Oncologist 9:173–181 147. Tsavaris N, Polyzos A (1998) Irinotecan (cpt11) in patients with advanced colon carcinoma (acc) relapsing after 5-fluorouracil (5-fu)-leucovorin (lv) combination (meeting abstract). Proc Am Soc Clin Oncol (Abstract 1171) 17:304a 148. Van Warmerdam LJC, Ten Bokkel Huinink WW, Rodenhuis S et al (1995) Phase I clinical and pharmacokinetic study of topotecan administered by a 24-hour continuous infusion. J Clin Oncol 13:1768–1776 149. Van Warmerdam LJC, Verweij J, Schellens JHM et al (1995) Pharmacokinetics and pharmacodynamics of topotecan administered daily for 5 days every 3 weeks. Cancer Chemother Pharmacol 35:237–245 150. Venook AP, Enders Klein C, Fleming G et al (2003) A phase I and pharmacokinetic study of irinotecan in patients with hepatic or renal dysfunction or with prior pelvic radiation: CALGB 9863. Ann Oncol 14:1783–1790

123 151. von Pawel J, Gatzemeier U, Pujol JL et al (2001) Phase II comparator study of oral versus intravenous topotecan in patients with chemosensitive small-cell lung cancer. J Clin Oncol 19:1743–1749 152. von Pawel J, Schiller JH, Shepherd FA et al (1999) Topotecan versus cyclophosphamide, doxorubicin, and vincristine for the treatment of recurrent small-cell lung cancer. J Clin Oncol 17:658–667 153. Vredenburgh JJ, Desjardins A, Herndon JE et al (2007) Bevacizumab plus irinotecan in recurrent glioblastoma multiforme. J Clin Oncol 25:4722–4729 154. Vredenburgh JJ, Desjardins A, Herndon JE et al (2007) Phase II trial of bevacizumab and irinotecan in recurrent malignant glioma Clin Cancer Res 13: 1253–1259 155. Wall ME, Wani MC, Cook CE et al (1966) Plant antitumor agents, I: the isolation and structure of camptothecin, a novel alkaloidal leukemia and tumor inhibition from Campotheca acuminata. J Am Chem Soc 88: 3888–3890 156. Wang JC (1996) DNA topoisomerases. Annu Rev Biochem 65:635–692 157. Wani MC, Nicholas AW, Wall ME (1987) Plant antitumor agents. 28. Resolution of a key tricyclic synthon, 5’ (RS)-1,5-dioxo-5’-ethyl’-hydroxy-2’H, 5’H, 6’H-6’oxopyranol [3’,4’-fJdelta 6,8-tetrahydro-indolizine: total R synthesis and antitumor activity of 20(S)- and 20 camptochecin. J Med Chem 30:2317–2319 158. Zamboni WC, Egorin MJ, Van Echo DA et al (2000) Pharmacokinetic and pharmacodynamic study of the combination of docetaxel and topotecan in patients with solid tumors. J Clin Oncol 18(18): 3288–3294 159. Zamboni WC, Gajjar AJ, Heideman RL et al (1998) Phenytoin alters the disposition of topotecan and N-desmethyl topotecan in a patient with medulloblastoma. Clin Cancer Res 4(3):783–789 160. Zamboni WC, Gajjar AJ, Mandrell TD et al (1998) A four-hour topotecan infusion achieves cytotoxic exposure throughout the neuraxis in the nonhuman primate model: implications for treatment of children with metastatic medulloblastoma. Clin Cancer Res 4: 2537–2544 161. Zamboni WC, Lüftner DI, Egorin MJ et al (2001) The effect of increasing topotecan infusion from 30 minutes to 4 hours on the duration of exposure in cerebrospinal fluid. Ann Oncol 12:119–122 162. Zhang Y, Fujita N, Tsuruo T (1999) p21Waf/Cip1 acts in synergy with bcl-2 to confer multidrug resistance in a camptothecins-selected human lung-cancer cell line. Int J Cancer 83:790–797 163. Zunino F, Dallavalle S, Laccabue S, Beretta G, Merlini L, Pratesi G (2002) Current status and perspectives in the development of camptothecins. Curr Pharm Design 8:2505–2520

Chapter 7

Folate Antagonists Alex Ko

7.1 Introduction Folate antagonists, or antifolates, are cytotoxic drugs that have been extensively used for a wide range of diseases. They are part of chemotherapy regimens against many solid and hematologic malignancies, including acute lymphoblastic lymphoma (ALL), choriocarcinoma, osteosarcoma, lymphoma, and cancers of the breast, bladder, and head and neck. Lower doses are given to treat several nonmalignant diseases, including rheumatoid arthritis, systemic lupus erythematosus (SLE), psoriasis, inflammatory bowel disease, graftversus-host disease, and various bacterial, fungal, and protozoal infections. Methotrexate (4-amino-4-deoxy10-N-methyl-pteroylglutamic acid, MTX), introduced over 50 years ago, continues to be the most widely used of the antifolates and its use in cancer treatments will be the focus of this review.

7.2 Historical Background Folate antagonists were originally developed as antileukemic agents. In the early 1940s, the combined observation that many patients with acute leukemia suffered from folate deficiency and that bone marrow megaloblasts of folate-deficient patients morphologically resemble leukemic blasts led to the theory

A. Ko () UCSD Department of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA e-mail: [email protected]; [email protected]

that folate deficiency was the prime culprit in the development of leukemia. However, administration of folic acid, first isolated from spinach in 1941 and synthesized in 1945 [1], to patients with leukemia not only failed to be curative, but also often accelerated the course of disease in patients with acute leukemia and chronic myelocytic leukemia [2]. This finding led to experiments studying the effect of treatment with antagonistic folate analogues to mimic folate deficiency in leukemia patients. In a landmark study, Farber and colleagues showed that aminopterin (AMT), one of the first folate analogues, was able to produce temporary remissions in 5 of 16 children with acute leukemia [3], proving for the first time that an antimetabolite could be antineoplastic. Methotrexate (MTX) soon replaced AMT in the 1950s because of its greater safety profile [4], and its antifolate action was soon shown to be the result of its inhibition of the enzyme dihydrofolate reductase (DHFR). Newer analogues of folates or MTX have since been developed in response to increased cellular resistance to MTX or to target other folate-dependent processes. They are now used to treat a wide variety of malignant and non-malignant diseases.

7.3 Folate Metabolism Folate is a B-vitamin that functions as a single-carbon donor essential for nucleotide, methionine, and consequently, DNA synthesis required for normal cell growth and replication. The folate enters the cell via the reduced folate carrier (RFC), which has a high affinity for reduced folates, such as monoglutammate 5-methyltetrahydrofolate (5-Me-THF), the commonly

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_7, © Springer Science+Business Media B.V. 2011

125

126

circulating and active form of folate. Once the folate is inside the cell, folylpolyglutamyl synthase (FPGS) adds glutamyl groups to the y-glutamyl group of the folate molecule, trapping it within the cell. Conversely, y-glutamyl hydrolase (GGH) is able to cleave glutamyl groups off the polyglutamated folate. This balance between FPGS and GGH is one important mechanism used to regulate intracellular folate levels, as well as folate antagonist and TS inhibitor levels. 5-Me-THF then serves as a methyl-group donor for the conversion of homocysteine to methionine synthase (MS). THF is converted to 5,10-methylene-THF by either serine hydroxylmethyltransferase (SHMT) or the trifunctional methylenetetrahydrofolate dehydrogenase (MTHFD) enzyme complex. 5,10-methylene-THF is an important substrate in folate metabolism that can be directed towards thymidine, purine, or methionine synthesis depending on its intracellular concentration. Thymidylate synthase (TS) is the limiting irreversible step in de novo DNA synthesis, catalyzing the transfer of a methyl group from 5,10-methylene-THF to deoxyuridine monophosphate (dUMP), creating deoxythymidine monophosphate (dTMP) and dihydrofolate (DHF). The DHF is then recycled back to THF by the enzyme dihydrofolate reductase (DHFR). Both THF and 5,10-methylene-THF can enter the purine synthesis pathway by the addition of a formyl group. The enzyme methylenetetrahydrofolate reductase (MTHFR) can reduce 5,10-methylene-THF and is a key regulatory enzyme that can direct available folate towards the methylation of homocysteine.

7.4 Mechanism of Action of Folate Antagonists Folate antagonists are cytotoxic drugs that inhibit folate production by competing with folates for uptake into cells, by inhibiting folate coenzyme formation, or by inhibiting any of the reactions mediated by folate coenzymes. Today, the most effective and extensively used drugs work by inhibiting dihydrofolate reductase (DHFR) or thymidylate synthase (TS). Structurally similar to folate, folate antagonists are pterin compounds that have their 4-hydroxyl group substituted by an amino group, resulting in a folate analogue with a several thousand-fold increase in affinity for

A. Ko

these folate coenzymes. In MTX’s case, that enzyme is primarily DHFR. Binding to and inhibiting DHFR blocks the production of reduced folates needed for de novo thymidine synthesis [5]. The insufficient conversion of dUMP to dTMP results in uracil misincorporation into DNA strands during replication, leading to increased double-strand DNA breaks during uracil excision repair. There is also evidence that high dose MTX inhibits THF formation, leading to inhibition of purine synthesis and rapid cell death in lymphoblasts [6]. There are two additional mechanisms by which MTX exerts its antineoplastic action. The first includes the inhibition of folate-dependent remethylation of homocysteine to methionine, causing increased intracellular levels of homocysteine and a secondary elevation in S-adenosyl-homocysteine (SAH), a potent inhibitor of many folate-dependent methylation reactions, including the membrane localization of ras [7], a critical signal transduction protein that is constitutively activated in many human cancers. It has also been shown that MTX can inhibit endothelial cell proliferation [8], which may contribute to both its antineoplastic and anti-inflammatory properties when given in sub-cytotoxic amounts. These findings are consistent with several studies that have shown that intracellular reduced folates are depleted by only 50–70% after malignant cells are exposed to inhibitory concentrations of MTX, which insufficiently accounts for the observed inhibition in DNA synthesis [9]. Another group of widely used folate-related drugs include the activated metabolites of fluoropyrimidine, such as 5-fluorouracil (5-FU). This drug is structurally similar to pyrimidine nucleotides and inhibits TS by forming a covalently bound ternary complex with the enzyme. Newer drugs aim at targeting multiple folatemetabolizing enzymes including TS, DHFR, and two of the rate limiting steps of de novo purine synthesis, glycinamide ribonucleotide transformylase (GARFT) and aminoimidazole carboxamide ribonucleotide transformylase (AICARFT) [10]. Since folate is needed for DNA synthesis and repair, rapidly dividing cells such as hematopoietic cells and those found in the gastrointestinal tract are most affected. Hence, folate antagonists are frequently used against gastrointestinal and hematopoietic cancers. For the same reasons, toxicities are also most apparent at these sites. MTX’s action, and consequently, its toxic effects, can

7

Folate Antagonists

be prevented or reversed by coadministration of leucovorin (LV), a THF derivative readily converted to reduced folic acid derivatives in a DHFR-independent process. This is often referred to as “LV rescue.”

7.4.1 Pharmacokinetics 7.4.1.1 Absorption Plasma concentrations peak 1–5 h after an oral dose of 15–30 mg/m2 . Since food, antibiotics, and bile salts can decrease the absorption rate, it is recommended that MTX be taken with clear liquids on an empty stomach. While there is some evidence in the unpredictability of oral MTX absorption, a recent study in which four doses of MTX at 25 mg/m2 was given orally every 6 h resulted in a plasma concentration greater than 0.5 uM in more than 85% of pediatric patients with ALL [11]. Even so, MTX is usually administered intravenously.

7.4.2 Distribution After intravenous administration of MTX, the initial volume of distribution (Vd) is approximately 0.18 L/kg, with a steady-state Vd between 0.4 and 0.8 L/kg [12]. The initial distribution phase has a half-life of 30–45 min. Serum concentrations between 0.0001 and 0.001 M are achieved after administration of high doses of MTX (>6 g/m2 ) [13]. MTX enters cells by the same normal folate transport mechanisms, including the classic reduced folate carrier (RFC), which has a relatively low affinity for MTX, and a second, highaffinity folate receptor protein (FR) that is expressed on the surface of various normal tissues, including the choroid plexus, renal tubules, fallopian tubes, and human placenta, and several epithelial tumors, including ovarian cancer. High extracellular concentrations of MTX saturate transmembrane transport and inhibit the uptake of reduced folates, which explains the need for larger doses of exogenously administered leucovorin (LV) to reverse MTX action. Approximately 50% of MTX is bound to plasma proteins, especially albumin [14]. The highest tissueto-plasma concentrations in humans are found in the liver, kidney, and gastrointestinal tract. Prolonged

127

plasma levels after high-dose MTX infusions have resulted from decreased transit rate in patients with gastrointestinal obstruction. The blood-brain barrier and several active efflux mechanisms prevent MTX from reaching cerebrospinal fluid concentrations greater than 1% of the serum concentration, with concentrations roughly equal in the lumbar and ventricular CSF. Irradiation followed by MTX treatment may increase the likelihood of adverse neurotoxic effects as a result of damage to the blood-brain barrier. It has also been shown that cytocidal concentrations in the CSF can be reached with higher doses (greater than 500 mg/m2 ) [15]. However, a recent meta-analysis of CNS-directed therapy for pediatric patients with ALL showed that administration of high-dose MTX failed to lower the rate of CNS relapse [16]. While MTX is poorly accumulated in the CSF, small doses of oral LV significantly increase CSF folate concentration, which effectively rescues cells in the CSF compartment [17]. Following intrathecal injection, MTX slowly diffuses into the systemic circulation with a half-life of 8–10 h [18]. Systemic toxicity can result after multiple doses of intrathecal MTX without LV rescue. Increased toxicity to high-dose MTX has been seen secondary to “third-spacing” and the slow release of MTX into the serum in patients with pleural or peritoneal effusions. It is recommended to evacuate these fluid collections before treatment and monitor plasma drug concentrations closely. More prolonged and higher doses of LV may be used until MTX serum level decreases to less than 5 × 10−8 M.

7.4.3 Metabolism MTX is converted into three main metabolites: 1) 7-OH MTX: hepatic aldehyde oxidase converts MTX to its major metabolite, 7-OH MTX, which is only 1% as potent an inhibitor of DHFR as MTX [19]. It is also less water-soluble and may lead to the increased nephrotoxicity seen after high doses of MTX [20]. 2) dAMPA: In the intestine, MTX is hydrolyzed by bacteria to pteroate (4-deoxy-4-amino-N10-methyl pteroic acid, dAMPA) and glutamic acid [21]. dAMPA is also a relatively inactive metabolite with approximately 0.5% the affinity of MTX for DHFR.

128

3) MTX polygutamate: Intracellularly, FPGS adds glutamate residues in y-carbyl linkage to both folate coenzymes and classic folate antagonists. Polyglutamation is a time-and concentrationdependent process that occurs predominately in tumor cells. Polyglutamation prevents efflux of the drug from the cell, prolonging its half-life and activity. MTX polyglutamates are more potent inhibitors of DHFR because they dissociate less rapidly than their parent compound [22]. Like MTX, 7-OH MTX is also polyglutamylated intracellularly, contributing to MTX cytotoxicity [23]. As much as 80% of MTX present in malignant tissues is in the polyglutamated forms [24]. Only polyglutamated MTX can act on GARFT and AICARFT. They are hydrolyzed in lysosomes by GGH.

7.4.4 Excretion The elimination half-life of MTX is about 3 h. Most of the administered MTX and its metabolites are renally excreted unchanged in the urine [25], so dosing based on renal function is critical. Active secretion of MTX occurs in the proximal tubules and results in renal clearance of MTX that can exceed creatinine clearance. Excretion through organic acid transporters can be inhibited by probenecid or competitively blocked by other weak organic acids, including aspirin and penicillins. Elimination is increased by drugs that block distal tubular reabsorption, such as folic acid, sulfamethoxazole, and some cephalosporins. Hepatic metabolism is minimal, accounting for approximately 10% of overall MTX clearance when renal function is normal. After IV doses of 30–80 mg/m2 , 0.4–20% of the administered dose is excreted through the canalicular multiorganic acid transporter (cMOAT) into bile, mostly as intact drug. Overexpression of this transporter confers resistance to MTX in vitro [26]. Less than 10% of MTX is excreted in the feces [27].

7.4.5 Drug Interactions Several harmful and even fatal reactions have been reported between MTX and nonsteroidal antiinflammatory drugs (NSAIDs), especially naproxen

A. Ko

and ketoprofen [28], possibly as the result of competitive inhibition of renal secretion [29]. Phenylbutazone, salicylates, probenecid, and trimethoprim have also been shown to increase MTX toxicity [30, 31]. Trimethoprim, an antifolate antibacterial agent with weak binding affinity to DHFR, lowers folate stores and makes marrow cells more susceptible to the effects of MTX. Concurrent alcohol use increases risk of hepatic fibrosis and cirrhosis, and patients are instructed to abstain from alcohol while on MTX.

7.4.6 Neoplastic Treatments 7.4.6.1 Acute Leukemia MTX is used as part of all postremission chemotherapeutic regimens for acute lymphoblastic leukemia (ALL). The optimum dose and schedule of MTX may vary depending on each disease. Studies have shown that twice-weekly doses of 20 mg/m2 were more effective treatment than daily oral administration during remission [32]. A 5-day course administered every 3–4 weeks and high-dose MTX regimens with LV rescue have also been shown to be beneficial [33, 34]. It is administered intrathecally for the prophylaxis, treatment, and remission induction of meningeal leukemia. In contrast to its effectiveness in treating ALL, MTX has limited efficacy against acute nonlymphocytic leukemias. High dose regimens with LV rescue have rapid, transient effects on peripheral blood count, but have failed to produce marrow remissions in most of these patients [35].

7.4.6.2 Lymphoma MTX with LV rescue is included in chemotherapy regimens for intermediate-grade and high-grade lymphomas. Phase II studies have shown that moderate to high doses of MTX (200–3000 mg/m2 ) with LV rescue promotes transient regression of large-cell lymphomas [36]. MTX and cytarabine, an antimetabolite that leads to termination of DNA synthesis, are used in combination to treat some lymphomas because of their additive and possibly synergistic effects [37]. MTX with LV rescue has also been added to cyclophosphamide, vincristine, doxorubicin (Adriamycin), and

7

Folate Antagonists

dexamethasone (CVAD), cytarabine, and intrathecal therapy for patients with Burkitt’s lymphoma [38]. Rituximab can be added to the hyper-CVAD regimen, which involves alternating high-dose MTX with cytarabine, to improve results in patients with B-ALL and Burkitt’s lymphoma, especially in the elderly [39]. Two other currently used regimens for Burkitt’s include CODOX-M (cyclophosphamide, vincristine, doxorubicin, high-dose MTX) and IVAC (ifosfamide, etoposide, high-dose cytarabine, intrathecal MTX), both of which increase survival. A recent study showed that hyper-CVAD treatment induced complete remission in 91% and a 3-year estimated progression-free survival of 66% in 33 patients with ALL [40]. High-dose MTX is effective against primary central nervous system (CNS) lymphomas, with even better results when used with radiotherapy and other agents like cytarabine [41, 42]. A retrospective review of 226 patients with primary CNS lymphoma showed that patients treated with high-dose MTX followed by radiotherapy had improved survival compared with radiation alone without a higher risk of neurotoxicity [43]. Retreatment with high dose MTX is effective for relapsed disease if there had been a prior complete remission with this agent. CNS prophylaxis is critical, since the CNS is a major site for recurrence.

7.4.6.3 Breast Cancer In one study, MTX alone caused regression of breast cancer in 30% of patients. When followed by 5-FU administration, the response rate improved to 50% and improved disease-free survival when used as adjuvant therapy [44]. The combination of cyclophosphamide, MTX, and 5-FU (CMF) significantly reduces the risk of relapse [45]. The regimen of MTX, 5-FU, and vinorelbine (VMF) instead of cyclophosphamide is effective against advanced breast cancer [46]. Low dose oral MTX (2.5 mg twice a day, two times a week) with daily oral cylcophosphamide has shown to be beneficial against heavily pretreated patients with advanced metastatic breast cancer [47]. Adjuvant chemotherapy with standard CMF has been shown effective in older women with early stage breast cancer, with a relapse-free survival of 85% [48]. Many trials have shown anthracycline-based chemotherapies, such

129

as FAC (fluorouracil, doxorubicin, cyclophosphamide) to be superior to traditional agents. Combination of standard CMF therapy with the anthracycline epirubicin is superior than CMF alone [49]. High dose chemotherapy results in higher event-free and overall survival compared with a dose-dense conventional regimen [50]. CMF has also been studied as primary chemotherapy prior to breast conservative surgery [51]. 7.4.6.4 Choriocarcinoma Choriocarcinoma is the only cancer known to respond to single-drug treatment with either MTX or actinomycin D [52]. The human choriocarcinoma cell line (JAR) was shown to have active-receptor coupled uptake of folates and antifolates, which may lead to increased accumulation and retention of the drug [53]. MTX is currently used in combination with other drugs in the treatment of choriocarcinoma, including etoposide, actinomycin D, cyclophosphamide, and vincristine, with greater than 90% survival [54]. 7.4.6.5 Osteogenic Sarcoma The survival of patients with malignant bone sarcomas has improved dramatically over the past 30 years as a result of advances in chemotherapy. Before routine use of chemotherapy, approximately 80% of patients developed metastases despite achieving local tumor control, indicating the presence of subclinical metastases. Randomized trials have shown the efficacy of high-dose MTX with LV rescue in treatment of osteogenic sarcoma [55], with some evidence that response rates are correlated with MTX dose density [56]. Another recent study showed that higher MTX doses did not improve outcomes in patients with localized osteosarcoma [57]. When MTX in osteogenic sarcoma biopsy specimens were analyzed, 200-fold increased doses of MTX produced only a 2.5-fold increase in intracellular MTX polyglutamates [58], which may explain the lack of clinical efficacy of these high doses, particularly in older adults. Cisplatin and doxorubicin are the agents most often used to treat osteogenic sarcomas in adults, with high-dose MTX reserved for poor responders [59] or patients under the age of 35.

130

7.4.6.6 Neoplastic Meningitis Intrathecal MTX is frequently used in treating solidtumor neoplastic meningitis. High-dose MTX with LV rescue is also used. A recent study showed longer duration of cytotoxic MTX concentrations in the CSF and prolonged survival in patients treated with IV MTX compared with patients administered intrathecal MTX [60]. Another study comparing intrathecal MTX with depot cytosine arabinoside liposomal injection (DepoCyt) showed increased survival, but with more toxicity, with DepoCyt [61].

A. Ko

of patients with previously treated advanced gastric cancer [68] as well as those with malignant ascites [69].

7.4.6.10 Lung Cancer MTX has limited activity against small-cell lung cancer, while conferring almost no benefit in non-small cell lung cancer [70].

7.4.7 MTX Toxicities

7.4.6.7 Head and Neck Cancer

7.4.7.1 Hematologic

MTX and cisplatin are the two most widely used single agents in the treatment of advanced carcinomas of the head and neck. High-dose MTX with LV rescue improve response rates from 30 to 50%, but do not improve remission duration or survival [62]. The combination of MTX and 5-FU has resulted in response rates of up to 60% [63].

Rapidly dividing cells, which have the highest percentage undergoing DNA synthesis (S-phase), are most affected by the folate antagonists. While differentiation of all bone marrow progenitor cells are inhibited, neutrophils are the most affected, leading to neutropenia. These effects are both dose- and patientdependent. Young age, impaired renal function, previous radiation-induced marrow damage, chemotherapy, infection, or treatment/prophylaxis of Pneumocystic carinii with trimethoprim-sulfamethoxazole (TMPSMX) all increase the risk of MTX toxicity. The nadir is reached 10 days after administration of the drug, and recovery begins approximately 14–21 days later. Giving LV within 42 h of MTX administration can reduce toxicity and allow larger doses to be administered [71].

7.4.6.8 Genitourinary Cancer Studies have shown that MTX alone or in high doses with LV rescue is effective against advanced bladder cancer, with a response rate (approximately 30%) similar to that of cisplatin therapy. The combination of MTX with cisplatin, vinblastine, and doxorubicin (M-VAC) has been shown effective in inducing longterm clinical remissions [64]. MTX in neoadjuvant treatments has conferred a clear survival advantage in patients with bladder cancer [65, 66].

7.4.6.9 Gastrointestinal Cancer Because of its relative ineffectiveness against gastrointestinal cancers, MTX’s main role is to modulate and improve the efficacy of 5-FU. MTX pretreatment 7–24 h before 5-FU administration inhibits purine synthesis and increases phosphoribosyl pyrophosphate (PPRP), a precursor for 5-FU nucleotide formation [67]. Phase II studies from Japan to evaluate the efficacy and toxicity of sequential treatment with MTX and 5-FU have shown efficacy in small percentages

7.4.7.2 Renal Toxicity It is thought that MTX damages the kidneys in two ways, by (1) direct action on the renal tubules, and (2) the precipitation of MTX and its less soluble metabolite, 7-OH MTX, in the renal tubules. Even conventional doses of MTX have been known to cause renal toxicity. In almost all cases, the acute renal failure is nonoliguric and reversible, but high-dose MTX can lead to severe renal damage, which reduces MTX clearance and leads to severe and sometimes fatal bone marrow and GI toxicity. It is essential to maintain creatinine clearance above 50 mL/min before each treatment dose. Vigorous hydration, osmotic diuresis, and alkalinization of urine

7

Folate Antagonists

to increase solubility of MTX and its metabolites can minimize toxicity. Methylxanthines like caffeine or aminophylline can also accelerate MTX clearance by acting as a competitive inhibitor of adenosine, which is increased by MTX and decreases the glomerular filtration rate (GFR) [72]. Hemo- and peritoneal dialysis are ineffective in significantly lowering MTX plasma levels. Oral charcoal and acholestyramine can bind to MTX and lower drug absorption [73]. There has been mild success with charcoal hemoperfusion columns [74]. The combination of thymidine, LV, and carboxypeptidase G2 (glucarpidase), a recombinant form of carboxypeptidase G1 that cleaves the peptide bond in MTX to form the inactive metabolites glutamate and dAMPA, has been shown to ameliorate severe MTX toxicity [75]. While not yet commercially available, it can be used uner an open-label Treatment protocol approved by the FDA.

7.4.7.3 CNS Toxicity The most common and immediate side effect of intrathecal MTX is an acute chemical arachnoiditis, a syndrome that includes severe headache, fever, vomiting, meningismus, and CSF pleocytosis. High doses can lead to motor paralysis of extremities, cranial nerve palsies, aphasia, and seizures, which occur within 6 days of treatment and are usually transient (2–3 days), but can lead to coma and death [76]. Subacute neurotoxicity beginning 7–14 days after intrathecal or intravenous high-dose MTX occurs in up to 20% of patients. Delayed MTX-induced development of chronic demyelinating encephalopathy, occurring months to years after receiving intrathecal MTX, is seen in up to 80% of children with ALL [77]. The exact underlying mechanism of CNS toxicity from MTX remains unknown, but it is theorized that increased levels of homocysteine in the CSF from the inhibition of remethylation to methionine by MTX may contribute to the observed CNS symptoms. Studies show that higher CSF homocysteine levels are found in patients with MTX-induced neurotoxicity than in asymptomatic patients receiving similar drug therapies [78]. CT scans show ventricular enlargement, cortical thinning, and diffuse intracerebral calcifications [79]. Methylxanthines, which blocks adenosine’s autocoid effects in the CNS, can be given to lessen toxicity.

131

Doses may have to be lowered or treatment changed to cytarabine if CNS symptoms persist. Intrathecal MTX overdoses (>100 mg) are treated by immediate ventricolumbar perfusion [80]. Another studied antidote is intrathecal carboxypeptidase G2, which markedly decreased mortality after lethal intrathecal doses of MTX in animals [81]. There is no evidence that therapeutic use of LV helps patients who develop neurotoxic symptoms.

7.4.7.4 Hepatotoxicity Portal fibrosis and cirrhosis can result from chronic low-dose MTX treatment, such as in patients being treated for psoriasis and rheumatoid arthritis. Liver enzymes, including bilirubin, often become elevated several days after high-dose MTX, but quickly return to baseline within 10 days and is not an accurate predictor of chronic liver toxicity [82]. From studies that show the reversal of MTX hepatotoxicity in rats by choline administration, it is postulated that the liver damage is caused by the inhibition of folate homeostasis [83]. Other hepatotoxic medications and alcohol should be avoided during MTX therapy. 7.4.7.5 Gastrointestinal Mucositis, an early and common side effect of MTX, usually presents in 3–5 days and is a good indicator that the drug should be discontinued. Other presentations of gastrointestinal toxicity include mild to moderate nausea and vomiting. Diarrhea may also occur, even occasionally progressing to bloody diarrhea, usually in the setting of high-dose MTX combined with renal damage. Patients receiving greater than 250 mg/m2 of MTX should be pretreated with a serotonin receptor antagonist and dexamethasone, with or without aprepitant [84]. 7.4.7.6 Pulmonary Pulmonary toxicity has been noted in patients receiving low-dose oral MTX for rheumatoid arthritis [85]. The majority develop toxicity within the first year of therapy, with cases reported between 12 days and 18 years after drug initiation. Subacute presentations are most common, including cough, dyspnea,

132

fever, and hypoxemia. Chest X-rays usually show a hypersensitivity pnemonitis involving nonspecific patchy interstitial infiltrates, similar to findings in Pneumocystis carinii infection, which must be ruled out in immunocompromised patients or those taking steroids. Histologic findings include diffuse interstitial lymphocytic infiltrates, noncaseating granulomas, and giant cells. Peripheral eosinophilia, suggesting an allergic pneumonitis, is occasionally observed, although rechallenge with MTX does not uniformly result in the return of symptoms. Failure to discontinue MTX may lead to irreversible pulmonary fibrosis. In contrast to bone marrow and gastrointestinal toxicity, the repletion of folate stores does not reduce the risk of MTX pulmonary toxicity.

A. Ko

7.4.8 Antifolate Resistance The development of cellular resistance to MTX continues to be a major obstacle to its clinical efficacy. MTX resistance is the result of one or more of the following five mechanisms: 1) 2) 3) 4) 5)

Decreased intracellular transport Decreased metabolism into polyglutamate forms Increased breakdown of polyglutamates Altered interaction with DHFR Increased efflux from cells

7.5 Intrinsic Resistance 7.4.7.7 Skin Approximately 5–10% of patients taking MTX suffer skin toxicity. The main clinical finding is an erythematous, sometimes pruritic rash on the neck and upper trunk that lasts for several days. More severe toxicity can result in bullae formation, desquamation [86], or cutaneous vasculitis [87]. Alopecia is occasionally seen.

7.4.7.8 Teratogenic and Mutagenic MTX is a known potent abortifacient, especially during the first trimester of pregnancy, and is currently used for the early voluntary termination of pregnancies. However, there is no direct evidence of mutagenic or carcinogenic effects from MTX use, and women successfully treated with MTX for choriocarcinoma do not have increased risk of secondary malignancies or fetal defects [88]. Current recommendations are that a woman being treated with MTX avoids pregnancy for at least one ovulatory cycle following treatment. Men on MTX should avoid pregnancy for at least 3 months following treatment.

7.4.7.9 Bone There is some evidence that chronic low-dose MTX can cause osteoporosis, possibly from MTX inhibition of osteoblastic differentiation [89].

Studies show a decreased ability to form long-chain MTX polyglutamates in AML patients versus ALL patients, which may explain the relative clinical resistance of AML to MTX. Sarcoma tumor cells resistant to MTX also do not form MTX polyglutamates as readily [90]. Impaired ability to transport MTX into cells by the reduced folate carrier (RFC) also contributes to intrinsic resistance. RT-PCR of osteosarcoma biopsies have shown decreased expression of RFC mRNA [91]. Mutations in the RFC gene leading to decreased transport function is seen in resistant cell lines [92]. Single nucleotide polymorphisms in the RFC gene result in a decreased affinity for antifolates without significantly affecting the transporter’s affinity for folate. The retinoblastoma protein is often deleted or mutated in many tumors, leading to increased levels of transcription factor E2F and increased production of DHFR [93].

7.6 Acquired Resistance Acquired resistance to MTX occurs through several different mechanisms: 1) DHFR gene amplification: Studies have shown the development of resistance as a result of DHFR gene amplification in patients treated with MTX [94]. The amplified gene can stably integrate into chromosomal DNA in the form of a homogeneously

7

Folate Antagonists

staining region or exist in extrachromosomal pieces of DNA called double-minute chromosomes [95]. Approximately 30% of relapsed ALL patients compared with 10% of newly diagnosed patients had some DHF amplification. 2) DHFR mutation: Several point mutations, mostly involving amino acids that bind the folate antagonist by hydrophobic interactions, have been found that decrease DHFR’s binding affinity for MTX [96]. 3) Decreased long-chain polyglutamate formation: Defects in polyglutamation that lead to decreased MTX uptake have been described in several MTXresistant cell lines [97]. Increased breakdown from increased levels of y-glutamylhydrolase (GGH), which removes the glutamate residues, also contributes to acquired resistance. Increased expressionof GGH has been shown to be associated with resistance to MTX in human sarcoma cell lines and a rat hepatoma cell line, although another study showed that forced overexpression of GGH did not result in MTX resistance [98]. 4) RFC mutation: Decreased RFC transport of MTX is a common mechanism of acquired MTX resistance in leukemic blasts from patients with relapsed ALL [99].

7.6.1 Description of Other Folate-Related Agents 7.6.1.1 5-Fluorouracil (5-FU, Efudex) First synthesized in 1957 after the observation that rat hepatoma cells used uracil more efficiently than normal rat intestinal mucosa, this fluoropyrimidine antimetabolite indirectly inhibits the enzyme thymidylate synthase (TS), which leads to depletion of dTMP and dTTP, resulting in decreased DNA synthesis and “thymine-less death.” TS inhibition also leads to an accumulation of dUMP, which is misincorporated into DNA and then excised, causing DNA strand breaks. Unlike folate antagonists, fluoropyrimidine TS inhibitors enter cells via a separate nucleoside transport system and do not require polyglutamation for activity. 5-FU is normally given intravenously because of its erratic bioavailability when given orally due to its rapid

133

breakdown by the gut mucosa enzyme dihydropyrimidine dehydrogenase (DPD). A cream incorporating 5-FU is also used topically for treating basal cell carcinomas. It is FDA approved for colon, rectum, gastric, pancreas, and breast carcinomas, and is also used in a wide range of combination regimens. It can be given with LV, which increases intracellular pools of reduced folates, enhancing the stability of the 5-FU-TS complex and prolonging TS inhibition [100]. Various agents, especially LV, have been used as biochemical modulators to enhance 5-FU’s antitumor activity. However, randomized trials have shown increased toxicities and not shown a meaningful survival benefit to adding LV. Another approach has been to alter the schedule of 5-FU administration to prolong the tumor cells’ exposure to the drug. Continuous infusional schedules have shown superior clinical efficacy compared to boluses of FU, and a hybrid schedule of bolus and infusional 5-FU with LV administration has become a main backbone for combination therapy for advanced colorectal cancer [101]. 5-FU also significantly enhances the cytotoxicity of ionizing radiation [102]. Another strategy to increase the effectiveness of 5-FU-based treatment has been to develop oral analogues to increase convenience and avoid complications associated with intravenous infusional therapies.

7.6.1.2 Capecitabine (Xeloda) In contrast to 5-FU, this oral fluoropyrimidine carbamate is rapidly and extensively absorbed by the gut mucosa, with about 80% oral bioavailability and peak blood levels occurring within 2 h. It is converted to its only active metabolite, 5-FU, by thymidine phosphorylase. Higher levels of this enzyme are found in several tumors and the liver, compared with normal healthy tissue. Dose-limiting toxicities include nausea, vomiting, diarrhea, and hand-foot syndrome. The drug is FDA-approved for use as (1) a first-line treatment of metastatic colorectal cancer when fluoropyrimidine therapy alone is preferred, (2) a single agent in metastatic breast cancer patients who are resistant to both anthracycline- and paclitaxel-based regimens or in whom further anthracycline treatment is contraindicated, and (3) in combination with docetaxel after failure of prior anthracycline-based chemotherapy. Single-agent and combination regimens have also

134

shown efficacy against prostate, pancreatic, renal cell, and ovarian cancers. Improved tolerability and similar efficacy compared with intravenous FU/LV in addition to oral administration make capecitabine an attractive treatment option as well as the focus of ongoing trials [103]. Capecitabine plus oxaliplatin has shown promise in patients with unresectable rectal cancer [104], advanced pancreatic cancer [105], and advanced esophagogastric cancer [106]. It was shown to be inferior to standard chemotherapy in older patients with breast cancer [107].

7.6.1.3 Aminopterin (4-Aminopteroic Acid, AMT) Discovered prior to MTX, this DHFR inhibitor was soon replaced by MTX, which has similar efficacy with decreased toxicity. However, recent studies have suggested that AMT may have better uptake and polyglutamation than MTX. One study showed that in-vivo activity of MTX and AMT were equivalent in preclinical models [108]. Now in a more pure preparation, aminopterin is back in clinical trials for patients with leukemia [109].

7.6.1.4 Leucovorin Leukovorin (LV) is a folate derivative and an enzyme cofactor for TS and other purine and pyrimidine synthesis steps. It bypasses the DHFR step and therefore can be used to prevent or reverse the toxic side effects of antifolates, allowing higher doses to be used. It can also modulate antitumor activity in some cases, particularly colorectal cancers [110]. As LV can only rescue normal cells that have not already had lethal DNA damage from MTX, it must be initiated within 24–36 h of starting MTX. Given the competitive nature of MTX and LV, the dose of LV must be increased in proportion to the plasma concentration of MTX. LV selectively rescues normal but not malignant cells from the effects of MTX for unclear reasons, and there is no clinical evidence of any LV dose that is high enough to interfere with antitumor efficacy. Plasma MTX levels are followed daily, and LV doses are adjusted based upon MTX drug levels. A typical dosage is 10 mg/m2 IV or 15 mg/m2 orally every 6 h until plasma MTX levels are less than 0.1 microM.

A. Ko

7.6.2 New Folate Antagonists 7.6.2.1 Edatrexate (10-Ethyldeazaaminopterin) Hydrophobic N-10 substitutions to aminopterin result in improved uptake and retention by tumor cells compared with normal cells [111]. This drug has shown benefit in non-small cell lung cancer, breast cancer, head and neck cancers, and malignant fibrous histiocytoma [112–114]. However, because it uses the same transport and polyglutamylation mechanisms as MTX, it has limited activity against MTX-resistant cells. A newer analogue, 10-propargyl-deazaaminopterin (PDX), has been developed that is more potent than edatrexate because of increased RFC uptake and intracellular polyglutamylation. Phase II trials of PDX given to patients with previously treated non-small cell lung cancer have shown promise [115].

7.6.2.2 Trimetrexate (TMTX) Like MTX, this lipophilic analog is a potent inhibitor of DHFR. Unlike MTX, it lacks a glutamate moiety (making it a nonclassical antifolate) and crosses the cell membrane by passive or facilitative diffusion rather than through the RFC [116]. As a result, TMTX and other nonclassical antifolates are cytotoxic against even MTX-resistant cells. When TMTX is used in combination with LV to specifically target tumor cells that have decreased levels of functional RFC and cannot transport reduced folates; these cells will uptake only the TMTX, while normal cells will also uptake the LV rescue agent [117]. Preclinical data shows that TMTX followed by 5-FU and high-dose LV synergistically kills cells in advanced GI cancers, while the same regimen with TMTX replaced with MTX did not [118]. In another study, treatment with TMTX, 5-FU, and LV (NFL) was well-tolerated in patients with advanced pancreatic cancer, with median survivals and 1-year survivals that compared favorably with other treatment options [119].

7.6.2.3 Raltitrexed (Tomudex) This quinazoline folate analogue primarily inhibits thymidylate synthetase, but also inhibits DHFR and GARFT. Like MTX, raltitrexed is actively transported

7

Folate Antagonists

into the cell via the RFC and undergoes polyglutamation, which increases cytotoxicity 100-fold (more so than MTX). It is eliminated renally, with a halflife of 10–22 h. Several mechanisms of resistance to Raltitrexed have been identified, including decreased polyglutamation, reduced transport, and overexpression of the target enzyme, TS [120–121]. A phase I trial in children with refractory leukemia showed minimal toxicity and responses in 3 of 18 patients [122]. It has shown clinical efficacy against many solid tumors, including advanced colorectal, breast, hepatocellular, non-small cell lung, and pancreatic cancers. It is licensed in Canada and Europe as a first-line therapy for advanced colon cancer, but it remains an investigational drug in the United States. Novel combination regimens incorporating raltitrexed are in development, and the combination of raltitrexed with oxaliplatin appears especially promising for the treatment of advanced colorectal cancer and malignant mesothelioma [123, 124]. 7.6.2.4 ZD9331 Like raltitrexed, this third-generation specific anitfolate inhibitor of TS does not require polyglutamation for its activity. This quality prevents resistance from reduced expression of folylpolyglutamate synthetase (FPGS), while reducing toxicities from the increased retention of polyglutamated drugs in normal tissues. Preclinical studies have shown it to be transported by the ubiquitously expressed reduced folate carrier as well as the alpha-folate receptor which is overexpressed in some cancers, especially ovarian [125]. A large number of monotherapy and combination studies have been undertaken, and overall activity has been most promising, particularly in platinumrefractory relapsed ovarian [126], pancreatic [127] and gastric cancers [128]. Its role in the treatment of these diseases may be important, especially if patients were to be selected on the basis of their folate transport and FPGS status. 7.6.2.5 Lometrexol (5–10-Dideazatetrahydrofolate, DDTHF, LMTX) An extremely potent inhibitor of purine synthesis, it selectively inhibits glycinamide ribonucleotide

135

formyltransferase (GARFT), an enzyme that catalyzes the formation of purines. As an excellent substrate for FPGS, LMTX is very susceptible to polyglutamation, and once formed, these long-chain polyglutamates turn over so slowly intracellularly that they are almost impossible to eliminate. Low doses have led to prolonged bone marrow suppression and thrombocytopenia, possibly due to rapid accumulation in folate receptor-positive cells [129]. Consequently, production of this drug has since stopped in favor of more benign analogues, such as pemetrexed.

7.6.2.6 Pemetrexed (LY231514) In clinical trials since 1995, this pyrrolopyrimidine multi-targeted antifolate analogue primarily inhibits TS, but has activity against several other target enzymes involved in biosynthetic pathway of folate, including GARFT, AICAR transformylase, and DHFR. Its advantages over other antifolates include: (1) its very rapid conversion to active polyglutamate derivatives in cells that build to high and prolonged levels in cells, (2) its high affinity for three different folate transporters, and (3) its marked sensitivity to the level of physiologic folates in cells [130]. The optimal dose schedule is 500–600 mg/m2 intravenously administered every 3 weeks. Toxicities are similar to those of other antifolates, with neutropenia being the major dose-limiting toxicity. Other common adverse events include nausea, vomiting, anorexia, rash, and fatigue. These toxicities are markedly decreased by folic acid supplementation (350 ug daily) and vitamin B12 (1000 ug IM every 3 weeks), with no decrease in pemetrexed’s clinical efficacy [131]. Recent phase III studies showed comparable efficacy of pemetrexed compared with docetaxel in previously treated patients with non-small cell lung cancer, with far less toxicity in patients treated with pemetrexed [132]. As a result, pemetrexed in combination with cisplatin was FDA- approved as a first-line treatment of non-small cell lung cancer. Its use in combination with cisplatin results in increased response rate and overall survival compared to cisplatin alone in the treatment of malignant pleural mesothelioma, and this combination regimen has also been FDA approved [133]. Pemetrexed in combination with other chemotherapeutic agents has shown activity against many other

136

solid tumors, including breast, colorectal, gastric, cervical, bladder, and small cell lung cancer [134]. There has been special interest in its co-administration with gemcitabine, which is synergistic in vitro [135]. It is known that pemetrexed increases expression of the hENT1 nucleoside transporter that mediates gemcitabine influx [136], suggesting that pre-treatment with pemetrexed would increase gemcitabine’s efficacy. In a phase II trial in non–small cell lung cancer comparing a variety of pemetrexed-gemcitabine schedules, the response rate to pemetrexed administered 90 min before gemcitabine was far superior to the response rate with the reverse sequence of administration [137].

7.6.2.7 Nolatrexed (Thymitaq, AG337) This drug is a noncompetitive, high-affinity inhibitor of TS synthesis, leading to dTMP depletion and dUMP accumulation and thymine-less death. It is not dependent on the cell cycle and high concentrations fail to induce S-phase arrest while still causing apoptosis. Because of its lipophilic properties, the drug can enter cells via passive diffusion. Since it cannot be polyglutamated, and as a result has no requirements for membrane transport or intracellular activation, it is not susceptible to most mechanisms of drug resistance. Point mutations and TS gene amplification contribute to some acquired resistance. Randomized trials have been done to compare the efficacy of nolatrexed with other currently used agents. One study showed similar efficacies between nolatrexed and methotrexate in the treatment of head and neck cancer [138]. Due to some evidence of activity against hepatocellular cancer, recent efforts have been made to study its possible role in the treatment of HCC. A recent phase III study of nolatrexed in advanced unresectable HCC patients, however, demonstrated minimal activity and significant toxicities, including

A. Ko

stomatitis, diarrhea, vomiting, and thrombocytopenia [139].

7.7 Conclusions and Future Directions Old and current folate antagonists primarily inhibit thymidylate synthase, DHF reductase, and the enzymes involved in de novo purine synthesis, GARFT and AICARFT. Classical folate antagonists act in the polyglutamated form, leading to the development of resistance through alterations in cellular transport or intracellular polyglutamation mechanisms. Research has thus moved towards the creation and study of lipophilic, nonclassical folate antagonists like trimetrexate and Thymitaq that do not require a transport mechanism or polyglutamation. Since much clinical resistance is the result of amplification or mutation of single target enzymes, there are efforts to find newer drugs, like pemetrexed, that target multiple steps or biosynthetic pathways, which would theoretically minimize the development of significant resistance [140]. Pharmacogenetics is also being utilized as a tool to predict drug response in patients with the hope of reducing toxicities and treatment costs. Initial studies have shown promising relationships between genotype and treatment-related toxicity and outcomes, indicating that certain genetic polymorphisms in folate metabolism can be important predictors of drug response. For example, there is evidence that patient with lower expression of TS have increased drug response as well as toxicities [141]. Most studies have yet to evaluate multiple polymorphisms in the folate pathway simultaneously, and this is an area of future research. Finding ways of relieving cytotoxicity while maintaining a high degree of antitumor efficacy and exploring new synergistic drug combinations are other important goals for the future.

7

Folate Antagonists

7.8 Graphics 7.8.1 Folate Metabolism Adapted from cdc.gov

137

138

A. Ko

7.8.2 Folate-Related Agents Name (brand name)

Target enzyme(s)

Oncologic uses

Methotrexate Trimetrexate (Neutrexin) Edatrexate

DHFR (primary), TS, MTHFR, GARFT, AICARFT DHFR DHFR

Lometrexol (T64) Fluorouracil (5-FU) Capecitabine (Xeloda) Pemetrexed (Alimta) Ralitrexed (Tomudex) Nolatrexed (Thymitaq) ZD9331

GARFT (primary), AICARFT TS TS TS (primary), DHFR, GARFT TS TS TS

Leukemia, lymphomas (Burkitt’s and non-Hodgkin’s), breast cancer, head and neck cancer, osteosarcoma Non-small cell lung, prostate, colorectal Non-small cell lung, advanced breast, head and neck, soft tissue sarcoma, NHL Non-small cell lung Colorectal, pancreatic, stomach, breast, basal cell (skin) Colorectal, breast Malignant pleural mesothelioma, non-small cell lung Colon cancer Hepatocellular Ovarian, pancreatic, gastric

7.8.3 Chemical Structure Comparison of Folate and MTX

7

Folate Antagonists

139

7.8.4 Chemical Structures of Folate Antagonists

References 1. Angier RB, Boothe JH, Hutchings BL (1945) Synthesis of a compound identical with the L. Casei Factor. Science 102:227 2. Farber S, Cutler EC, Hawkins JW et al (1947) Action of pteroylglutamic conjugates on man. Science 106:619–621 3. Farber S, Diamond L, Mercer RD et al (1948) Temporary remissions in acute leukemia in children produced by folic acid antagonist, 4-aminopteroyl-glutamic acid (aminopterin). N Engl J Med 238:787 4. Meyer LM, Fink H, Sawisky A et al (1949) Aminopterin (a folic acid antagonist) in the treatment of leukemia. Am J Clin Pathol 19:119–126 5. Osborne MJ, Freeman MB, Huennekens FM (1958) Inhibition of DHFR by aminopterin and amethopterin. Proc Soc Exp Biol Med 97:429–431 6. Hryniuk WM (1972) Purineless death as a link between growth rate and cytotoxicity by methotrexate. Cancer Res 32:1506–1511 7. Winter-Vann AM, Kamen BA, Bergo MO et al (2003) Targeting Ras signaling through inhibition of carboxyl methylation: an unexpected property of methotrexate. Proc Nat Acad Sci USA 100:6529–6534 8. Hirata S, Matsubara T, Saura R et al (1989) Inhibition of in vitro vascular endothelial cell proliferation and in vivo neovascularization by low-dose methotrexate. Arthritis Rheum 32:1065–1073

9. Kummar S, Noronha V, Chu E (2005) Antimetabolites. Cancer principles and practice of oncology, 7th edn. Lippincott Williams & Wilkins, Philadelphia, USA, pp 358–374 10. Baram J, Chabner BA, Drake JC et al (1988) Identification and biochemical properties of 10-formyldiydrofolate, novel folate found in methotrexate-treated cells. J Biol Chem 263:7105–7111 11. Winick N, Shuster JJ, Bowman WP et al (1996) Intensive oral methotrexate protects against lymphoid marrow relapse in childhood B-precursor acute lymphoblastic leukemia. J Clin Oncol 14:2803–2811 12. Huffman DH, Wan SH, Azarnoff DL et al (1973) Pharmacokinetics of methotrexate. Clin Pharmacol Ther 14:572–579 13. Evans WE, Pratt CB, Taylor RH et al (1979) Pharmacokinetic monitoring of high-dose methotrexate. Early recognition of high-risk patients. Cancer Chemother Pharmacol 3:161–166 14. Steele WH, Lawrence JR, Stuart JF et al (1979) The protein binding of methotrexate by the serum of normal subjects. European J Clin Pharmacol 15:363–366 15. Shapiro WR, Young DF, Mehta BM (1975) Methotrexate: distribution in CSF after intravenous, ventricular and lumbar injections. N Engl J Med 293: 161–166

140 16. Clarke M, Gaynon P, Hann I et al (2003) CNS-directed therapy for childhood acute lymphoblastic leukemia: childhood ALL. Collaborative Group overview of 43 randomized trials. J Clin Oncol 21:1798–1809 17. Thyss A, Milano G, Etienne MC et al (1989) Evidence for CSF accumulation of 5-methyltetrahydrofolate during repeated courses of methotrexate plus folinic acid rescue. Br J Cancer 9:627–630 18. Bode U, Manan I, Bleyer WA et al (1980) Active transport of methotrexate from CSF in humans. Cancer Res 40:2184–2187 19. Erttmann R, Bielack S, Landbeck G (1985) Kinetics of 7-hydroxy-metotrexate after high-dose methotrexate therapy. Cancer Chemother Pharmacol 15:101–104 20. Jacobs SA, Stoller RG, Chabner BA et al (1976) 7-Hydroxymethotrexate as a urinary metabolite in human subjects and rhesus monkeys receiving high dose methotrexate. J Clin Invest 57:534–538 21. Valerino DM, Johns DG, Zaharko DS et al (1972) Studies of the metabolism of methotrexate by intestinal flora. I. Identification and study of biological properties of the metabolite 4-amino-4-deoxy-N 10-methylpteroic acid. Biochem Pharmacol 21:821–831 22. Jolivet J, Chabner BA (1983) Intracellular pharmacokinetics of methotrexate polyglutamates in human breast cancer cells. J Clin Invest 72:773–778 23. McGuire JJ, Hsieh P, Bertino JR (1984) Enzymatic synthesis of polyglutamate derivatives of 7-hydroxymethotrexate. Biochem Pharmacol 33:1355–1361 24. Messmann RA, Allegra CJ (2001) Antifolates. In: Chabner BA, Longo DL (eds) Cancer chemotherapy and biotherapy: principles and practice, 3rd edn. LippincottRaven, Philadelphia, 139 25. Freeman MV (1958) The fluorometric measurement of the absorption, distribution and excretion of single doses of 4-amino-10-methyl-pteroylglutamic acid (amethopterin) in man. J Pharmacol Exp Ther 122:154 26. Koike K, Kawabe T, Tanaka T et al (1997) A canalicular multispecific organic anion transporter (cMOAT) antisense cDNA enhances drug sensitivity in human hepatic cancer cells. Cancer Res 57:5475–5479 27. Creaven PJ, Hansen HH, Alford DA et al (1973) Methotrexate in liver and bile after intravenous dosage in man. Br J Cancer 28:589–591 28. Thyss A, Milano G, Kubar J et al (1986) Clinical and pharmacokinetic evidence of a life-threatening interaction between methotrexate and ketoprofen. Lancet 1:1390 29. Huang KC, Wenczak BA, Liu YK (1979) Renal tubular transport of methotrexate in the rhesus monkey and dog. Cancer Res 39:4843–4848 30. Aherne GW, Piall E, Marks V et al (1978) Prolongation and enhancement of serum methotrexate concentrations by probenecid. BMJ 1:1097–1099 31. Liegler DG, Henderson ES, Hahn MA et al (1969) The effect of organic acids on renal clearance of methotrexate in man. Clin Pharmacol Ther 10:849–857 32. Anonymous (1965) New treatment schedule with improved survival in childhood leukemia. Intermittent parenteral vs daily oral administration of methotrexate for maintenance of induced remission. Acute leukemia group B. JAMA 194:75–81

A. Ko 33. Favre R, Monjanel S, Alfonsi M et al (1982) Highdose methotrexate: a clinical and pharmacokinetic evaluation. Treatment of advanced squamous cell carcinoma of the head and neck using a prospective mathematical model and pharcokinetic surveillance. Cancer Chemother Pharmacol 9:156–160 34. Frei E, 3rd , Blum RH, Pitman SW et al (1980) High dose methotrexate with leucovorin rescue. Rationale and spectrum of antitumor activity. Am J Med 68:370–376 35. Hryniuk WM, Bertino JR (1969) Treatment of leukemia with large doses of methotrexate and folinic acid: clinicalbiochemical correlates. J Clin Invest 48:2140–2155 36. Rizzoli V, Mangoni L, Caramattti C et al (1985) Highdose methotrexate-leucovorin rescue therapy; selected application in non-Hodgkin’s lymphoma. Tumori 71: 155–158 37. Edelstein M, Vietti T, Valeriote F (1975) The enhanced cytotoxicity of combinations of 1-beta-Darabinofuranosylcytosine and methotrexate. Cancer Res 35:1555–1558 38. Thomas DA, Cortes J, O’Brien S et al (1999) HyperCVAD program in Burkitt’s-type adult acute lymphoblastic leukemia. J Clin Oncol 17:2461–2470 39. Thomas, DA, Faderl, S, O’Brien, S et al (2006) Chemoimmunotherapy with hyper-CVAD plus rituximab for the treatment of adult Burkitt and Burkitt-type lymphoma or acute lymphoblastic leukemia. Cancer 106:1569 40. Thomas DA, O’Brien S, Cortes J et al (2004) Outcome with the hyper-CVAD regimens in lymphoblastic lymphoma. Blood 104:1624 41. Ferreri, AJ, Reni, M, Pasini, F et al (2002) A multicenter study of treatment of primary CNS lymphoma. Neurology 58:1513 42. Ferreri A, Reni M, Foppoli M et al (2009) Highdose cytarabine plus high-dose methotrexate versus high-dose methotrexate alone in patients with primary CNS lymphoma: a randomised phase 2 trial. Lancet 374(9700):1512–1520 43. Blay JY, Conroy T, Chevreau C et al (1998) Highdose methotrexate for the treatment of primary cerebral lymphomas: analysis of survival and late neurologic toxicity in a retrospective series. J Clin Oncol 16: 864–871 44. Marsh JC, Bertino JR, Katz KH et al (1991) The influence of drug interval on the effect of methotrexate and fluorouracil in the treatment of advanced colorectal cancer. J Clin Oncol 9:371–380 45. Bonadonna G, Moliterni A et al (2005) 30 years’ follow up of randomized studies of adjuvant CMF in operable breast cancer: cohort study. BMJ 330:217 46. Elomaa I, Joensuu H, Blomqvist C (2003) Vinorelbine, methotrexate and fluorouracil (VMF) as first-line therapy in metastatic breast cancer: a randomized phase II trial. Ann Oncol 14:699–703 47. Colleoni M, Rocca A et al (2002) Low-dose oral methotrexate and cyclophosphamide in metastatic breast cancer: antitumor activity and correlation with vascular endothelial growth factor levels. Ann Oncol 13:73–80 48. Muss HB, Berry DA, Cirrincione CT et al (2009) Adjuvant chemotherapy in older women with early-stage breast cancer. N Engl J Med 360(20):2055–2065

7

Folate Antagonists 49. Poole CJ, Earl HM, Hiller L, Dunn JA et al (2006) Epirubicin and cyclophosphamide, methotrexate, and fluorouracil as adjuvant therapy for early breast cancer. N Engl J Med 355(18):1851–1862 50. Nitz UA, Mohrmann S, Fischer J, Lindemann W et al (2005) Comparison of rapidly cycled tandem high-dose chemotherapy plus peripheral-blood stem-cell support versus dose-dense conventional chemotherapy for adjuvant treatment of high-risk breast cancer: results of a multicentre phase III trial. Lancet 366(9501):1935–1944 51. Falo C, Moreno A, Benito E et al (2005) Primary chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil in operable breast carcinoma. Cancer 103(4):657–663 52. Hammond CB, Hertz R, Ross GT et al (1967) Primary chemotherapy for nonmetastatic gestational trophoblastic neoplasms. Am J Obstet Gynecol 98:71–78 53. Prasad PD, Mahesh VB, Leibach FH, Ganapathy V (1994) Functional coupling between a bafilomycin A1-sensitive proton pump and a probenecid-sensitive folate transporter in human placental choriocarcinoma cells. Biochimica et Biophysica Acta 1222:309–314 54. Turan T, Karacay O, Tulunay G et al (2006) Results with EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine) chemotherapy in gestational trophoblastic neoplasia. Int J Gynecol Cancer 16(3):1432–1438 55. Eilber F, Giuliano A, Eckardt J et al (1987) Adjuvant chemotherapy for osteosarcoma: a randomized prostpective trail. J Clin Oncol 5:21–26 56. Aquerreta I, Aldaz A, Giraldez J et al (2004) Methotrexate pharmacokinetics and survival in osteosarcoma. Pediatr Blood Cancer 42:52–58 57. Crews KR, Liu T, Rodriguez-Galindo C et al (2004) High-dose methotrexate pharmacokinetics and outcome of children and young adults with osteosarcoma. Cancer 100:1724–1733 58. Winick NJ, Kamen BA, Streckfuss A et al (1987) Methotrexate concentration in tumors following lowdose methotrexate. Cancer Chemother Pharmacol 20: 78–80 59. Ackland SP, Schilsky RL (1987) High-dose methotrexate: a critical reappraisal. J Clin Oncol 5:2017–2031 60. Glantz MJ, Cole BF, Recht L et al (1998) High-dose intravenous methotrexate for patients with nonleukemic leptomeningeal cancer: is intrathecal chemotherapy necessary? J Clini Oncol 16:1561–1567 61. Cole BF, Glantz MJ, Jaeckle KA et al (2003) Qualityof-life-adjusted survival comparison of sustained-release cytosine arabinoside versus intrathecal methotrexate for treatment of solid tumor neoplastic meningitis. Cancer 97(12):3053–3060 62. Browman GP, Levine MN, Goodyear MD et al (1988) Methotrexate/fluorouracil scheduling influences normal tissue toxicity but not antitumor effects in patients with squamous cell head and neck cancer: results from a randomized trial. J Clin Oncol 6:963–968 63. Coates AS, Tattersall MH, Swanson C et al (1984) Combination therapy with methotrexate and 5-fluorouracil: a prospective randomized clinical trial of order of administration. J Clin Oncol 2:756–761

141 64. Sternberg CN, Yagoda A, Scher HI et al (1985) Preliminary results of M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) for transitional cell carcinoma of the urothelium. J Urol 133:403–407 65. Sengelov L, von der Maase H, Lundbeck F et al (2002) Neoadjuvant chemotherapy with cisplatin and methotrexate in patients with muscle –invasive bladder tumors. Acta Oncol 41:447–456 66. Anonymous (2005) Neoadjuvant chemotherapy for invasive bladder cancer. Cochrane Database of Systematic Reviews:CD001426 67. Anonymous (1989) Superiority of sequential methotrexate, fluorouracil, and leucovorin to fluorouracil alone in advanced symptomatic colorectal carcinoma: a randomized trial. The Nordic gastrointestinal tumor adjuvant therapy group. J Clin Oncol 7:1437–1446 68. Hamaguchi T, Shirao K, Yamamichi N et al (2008) A phase II study of sequential methotrexate and 5-fluorouracil chemotherapy in previously treated gastric cancer: a report from the gastrointestinal oncology group of the Japan clinical oncology group, JCOG 9207 trial. Jpn J Clin Oncol 38(6):432–437 69. Yamao T, Shimada Y, Shirao K et al (2004) Phase II study of sequential methotrexate and 5-fluorouracil chemotherapy against peritoneally disseminated gastric cancer with malignant ascites: a report from the gastrointestinal oncology study group of the Japan clinical oncology group, JCOG 9603 trial. Jpn J Clin Oncol 34(6): 316–322 70. Sorenson JB, Hansen HH (1989) Chemotherapy in adenocarcinoma of the lung. Cancer Surveys 8:671–679 71. Bertino JR (1977) “Rescue” techniques in cancer chemotherapy: use of leucovorin and other rescue agents after methotrexate treatment. Sem Oncol 4:203–216 72. Bernini JC, Fort DW, Griener JC et al (1995) Aminophylline for methotrexate-induced neurotoxicity. Lancet 345:544–547 73. Erttmann R, Landbeck G (1985) Effect of oral cholestyramine on the elimination of high-dose methotrexate. J Cancer Res Clin Oncol 110:48–50 74. Djerassi I, Ciesielka W, Kim JS (1977) Removal of methotrexate by filtration-adsorption using charcoal filters or by hemodialysis. Cancer Treat Rep 61:751–752 75. Widemann BC, Balis FM, Murphy RF et al (1997) Carboxypetpidase-G2, thymidine, and leucovorin rescue in cancer patients with methotrexate-induced renal dysfunction. J Clin Oncol 15:2125–2134 76. Fritsch G, Urban C (1984) Transient encephalopathy during the late course of treatment with hig-dose methotrexate. Cancer 53:1849–1851 77. Reddick WE, Glass JO, Helton KJ et al (2005) Prevalence of leukoencephalopathy in children treated for acute lymphoblastic leukemia with high-dose methotrexate. Am J Neuroradiol 26:1263–1269 78. Drachtman RA, Cole PD, Godlen CB et al (2002) Dextromethorphan is effective in the treatment of subacute methotrexate neurotoxicity. Pediatr Hematol Oncol 19:319–327 79. Peylan-Ramu N, Poplack DG, Blei CL et al (1977) Computer assisted tomography in methotrexate encephalopathy. J Comput Assist Tomogr 1:216–221

142 80. Spiegel RJ, Cooper PR, Blum RH et al (1984) Treatment of massive intrathecal methotrexate overdose by ventriculolumbar perfusion. N Engl J Med 311:386–388 81. Adamson PC, Balis FM, McCully CL et al (1991) Rescue of experimental intrathecal methotrexate overdose with carboxypeptidase-G2. J Clin Oncol 9:670–674 82. Weber BL, Tanyer G, Poplack DG et al (1987) Transient acute hepatotoxicity of high-dose methotrexate therapy during childhood. NCI Monogr 5:207–212 83. Freeman-Narrod M, Narrod SA, Custer RP (1977) Chronic toxicity of methotrexate in rats: partial to complete projection of the liver by choline: brief communication. J Natl Cancer Inst 59:1013–1017 84. Kris, MG, HEsketh, PJ, Somerfield, MR et al (2006) American society of clinical oncology guideline for entiemetics in oncology: update 2006. J Clin Oncol 24:2932 85. Carson CW, Cannon GW, Egger MJ et al (1987) Pulmonary diseases during the treatment of rheumatoid arthritis with low dose pulse methotrexate. Semin Arthritis Rheum 16:186–195 86. Doyle LA, Ber C, Bottino G et al (1983) Erythema and desquamation after high-dose methotrexate. Ann Intern Med 98:611–612 87. Fondevila CG, Milone GA, Santiago P (1989) cutaneous vasculitis after intermediate dose of methotrexate (IDMTX). B Haematol 72:591–592 88. Shamberger RC, Rosenberg SA, Seipp CA et al (1981) Effects of high-dose methotrexate and vincristine on ovarian and testicular functions in patients undergoing postoperative adjuvant treatment of osteosarcoma. Cancer Treat Res 65:739–746 89. Uehara R, Suzuki Y, Ichikawa Y (2001) Methotrexate inhibits osteoblastic differentiation in vitro: possible mechanism of MTX osteopathy. J Rheumatol 28:251–256 90. Curt GA, Jolivert J, Carney DN et al (1985) Determinants of the sensitivity fo human small-cell lung cancer cell lines to methotrexate. J Clin Invest 76:1323–1329 91. Guo W, Healey JH, Meyers PA et al (1999) Mechanisms of methotrexate resistance in osteosarcoma. Clin Cancer Res 5:621–627 92. Zhao R, Assaraf YG, Goldman ID (1998) A mutated murine reduced folate carrier (RFC1) with increased affinity for folic acid, decreased affinity fro methotrexate, and an obligatory anion requirement for transport function. J Biol Chem 273:19065–19071 93. Li W, Fan J, Hochhauser D et al (1995) Lakc of functional retinoblastoma protein mediates increased resistance to antimetabolites in human sarcoma cell lines. Proc Natl Acad Sci USA 92:10436–10440 94. Horns RC, Jr., Dower WJ, Schimke RT (1984) Gene amplification in a leukemic patient treated with methotrexate. J Clin Oncol 2:2–7 95. Haber DA, Schimke RT (1981) Unstable amplification of an altered dihydrofolate reductase gene associated with double-minute chromosomes. Cell 26:355 96. Schweitzer BI, Dicker AP, Bertino JR (1990) Dihydrofolate reductase as a therapeutic target. FASEB J 4:2441–2452 97. Pizzorno G, Chang YM, McGuire JJ et al (1989) Inherent resistance of human squamous carcinoma cell lines to

A. Ko

98.

99.

100.

101.

102.

103. 104.

105.

106.

107.

108.

109.

110.

111.

112.

methotrexate as a result of decreased polyglutamylation of this drug. Cancer Res 49:5275–5280 Cole PD, Kamen BA, Gorlick R et al (2001) Effects of overexpression of gamma-glutamyl hydrolase on methotrexate metabolism and resistance. Cancer Res 61:4599–4604 Gorlick R, Goker E, Trippett T et al (1997) Defective transport is a common mechanism of acquired methotrexate resistance in acute lymphocytic leukemia and is associated with decreased reduced folate carrier expression. Blood 89:1013–1018 Haber DA, Schimke RT (1981) Unstable amplification of an altered dihydrofolate reductase gene associated with double-minute chromosomes. Cell 26:355 De Gramont A, Bosset JF, Milan C et al (1997) Randomized trial comparing monthly low-dose leucovorin and fluorouracil bolus with bi-monthly high-dose leucovorin and fluorouracil bolus plus continuous infusion for advanced colorectal cancer: a French intergroup study. J Clin Oncol 15:808 O’Connell MJ, Martenson JA, Wieand HS et al (1994) Improving adjuvant therapy for rectal cancer by combining protracted infusion fluorouracil with radiation therapy after curative surgery. N Engl J Med 331:502 Walko CM, Lindley C (2005) Capecitabine: a review. Clin Ther 27(1):23–44 Glyne-Jones R, Sebag-Montefiore D et al (2006) A phase I dose escalation study of continuous oral capecitabine in combination with oxaliplatin and pelvic radiation (XELOX-RT) in patients with locally advanced rectal cancer. Ann Oncol 17:50–56 Xiong HQ, Varadhachary GR, Blais JC et al (2008) Phase 2 trial of oxaliplatin plus capecitabine (XELOX) as second-line therapy for patients with advanced pancreatic cancer. Cancer 113(8):2046–2052 Cunningham D, Starling N, Rao S et al (2008) Capecitabine and oxaliplatin for advanced esophagogastric cancer. N Engl J Med 358(1):36–46 Muss HB, Berry DA, Cirrincione CT et al (2009) Adjuvant chemotherapy in older women with early-stage breast cancer. N Engl J Med 360(20):2055–2065 Kang MH, Harutyunyan N, Hall CP et al (2009) Methotrexate and aminopterin exhibit similar in vitro and in vivo preclinical activity against acute lymphoblastic leukaemia and lymphoma. Br J Haematol 145(3):389–393 Cole PD, Drachtman RA, Masterson M et al (2008) Phase 2B trial of aminopterin in multiagent therapy for children with newly diagnosed acute lymphoblastic leukemia. Cancer Chemother Pharmacol 62(1):65–75 Rustum YM (1989) Toxicity and antitumor activity of 5-fluorouracil in combination with leucovorin. Role of dose schedule and route of administration of leucovorin. Cancer 63(6 Suppl):1013–1017 Sirotnak FM, Schmid FA, Samuels LL et al (1987) 10-Ethyl-10-deaza-aminopterin: structural design and biochemical, pharmacologic, and antitumor properties. NCI Monogr 5:127–131 Casper ES, Christman KL, Schwartz GK et al (1993) Edatrexate in patients with soft tissue sarcoma. Activity in malignant fibrous histiocytoma. Cancer 72: 766–770

7

Folate Antagonists

113. Schornagel JH, Verweij J, de Mulder PH et al (1995) Randomized phase III trial of edatrexate vs methotrexate in patients with metastatic and/or recurrent squamous cell carcinoma of the head and neck: a European organization for research and treatment of cancer head and neck cancer cooperative group study. J Clin Oncol 13:1649–1655 114. Kuriakose P, Gandara DR, Perez EA (2002) Phase I trial of edatrexate in advanced breast and other cancers. Cancer Invest 20:473–479 115. Krug LM, Azzoli CG, Kris MG et al (2003) 10-propargyl-10-deazaaminopterin: an antifolate with activity in patients with previously treated non-small cell lung cancer. Clin Cancer Res 9:2072–2078 116. Duch DS, Edelstein MP, Bowers SW et al (1982) Biochemical and chemotherapeutic studies on 2,4diamino-6-(2,5-dimethoxybenzyl-5-methylpyrido[2,3-d] pyrimidine (BW 301U), a novel lipid-soluble inhibitor of dihydrofolate reductase. Cancer Res 42:3987–3994 117. Hum M, Holcenberg JS, Tkaczewski I et al (1998) Highdose trimetrexate and minimal-dose leucovorin: a case for selective protection? Clin Cancer Res 4:2981–2984 118. Machiavelli MR, Salum G, Perez JE et al (2004) Double modulation of 5-fluorouracil by trimetrexate and leucovorin in patients with advanced colorectal carcinoma. Am J Clin Oncol 27(2):149–154 119. Garcia AA, Leichman L et al (2003) Phase II clinical trial of 5-fluorouracil, trimetrexate, and leucovorin (NFL) in patients with advanced pancreatic cancer. Int J Gastrointest Cancer 34(2–3):79–86 120. Takimoto CH (1997) Antifolates in clinical development. Semin Oncol 24(Suppl 18):S18 121. Van Custem E, Cunningham D, Maroun J et al (2002) Raltitrexed: current clinical status and future directions. Ann Oncol 13:513 122. Horton TM, Blaney SM, Langevin AM et al (2005) Phase I trial and pharmacokinetic study of raltitrexed in children with recurrent or refractory leukemia: a pediatric oncology group study. Clin Cancer Res 11:1884–1889 123. Gambacorta MA, Valentini V et al (2004) Chemoradiation with raltitrexed and oxaliplatin in preoperative treatment of stage II-III resectable rectal cancer: phase I and II studies. Int J Radiat Oncol Biol Phys 60(1):139–148 124. Ray M, Kindler HL (2009) Malignant pleural mesothelioma: an update on biomarkers and treatment. Chest 136(3):888–896 125. Benepal TS, Judson I (2005) ZD9331: discovery to clinical development. Anticancer Drugs 16(1):1–9 126. Rader JS, Clarke-Pearson D, Moore M et al (2003) A phase II study to determine the efficacy and tolerability of intravenous ZD9331 in heavily pretreated patients with ovarian cancer. Gynecol Oncol 91(2):318–325 127. Smith D, Gallagher N (2003) A phase II/III study comparing intravenous ZD9331 with gemcitabine in patients with pancreatic cancer. Eur J Cancer 39(10):1377–1383 128. Schulz J, Keller A, Canfield V et al (2004) ZD9331 as second- or third-line therapy in patients with advanced

143

129.

130.

131.

132.

133.

134.

135.

136.

137.

138.

139.

140.

141.

colorectal cancer: a phase II multicenter trial. Am J Clin Oncol 27(4):337–342 Laohavinij S, Wedge SR, Lind MJ et al (1996) A phase I clinical study of the antipurine antifolate lometrexol (DDATHF) given with oral folic acid. Invest New Drugs 14(3):325–335 Chattopadhyay S, Moran RG, Goldman ID (2007) Pemetrexed: biochemical and cellular pharmacology, mechanisms, and clinical applications. Mol Cancer Ther 6(2):404–417 Scagliotti GV, Shin DM, Kindler HL et al (2003) Phase II study of pemetrexed with and without folic acid and vitamin B12 as front-line therapy in malignant pleural mesothelioma. J Clin Oncol 21:1556 Hanna N, Shepherd FA, Fossella FV et al (2004) Randomized phase III trial of pemetrexed versus docetaxel in patients with non-small-cell lung cancer previously treated with chemotherapy. J Clin Oncol 22: 1589–1597 Vogelzang N, Rusthoven J, Symanowski J et al (2003) Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol 21:2636 Adjei AA (2004) Pemetrexed (ALIMTA), a novel multitargeted antineoplastic agent. Clin Cancer Res 10: 4276S–4280S Tonkinson JL, Worzalla JF, Teng CH, Mendelsohn LG (1999) Cell cycle modulation by a multitargeted antifolate, LY231514, increases the cytotoxicity and antitumor activity of gemcitabine in HT29 colon carcinoma. Cancer Res 59:3671–3676 Giovannetti E, Mey V, Nannizzi S et al (2005) Cellular and pharmacogenetics foundation of synergistic interaction of pemetrexed and gemcitabine in human non-small-cell lung cancer cells. Mol Pharmacol 68: 110–118 Ma CX, Nair S, Thomas S et al (2005) Randomized phase II trial of three schedules of pemetrexed and gemcitabine as front-line therapy for advanced non-small-cell lung cancer. J Clin Oncol 23:5929–5937 Pivot X, Wadler S et al (2001) Result of two randomized trials comparing nolatrexed vs methotrexate in patients with recurrent head and neck cancer. Ann Oncol 12(11):1595–1599 Gish RG, Porta C, Lazar L et al (2007) Phase III randomized controlled trial comparing the survival of patients with unresectable hepatocellular carcinoma treated with nolatrexed or doxorubicin. J Clin Oncol 25(21): 3069–3075 Cole PD, Kamen BA, Bertino JR (2006) Folate antagonists. Cancer medicine, 7th edn. BC Decker, Hamilton, ON, pp 648–660 Robien K, Boynton A, Ulrich CM (2005) Pharmacogenetics of folate-related drug targets in cancer treatment. Pharmacogenomics 6(7):673–689

Chapter 8

Platinum Complexes for the Treatment of Cancer David Roberts, Peter J. O’Dwyer, and Steven W. Johnson

8.1 Introduction

8.2 Cisplatin – Discovery

Though its antitumor activity was discovered four decades ago, cis-diamminedichloroplatinum (II) (cisplatin) continues to be widely used for the treatment of many solid tumor types. When combined with other cytotoxic drugs or some of the newer “targeted” agents, significant improvements in response and survival rates have been observed in cancers of the ovary, lung, bladder and head and neck. Its most remarkable contribution, however, has been in the treatment of testicular cancer. Prior to the introduction of cisplatin to the clinic, testicular tumors were treated with a combination of vinblastine, adriamycin and bleomycin resulting in response rates of approximately 50%. Treatment with cisplatin-based therapy now cures the majority of testicular cancer patients presenting with advanced stage disease. The extraordinary antitumor activity observed with cisplatin in early clinical trials prompted further investigations into understanding its mechanism of action and developing less toxic analogs with different cytotoxicity profiles. These efforts have resulted in the development of two more platinum complexes, carboplatin and oxaliplatin, which are approved for clinical use. In this chapter, we will provide a review of the attributes of the platinum drugs including their chemistry, clinical pharmacology, mechanism of action, and mechanisms of resistance.

Though cis-diamminedichloroplatinum II was originally synthesized in 1890, the idea that this inorganic compound had biological activity remained unknown until 1961 when Dr. Barnett Rosenberg initiated a series of experiments at the University of Michigan designed to study the effects of an electromagnetic field on the growth of E. coli bacteria [1]. Using an apparatus consisting of platinum electrodes and bacteria in an ammonium chloride containing medium, Dr. Rosenberg observed that exposure of the bacteria to the electric current caused filamentous growth without cell division. He subsequently discovered this effect was not caused directly by the electric field, but by electrolysis products, of which a major component was ammonium chloroplatinate [NH4 ]2 [PtCl6 ]. This compound was inactive at reproducing the filamentous growth of E. coli, however, Rosenberg discovered that the conversion of this complex to a neutral species by ultraviolet light was required to obtain an active complex. Attempts to synthesize the active neutral platinum complex failed. It was soon realized, however, that the neutral compound could exist in two isomeric forms, cis or trans, and the latter species is the one that they had synthesized. Subsequently, the cis isomer was synthesized and shown to be the active compound. Rosenberg tested the antitumor activity of cis and trans isomers of diamminedichloroplatinum II and diamminetetrachloroplatinum IV in mice bearing Sarcoma-180 solid tumors and L1210 leukemia cells [2]. Though all four compounds exhibited significant antitumor activity, cis-diamminedichloroplatinum II (cisplatin) was the most effective. Studies in other tumor models confirmed these results and indicated

S.W. Johnson () Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA 19104, USA e-mail: [email protected]

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_8, © Springer Science+Business Media B.V. 2011

145

146

that cisplatin exhibited a broad spectrum of activity. Early clinical trials demonstrated cisplatin’s activity against several tumor types, with testicular cancers being particularly sensitive. However, a major problem with cisplatin administration was severe renal and gastrointestinal toxicity. This nearly ended its clinical use until Cvitkovic et al. [3, 4] showed that these toxic side effects could be circumvented by aggressive prehydration. Overcoming this obstacle enabled the large-scale testing of cisplatin alone and in combination with other drugs for the treatment of various malignancies [5].

D. Roberts et al.

NH3

Cl Pt

Cisplatin NH3

Cl

NH3

O

C

O

C

O

Carboplatin

Pt NH3

O

8.3 Cisplatin Analogs Platinum complexes primarily exist in either a 2+ or 4+ oxidation state, which determines the overall stereochemistry of the ligands associated with the platinum atom (Fig. 8.1). The structure of these ligands influences the stability of the complex and the rate of substitution. Most platinum complexes exhibiting antitumor activity consist of leaving groups and carrier ligands. In aqueous solution, the leaving groups are labile and are prone to mono- and di-aqua substitution. This process is termed aquation and is a prerequisite step for drug activation. The carrier ligands represent stable moieties that remain bound to the platinum atom during drug uptake, distribution and binding to its cytotoxic target. Progress in understanding the chemistry and pharmacokinetics of cisplatin has guided the development of new analogs. In general, modification of the chloride leaving groups of cisplatin results in compounds with altered pharmacokinetics, whereas modification of the diammine carrier ligands affects the activity of the complex. The systematic design and testing of platinum compounds with various leaving groups and carrier ligands has been a goal of both academic and industrial laboratories in an effort to create drugs with unique activity and reduced toxicity.

8.3.1 Carboplatin The effect of altering the chloride leaving groups of cisplatin on pharmacokinetics and toxicity is exemplified by cis-diamminecyclobutanedicarboxylato platinum II (carboplatin). Carboplatin contains the same

Carrier Ligands

Leaving Groups

Fig. 8.1 Structures of the carrier ligands and leaving groups of cis-diamminedichloroplatinum II (cisplatin) and cisdiamminecyclobutanedicarboxylato platinum II (carboplatin)

ammine carrier ligands as cisplatin, however, a more stable cyclobutanedicarboxylate moiety serves as the leaving group [6, 7]. This results in a drug with a considerably longer plasma half-life and reduced renal toxicity. In fact, carboplatin was isolated using a murine screen for nephrotoxicity in an effort to find cisplatin analogs with more favorable toxicity profiles. Carboplatin may be administered at doses approximately ten times that of cisplatin and results in comparatively less nausea, vomiting, nephrotoxicity and neurotoxicity. Calvert and colleagues [8] showed that carboplatin concentration in patient plasma ultrafiltrates is correlated with renal clearance. From this observation, a dosing formula was developed that enables efficacy and toxicity in patients to be more predictable [9]. With respect to preclinical and clinical activity, carboplatin is essentially indistinguishable from cisplatin. Thus, its overall reduced renal and gastrointestinal toxicity and ease of administration has resulted in its substitution for cisplatin in the treatment of most tumor types.

8.3.2 Oxaliplatin and DACH Complexes Just as carboplatin represents a leaving group modification that affects pharmacokinetics, the

8

Platinum Complexes for the Treatment of Cancer Cl

O NH2

O

C

Cl

NH2 Pt

Pt NH2

147

NH2

O C O

Oxaliplatin

Fig. 8.2 Structures of platinum drugs diaminocyclohexane (DACH) carrier ligand

Cl Cl

Ormaplatin

containing

the

diaminocyclohexane (DACH) platinum complexes represent the effects of altering the diammine carrier ligands of cisplatin (Fig. 8.2). Following the discovery of cisplatin’s antitumor activity by Rosenberg, Dr. Tom Connors synthesized and evaluated a series of compounds with varying carrier ligands [10]. He found that platinum analogs containing the DACH moiety were active in preclinical cancer models. These results were confirmed and extended by Burchenal who provided in vivo data showing that DACH compounds were indeed active in tumors in which cisplatin had little or no activity [11]. Subsequent in vitro studies supported the concept that cisplatin-resistant cells are collaterally sensitivity to DACH platinum complexes [12, 13]. In support of these studies, Rixe et al. [14] showed that DACH derivatives exhibit a unique cytotoxicity profile as compared to cisplatin and carboplatin using the NCI 60 cell line screen. The first DACH compound to be tested in the clinic was tetrachloro(d,l-trans)-1,2-diaminocyclohexaneplatinum IV (ormaplatin, tetraplatin), a stable platinum (IV) analog which exhibits activity against cisplatin-resistant cells. Phase I studies conducted in the early 1990s indicated that severe and cumulative neurotoxicity was dose-limiting and prevented further development [15]. Chaney and colleagues have conducted several studies to determine the underlying basis for neurotoxicity associated with ormaplatin therapy [16, 17]. Following injection, ormaplatin undergoes a biotransformation yielding Pt(DACH)Cl2 as the primary metabolite. The plasma levels of this metabolite were associated with neurotoxicity in one study [17]. A second DACH analog, oxalato (transl-1,2-diaminocyclohexane) platinum II (oxaliplatin), has had considerably more clinical success. Originally synthesized by Kidani and colleagues in the early 1970s, oxaliplatin is substantially less lipophilic

than ormaplatin, but retains the DACH spectrum of activity in cisplatin-resistant tumor models. Shord et al. [18] found that oxaliplatin remains relatively intact in patient plasma ultrafiltrates and the concentrations of metabolites such as Pt(DACH)Cl2 are low, which may contribute to lower and reversible neurotoxicity. Oxaliplatin was first studied in two phase I trials in which suitable doses and schedules were evaluated, and an early hint of colorectal cancer activity identified [19, 20]. Oxaliplatin has since demonstrated significant activity in combination with 5-fluorouracil/leucovorin in colon cancer, a disease that was previously considered to be unresponsive to platinum drugs [21]. A series of consistent phase II and III clinical trials which followed confirmed activity of oxaliplatin in colorectal cancer. Oxaliplatin is now approved for the first-line treatment of advanced colorectal cancer, and preliminary data indicate that it improves the survival of patients with Stage II and III disease when used in the adjuvant setting. The antitumor activity of oxaliplatin in other malignancies is currently under investigation.

8.3.3 Other Platinum Complexes Cisplatin, carboplatin and oxaliplatin have been approved by the FDA for the treatment of cancers in the United States. Over the last several decades, however, a variety of other platinum complexes have been synthesized and evaluated preclinically and in clinical trials. Many of these compounds have been discarded while others are maturing and may soon be approved for use against certain tumor types. A summary of selected agents is provided in this section and the chemical structures are shown in Fig. 8.3.

8.3.3.1 Satraplatin (JM216) Platinum IV compounds have been designed in an effort to create platinum molecules with unique cytotoxic activity. Ormaplatin (tetraplatin, tetrachloro(d,ltrans)-1,2-diaminocyclohexaneplatinum) represents the first of this class to undergo clinical testing and the results, as discussed above, were quite negative with marked neurotoxicity preventing its further use. Though considerably less toxic, a second

148

D. Roberts et al.

Fig. 8.3 Structures of novel platinum drugs that have been clinically tested as anticancer drugs

Cl

OCOCH3 Cl

NH3

Cl

CH3

Iproplatin

NH2(CH2)6 NH2

NH3

AMD473

NH3

NH3

Cl

NH3

4+

Pt

Pt

Pt

Cl

N Cl Cl

JM216

Cl

Pt

CH3 CH-NH2 CH3

OCOCH3

NH3

Cl

Cl Pt

Pt NH2

NH3

CH3 CH-NH2 CH3

NH2 (CH2)6 NH2

NH3

BBR3464

complex, iproplatin (cis-dichloro-trans-dihydroxybis-isopropylamine platinum IV, CHIP, JM9), proved to be relatively inactive in phase II trials [22, 23]. Despite these disappointing results, satraplatin [bis(acetato)amminedichloro(cyclohexylamine) platinum (IV)] has yielded promising results. In preclinical studies, satraplatin (JM216) exhibited a lack of cross-resistance in cells that were selected for cisplatin resistance [24]. Another unique feature of this drug is its oral bioavailability, thus facilitating administration. To date, there has only been limited clinical testing of satraplatin, though the results have been encouraging. Activity has been observed in small cell and non-small cell lung cancer [25, 26]. In a phase II trial evaluating 39 patients with hormone-refractory prostate cancer, satraplatin exhibited activity in 2 of 20 (10%) evaluable patients with measurable disease [27]. Further testing of this compound in prostate cancer was done in a phase III trial in combination with prednisone [28]. The addition of satraplatin to a prednisone regimen resulted in an increase in both median survival and progression-free survival. Definitive results await the completion of a large phase III trial currently underway in this disease.

8.3.3.2 AMD473 Substitution of one of the amine groups of cisplatin for a 2-methylpyridine moiety resulted in a “sterically hindered” platinum molecule

know as AMD473 (ZD0473, cis-amminedichloro (2-methylpyridine)platinum II). This drug was rationally designed to react preferentially with nucleic acids over sulphur ligands such as glutathione, thus preventing inactivation from occurring and increasing the relative level of DNA damage [29, 30]. In support of this, AMD473 shows a non-cross-resistant cytotoxicity profile when compared to that of cisplatin and oxaliplatin. Clinical trials have been conducted to assess the toxicity and efficacy of this platinum drug. In a phase I study, single agent AMD473 was found to be well tolerated at a dose of 120 mg/m2 every 21 days [31]. Neutropenia and thrombocytopenia were dose limiting. AMD473 has also been tested in combination with taxanes and gemcitabine [32–34]. In the phase II setting, activity was observed in ovarian cancer (8.3 and 32.4% objective response in platinumresistant and -sensitive patients, respectively), but a low response rate (3.8%) in metastatic breast cancer is likely to preclude further development in this tumor type [35, 36].

8.3.3.3 BBR3464 In yet another approach to augment the cytotoxicity profile of cisplatin and its analogs, Farrell and colleagues [37] have synthesized a series of di- and tri-nuclear platinum molecules representing individual cis- and trans-platin molecules linked together. These molecules form adducts that span greater distances

8

Platinum Complexes for the Treatment of Cancer

across the minor groove of DNA, and exhibit a potent and significantly different cytotoxicity profile from that of other platinum complexes. This may be due in part to the formation of a different platinum-DNA adduct profile, comprised of a larger proportion of interstrand crosslinks. BBR3464 has been tested in phase I and II clinical trials. In a Phase I study involving 14 patients with advanced cancer, BBR3464 was administered beginning at 0.03 mg/ m2 /day and escalated to a dose of 0.17 mg/m2 /day [38]. The maximum tolerated dose in this study was defined as 0.13 mg/m2 /day. Observed toxicity included diarrhea and neutropenia. There was no significant nephrotoxicity, neurotoxicity or pulmonary toxicity. In a phase II study of patients with gastric and gastro-espohageal adenocarcinoma, only 1 of 17 (6%) patients responded [39].

8.3.4 Identification of New Platinum Analogs A number of lessons have been learned from the development of platinum analogs over the last few decades. Most importantly, that careful selection of preclinical models is an important aspect of drug development. This is clearly evident in the use of an antiemetic model for the development of carboplatin. Also, thorough testing of new analogs in both platinumsensitive and –resistant cell lines proved important to the development of DACH platinum complexes such as oxaliplatin. The continued development of platinumresistance models and incorporation of statistically significant numbers of cell lines into the analysis will be an important step to identify unique platinum cytotoxicity profiles. The importance of studying larger models was demonstrated in an analysis of the NCI anticancer drug screen consisting of growth inhibitory data for 60 unrelated cell lines [40]. The relationships between 107 platinum analogs was evaluated using a clustering algorithm and the results clearly showed a distinct pattern of sensitivity based on the structure of the platinum drug tested. Four well-defined groups emerged from this analysis consisting of a cisplatin, DACH, silane and pyridine group. As the latter two groups have not received significant attention, they could certainly represent compounds with unique antitumor activity. Efforts such as this aimed at identifying platinum analogs with unique profiles may

149

have a future impact on the treatment of notoriously platinum-insensitive tumors. A major challenge will be to correctly identify the most effective compounds to bring forward into the clinic.

8.4 Pharmacology Early in the clinical development of platinum analogs a dogma emerged regarding the control of drug efficacy and toxicity. It was realized that altering the carrier ligands of cisplatin attenuated the cytotoxicity profile of the drug, whereas changing the leaving groups influenced the pharmacokinetics. This phenomenon is readily apparent for the three FDA approved drugs cisplatin, carboplatin and oxaliplatin. The diaminocyclohexame moiety of oxaliplatin imparts a somewhat noncross-resistant cytotoxicity profile when compared to that of cisplatin and carboplatin. The relative activity of the latter two are nearly identical in preclinical models and are considered nearly equivalent clinically when tumor response and patient survival are considered as endpoints. However, the presence of a cyclobutanedicarboxylate group provides a more favorable pharmacokinetic profile for carboplatin and facilitates its administration.

8.4.1 Pharmacokinetics Of the three drugs, cisplatin has the shortest half-life. Ultrafilterable cisplatin disappears rapidly and in a biphasic fashion [41–43]. Half-lives of 10–30 min have been reported for the first phase and 40–50 min for the second. The disappearance of platinum from plasma following short infusions carboplatin occur in a biphasic or triphasic manner [44, 45]. The half-lives for total platinum during the first phase (t1/2 α) range from 12 to 98 min and from 1.3 to 1.7 h during the second phase (t1/2 β). Half-lives reported for the terminal phase range from 8.2 to 40 h. For oxaliplatin, plasma elimination of ultrafilterable platinum is also biphasic [46, 47]. The half-lives for the first and second phases are 0.3 and 24.2 h, respectively. Significant differences are also observed in protein binding. Following infusion, cisplatin rapidly diffuses into tissues and approximately 90% of platinum is bound to plasma protein after four hours [48].

150

Elimination occurs predominantly by the kidneys as approximately 23 and 40% appears in the urine at 24 hours post-infusion [49, 50]. Carboplatin is quite stable in plasma. At 4 hours post-infusion, only 24% of platinum is bound to protein. Carboplatin is excreted predominantly by the kidneys, and cumulative urinary excretion of platinum is 54–82%, most as unmodified carboplatin. The renal clearance of carboplatin is closely correlated with the glomerular filtration rate (GFR) [51]. Based on this observation, Calvert et al. [8] designed a dosing formula which is now widely used and provides a reliable method for controlling the pharmacokinetics and toxicity of carboplatin in individual patients. Similar to cisplatin, the majority (85%) of platinum following an infusion of oxaliplatin is bound to plasma protein. Prolonged retention of oxaliplatin is observed in red blood cells. Unlike cisplatin, however, oxaliplatin does not significantly accumulate following multiple courses of treatment [52]. This may explain why neurotoxicity associated with oxaliplatin is reversible whereas it is cumulative for cisplatin therapy. Oxaliplatin is eliminated predominantly by the kidneys with more than 50% of the platinum being excreted in the urine at 48 h.

8.4.2 Toxicity Initial clinical studies with cisplatin indicated its doselimiting toxicity was nephrotoxicity. This nearly ended its clinical evaluation, however, Cvitkovic and colleagues found that aggressive hydration of patients prior to infusion could prevent the development of acute renal failure [3, 4]. Other side effects include nausea and vomiting, nephrotoxicity, ototoxicity, neuropathy, and myelosuppression. Despite improvements in cisplatin administration and control of its side effects, a search for less toxic analogs was a priority for academia and industry. This led to the discovery of carboplatin. Myelosuppression, which is not usually severe with cisplatin, is the dose-limiting toxicity of carboplatin [53]. The drug is most toxic to the platelet precursors, but neutropenia and anemia are also observed. Other toxicities associated with carboplatin include nausea and vomiting which is easily controlled with standard antiemetics. Renal impairment is infrequent. Neurotoxicity is also less common when compared to cisplatin, although it is observed more frequently with the increasing use of high dose

D. Roberts et al.

regimens. The dose-limiting toxicity of oxaliplatin is sensory neuropathy, a characteristic of all DACHcontaining platinum derivatives. The persistence of neurotoxicity has led to approaches to circumvent it, including the use of protective agents (intravenous calcium and magnesium salts before and after each infusion) [52], or a modified administration schedule [54]. As with other platinum drugs, nausea and vomiting occurs which generally responds to 5-HT3 antagonists. Myelosuppression is uncommon and is not severe and oxaliplatin therapy is not associated with nephrotoxicity.

8.5 Platinum-Induced Cell Death 8.5.1 DNA Adducts DNA has been implicated as the cytotoxic target for the platinum drugs. This has been deduced from a wide variety of experiments [55–57]. Rosenberg’s initial studies showed that cisplatin inhibited DNA synthesis without affecting protein synthesis [1]. It has also been observed that cells deficient in the activity of specific DNA enzymes are hypersensitive to platinum drugs and other DNA damaging agents [58, 59]. Finally, the isolation and identification of individual platinumDNA adducts has been achieved. Platinum drugs bind covalently with DNA to form both monofunctional and bifunctional adducts. Reaction occurs preferentially at the N7 position of guanine and adenine residues [60–62]. The first step of the reaction involves the formation of monoadducts which then react further to form intrastrand or interstrand crosslinks. The relative amount of each adduct depends, in part, on the time of exposure and the manner in which the DNA is processed and analyzed. The predominate bifunctional lesions that are formed include the d(GpG)Pt, d(ApG)Pt and d(GpNpG)Pt intrastrand crosslinks, however, platinum drugs also form interstrand crosslinks between guanine residues located on opposite DNA strands. These lesions represent a minor portion of the total DNA bound platinum, but they may contribute to the drug’s cytotoxicity as they impair process that require the separation of DNA strands. Monoadducts are also formed at relatively high frequency, though they may be converted to bifunctional lesions or subject to quenching by other molecules.

8

Platinum Complexes for the Treatment of Cancer

Reports on the frequency of monoadducts in cultured cells range vary considerably, but these variations are likely due to different experimental conditions, in particular, time of exposure.

8.5.2 Damage Recognition The adducts formed between most platinum analogs are similar in type and frequency, thus the differences observed in cytotoxicity between the diammine (e.g. cisplatin, carboplatin), DACH, and other platinum compounds is more likely due to how the cell interprets and reacts to the presence of the damage. Once bound to DNA, platinum drugs may disrupt a variety of cellular processes while others may be activated. Research done in the last decade has begun to elucidate the pathways that contribute to the cytotoxicity of the platinum drugs. Adduct recognition or lack thereof is likely a key step in determining cell sensitivity or resistance to platinum drugs. A number of proteins have been identified that recognize platinum lesions, but their role in influencing drug sensitivity directly or indirectly remains unknown. One of the first groups of proteins shown to bind to DNA damaged by cisplatin are the HMG proteins. These proteins are capable of bending DNA and recognizing bent DNA structures, such as those produced by cisplatin [63–65]. The affinity for cisplatin-damaged DNA is considerably higher than that for the relatively inactive isomer, transplatin. It has been postulated that HMGB1 influences cisplatin sensitivity through a variety of mechanisms. This may occur directly, through the transmission of a damage signal to the cell’s apoptotic machinery or indirectly involving interactions with other proteins that initiate signal transduction. Evidence for the latter is supported by a study demonstrating an interaction between HMGB1 and p53. Yet another possible role for HMG domain-containing proteins is to shield adducts from recognition by DNA repair proteins. Further studies are still needed in this area to define a functional role for these proteins in platinum sensitivity/resistance and to show that these processes are important in clinical material. In addition to the HMG family members (HMGA, HMGB and HMGN), several other proteins have been shown to recognize platinum-DNA adducts including histone H1, RNA polymerase I transcription upstream binding factor (hUBF), the TATA binding protein

151

(TBP) and proteins of the mismatch repair complex. The MSH2 and MLH1 mismatch repair proteins can recognize DNA adducts formed by cisplatin [66]. The presence of a platinum lesion may result in the continuous futile cycle of repair synthesis on the DNA strand opposite the lesion. This could result in the accumulation of DNA strand breaks ultimately leading to cell death. Interestingly, oxaliplatin adducts are not well recognized by the mismatch repair protein complex, which may contribute to the differences in cytotoxicity observed between these two platinum molecules. It is also important to note that loss of mismatch repair activity has been associated with cisplatin resistance [67, 68], though it is not clear whether this is a direct effect on sensitivity or whether defective mismatch repair results in genomic instability, thus providing an environment leading to mutations in other drug sensitivity genes.

8.5.3 Damage Recognition, Signaling and Apoptosis Following platinum-DNA adduct formation, a cascade of signals occurs that leads to apoptosis in drugsensitive cells. At the present time, these events are not completely understood but remain an active area of investigation for platinum drugs and other anticancer agents. Sorting out the drug-specific signaling network(s) associated with cell death has been challenging as a number of factors must be considered including (1) the type of anticancer drug used, (2) drug concentration and exposure conditions, and (3) cell model under study. These factors have led to controversy regarding the role of some signaling molecules in promoting cell survival or cell death. Despite these discrepancies, significant progress has been made in several areas of the drug-induced signaling process including the initiation, commitment and terminal phases. In this section, we will provide a summary of the events that have been the subject of significant study. As discussed above, a number of proteins have been identified that recognize and bind to cisplatin adducts with high affinity. However, it remains unclear whether any of these proteins directly or indirectly initiate a DNA damage signaling event. This will be important to elucidate as resistance to platinum drugs could

152

involve the disruption of this process. Downstream of platinum-DNA adduct recognition, a number of signaling events have been shown to occur [69]. The ATM and ATR proteins appear to be important in this process. These kinases are phosphorylated and activated following cisplatin-induced DNA damage. ATM and ATR mediate the activation of serveral signal transduction pathways as a result of DNA damage. ATM interacts and stabilizes several known DNA damageresponse proteins such as p53, E2F1 and BLM. Luo et al. [70] provided evidence that ATM is involved in stabilizing the mismatch repair complex and, in conjunction with hMLH1, localizes this complex to the nucleus. This evidence provides a potentially important connection between platinum-DNA adduct recognition by mismatch repair proteins and the transduction of a repair/apoptotic signal mediated by TP53. The impact of disrupting one or members of this pathway should theoretically result in cells with a cisplatin-resistant phenotype. In the case of ATM, ATR and individual mismatch repair proteins, inhibition or down-regulation has been shown to decrease cisplatin sensitivity by a modest amount (2- to 3-fold). In addition, studies with p53 have been somewhat controversial with some reports of p53 disruption leading to cisplatin sensitivity and others the opposite effect [71, 72]. This raises the question as to the importance of these signaling pathways to drug resistance as it is well documented that cells can achieve quite high levels of cisplatin resistance (up to 1000-fold). It is possible that sufficient redundancy exists in the DNA damage signaling process that other pathways circumvent or complement the pathways described above. This has implications when choosing new targets for the design of therapies to augment cisplatin therapy.

8.5.4 Decision/Commitment Phase Platinum-induced drug sensitivity is intimately tied to the cell cycle. For example, proliferating cells are relatively sensitive to cisplatin, whereas quiescent cells or cells in G0 /G1 are relatively insensitive [73]. Thus, the interplay between DNA damage-induced signaling and cell cycle arrest and how this influences a cell’s decision to repair adducts or undergo apoptosis is important to understand. Shortly after the observation that apoptosis results from exposing cells to

D. Roberts et al.

chemotherapeutic drugs, Eastman and colleagues developed and analyzed the role of cell cycle in cisplatin-induced apoptosis using DNA repairdeficient CHO cells [74, 75]. In these studies, cisplatintreated CHO/AA8 cells experienced slow progression through S phase and accumulated in G2 . At low drug concentrations, the cells recovered and continued to cycle. At high drug concentrations, the cells died following a protracted G2 arrest. An aberrant mitosis was observed prior to apoptosis. Further studies with G2 -synchronized cells revealed that passage through S phase is necessary for G2 arrest and cell death suggesting that DNA replication on a damaged template may result in the accumulation of further damage causing the cells to ultimately die. Abrogating the G2 checkpoint with pharmacologic agents such as caffeine or 7-hydroxystaurosporine was shown to enhance the cytotoxicity of cisplatin [76]. Based on these studies, a connection may be made between signaling events mediated by proteins such as ATM and ATR and the cell cycle. In addition to these events, a number of other proteins/pathways have been shown to be activated by platinum drugs or have been shown to influence cell sensitivity to platinum drugs. Some of these include signaling mediated by AKT, MAP kinases (ERK, JNK, and p38 kinase), c-Abl, ras, p53, p73 and NF-κB [69, 77]. The complexity of the response increases as each of these signaling molecules influences the activity and expression of transcription factors and other proteins. As a result, it is not surprising that a lack of consistency exists in conclusions drawn by investigators as to the role of these pathways in cell survival and apoptosis. This is also due to the various experimental conditions employed including cell type, treatment, selection of endpoints and duration of the effect. As the field of signal transduction has grown, so has the number of candidate effectors and pathways that influence platinum drug sensitivity. The list is large and includes cytokines, growth factors, kinases, phosphatases, second messengers, transcription factors, redox proteins and extracellular matrix proteins. Some of these molecules may attenuate sensitivity to only platinum drugs and DNA damaging agents, whereas others influence cellular sensitivity to a variety of unrelated chemotherapeutic drugs. The collective activity of the signaling events described above may determine whether a cell can survive platinum-induced damage or undergo apoptosis. Thus every tumor cell may have

8

Platinum Complexes for the Treatment of Cancer

a threshold or rheostat that senses the balance of proand anti- apoptotic signals that are invoked following DNA damage.

8.5.5 Apoptosis/Terminal Phase Apoptosis consists of a cascade of events leading to the ordered dismantling of critical cell survival components and pathways. At least two apoptotic pathways exist in cells, each of which is modulated through proteins called caspases. The extrinsic pathway of apoptosis is activated when death domain containing Tumor Necrosis Factor Receptor (TNFR) family members become activated by TNFR ligands (TNFα, Fas-L, TRAIL and Tweak). Activation leads to the formation of a death inducing signaling complex (DISC) consisting of at least three proteins, namely the adaptor molecule Fas-associated death domain and caspases-8 and -10. Caspase 8, once activated by DISC, can activate caspases-3, -6, and -7, which in turn activate various caspase-dependent deoxynucleases (CAD/ICAD) leading to nucleosomal fragmentation. Cells treated with platinum compounds have been shown to induce the expression and/or activity of many members of this pathway. For example, cisplatin exposure has been shown to induce the expression of the DR4 and DR5 pro-apoptotic cell death receptors in esophageal squamous cell carcinoma cell lines [78]. Cisplatin exposure has also been demonstrated to induce the expression of Fas and FasL proteins [79, 80]. Similarly, HT29 human colon carcinoma cell lines treated with cisplatin exhibit enhanced DISC complex formation, while numerous cell model systems have documented cisplatin’s role in inducing caspase-3, -8, and -9 activities and mRNA expression [81–83]. Incidentally, MCF-7 cells deficient in caspase-3 are unable to undergo apoptosis following cisplatin treatment, thus stressing the importance of these proteins in platinum-induced cytotoxicity [84]. In addition to the extrinsic pathway, apoptosis may also be initiated by the release of a number of mitochondrial proteins (cytochrome c, endonuclease G, SMAC, AIF), all of which are frequently observed following platinum treatment [85]. During this process, cytochrome c and ATP are released from the mitochondria and together activate apoptotic protease-activating factor-1 (ApaF1). ApaF1 sequentially triggers caspase9, which is then free to stimulate caspase 3 [86, 87].

153

Both extrinsic and intrinsic apoptotic pathways are not mutually exclusive. Signaling through the death receptor pathway may modulate cytochrome c release through caspase-8/caspase-10 dependent Bid cleavage, leading to disruptions in mitochondrial membrane permeability. A number of cellular proteins have the ability to modulate these caspase dependent pathways. Two of the most well documented protein families capable of modulating apoptosis are the Bcl-2 and inhibitor of apoptosis (IAPs) families. The Bcl-2 family includes (but is nor limited to) pro-apoptotic (Bax and Bak) and anti-apoptotic (Bcl-2 and Bcl-XL ) proteins, which regulate mitochondrial permeability via the adenine nucleotide translocator and voltage dependent anion channel [88, 89]. In addition, Bcl-2 and Bcl-XL sequester BH3-only containing Bcl-2 family members (Bid and Bim), thus inhibiting Bax and Bak translocation to the mitochondria where they are thought to instigate the release of mitochondrial factors (cytochrome c). It is therefore not surprising to observe reductions in mRNA transcript and protein levels for Bcl-2 in the cisplatin-sensitive human ovarian cancer cell line 2008 following cisplatin treatment [90]. In contrast to Bcl-2 mRNA and protein reductions following cisplatin treatment, the mRNA expression and translocation of the pro-apoptotic protein Bax has been documented in a number of model systems subsequent to cisplatin exposure [91]. In contrast to the Bcl-2 family, the IAP family of proteins includes approximately eight family members (NAIP, cIAP1, cIAP2, XIAP, Livin-α, Livin-β, ILP-2, and Survivin), each of which has the capability to bind to and inhibit caspase activity [92]. In cisplatin-sensitive human ovarian cancer cell lines, XIAP is down-regulated following cisplatin treatment [93], a process which is antagonized by AKT phosphorylation [94]. Undoubtedly, future insight into cisplatin’s role in affecting this family of proteins, and thus apoptosis, will likely be presented in the future.

8.6 Mechanisms of Resistance Drug resistance is a problem for all types of anticancer drug and this phenomenon limits the effectiveness of the platinum drugs. Platinum resistance may be intrinsic or acquired and is quite pleiotropic. One can divide platinum resistance mechanisms into two

154

major groups: those that prevent DNA adduct formation and those that enable cells to survive following DNA damage (Fig. 8.2). The first group of mechanisms includes decreased drug accumulation and increased drug inactivation by cellular protein and non-protein thiols. The second group of mechanisms includes increased platinum-DNA adduct repair and increased platinum-DNA damage tolerance. The identification and measurement of these mechanisms has been possible through the development of resistant cell models and the establishment of cell lines from chemotherapyrefractory tumors. Though progress has been made in identifying putative resistance mechanisms, validating the quantitative and qualitative existence of these in patient tissues in association with response or outcome has been difficult. This will be an important step since identifying reliable markers of resistance will lead to the development of reversal strategies.

8.6.1 Reduced Accumulation Acquired resistance to cisplatin and its analogs frequently results in the emergence of a decrease platinum accumulation phenotype. Unlike that observed in cells that are resistant to natural product drugs, overexpression of P-glycoprotein is not involved platinum drug resistance. Cisplatin and its analogs may accumulate within cells by passive diffusion or facilitated transport [95]. Cisplatin uptake has been shown to be nonsaturable, even up to its solubility limit, and not inhibited by structural analogs. The passive uptake of these drugs may depend, in part, on their relative hydrophobicity. Recently, a significant amount of work in the area of facilitated uptake/efflux has been done by Howell and colleagues [96]. This grew out of early observations that cells resistant to cisplatin are cross-resistant to other metal-containing complexes [97]. A more recent study indicated that cross-resistance to copper also occurred in platinumresistant cells [98]. Insight into the molecular basis for this phenomenon resulted in the identification of several copper transporters previously associated with copper homeostasis. With respect to platinum uptake and efflux, these proteins include CTR1 and ATP7A/ATP7B, respectively. In a study by Lin et al. [99] using a yeast model, the copper transporter, CTR1, was shown to regulate the influx of cisplatin,

D. Roberts et al.

carboplatin, oxaliplatin and AMD473. Comparison of the wild-type and ctr-1 knockout strains revealed an 8-fold reduction in cisplatin uptake after one hour. These ctr-1 deficient yeast cells were also 2-fold more resistant to cisplatin. Analysis of the human CTR1 protein in platinum-sensitive and -resistant small cell lung cancer cells revealed a reduction of CTR1 in one of five resistant sublines [100]. Evidence has also presented to demonstrate a role for the coppertransporting P-type ATPases 7A and 7B in platinum drug efflux. Transfection of epidermoid carcinoma cells with ATP7B led to a 9-fold decrease in cisplatin sensitivity [101]. Howell and colleagues have confirmed this and demonstrated that acquired cisplatin resistance is accompanied by increased expression of these export pumps [102, 103]. This group also found that increased expression of ATP7A is associated with poor survival in ovarian cancer patients treated with platinum-based regimens [104]. The prospect of another active efflux mechanism for platinum drugs has emerged following the discovery of a group of MRP-related transport proteins, which function in the efflux of glutathione-coupled and unmodified anticancer drugs from cells [105]. Overexpression of MRP1 (ABCC1) confers resistance to a variety of drugs, but not to cisplatin. For platinum complexes, the formation of a glutathione-platinum drug conjugate may be the rate-limiting step for producing an MRP substrate. A related homologue, cMOAT (cannalicular multispecific organic anion transporter, ABCC2), has also been shown to have a similar substrate specificity with that of MRP. Overexpression of cMOAT (MRP2) has been found in some cisplatin-resistant human cancer cell lines exhibiting the decreased platinum accumulation phenotype [106]. Transfection of an antisense cMOAT cDNA into HepG2 cells resulted in reduced cMOAT protein levels and a 5-fold increased in cisplatin sensitivity [107]. Further evidence indicating a role for ABC transporters in platinum drug resistance was provided by Kool et al. [108], who examined the expression of MRP, cMOAT, MRP3, MRP4, and MRP5 in a set of cell lines selected for cisplatin resistance in vitro. MRP1 and MRP4 mRNA levels were not increased in any of the cisplatin-resistant sublines. MRP3 and MRP5 were overexpressed in a few cell lines, but the mRNA levels were not associated with cisplatin resistance. With respect to clinical relevance, an immunohistochemical analysis of the expression of P-glycoprotein, MRP1 and MRP2 revealed that none

8

Platinum Complexes for the Treatment of Cancer

of these transporters was associated with response to platinum-based chemotherapy in ovarian cancer [109]. However, Yoh et al. [110] reported increased BCRP levels in association with shorter progressionfree survival and overall survival in non-small cell lung cancer patients treated with platinum-based therapy. Additional translational studies will be required to fully understand the contribution of these transport proteins to platinum drug resistance.

8.6.2 Inactivation Aquated platinum compounds are highly reactive and may bind intracellularly to proteins and nucleic acids. Cells that are resistant to platinum drugs often develop that ability to inactivate these complexes by upregulating the expression of detoxication genes. Both the metallothioneins and glutathione have been implicated in this drug inactivation process. Glutathione (GSH) represents the most abundant non-protein thiol and in fact, the formation of a glutathione-platinum (GSPt) complex has been demonstrated in cultured cells. GSH has also been shown to quench platinum-DNA monoadducts in vitro, thus preventing their conversion to potentially cytotoxic crosslinks [111–113]. Over the years, attempts have been made to correlate platinum drug sensitivity with either GSH levels or the expression/activity of the enzymes involved in GSH metabolism. There have been many reports showing a strong association between platinum drug sensitivity and GSH levels [114–117], however, reducing intracellular GSH levels with modulators such as buthionine sulfoximine (BSO) has resulted in only low to modest potentiation of cisplatin sensitivity [118, 119]. One of the products generated during glutathione catabolism is cysteinylglycine. This reaction is catalyzed by gamma-glutamyltransferase (gamma-GT). The affinity of cysteinylglycine for cisplatin is significantly higher than that of glutathione and transfection studies have demonstrated that overexpression of gamma-GT confers resistance to cisplatin [120]. Direct protein-mediated Inactivation of platinum drugs may occur through binding to one or more of the metallothionein (MT) isoforms. The MT’s are a family of sulfhydryl-rich, small molecular weight proteins that participate in heavy metal binding and detoxication. In vitro, cisplatin binds stochiometrically to

155

metallothionein and up to 10 molecules of cisplatin can be bound to one molecule of metallothionein [121]. Kelley et al. [122] demonstrated that overexpression of the full-length MT-IIA in mouse C127 cells conferred a four-fold resistance to cisplatin. Furthermore, this group showed that embryonic fibroblasts isolated from MT-null mice were hypersensitive to cisplatin [123]. These studies clearly show that modulating MT levels can alter cisplatin sensitivity, however, the contribution of MT to clinical platinum drug resistance is unclear. In some cell lines, elevated MT levels have been shown to be associated with cisplatin resistance, while in others, they have not [116, 124]. Studies with human tumors have shown that, in some instances, metallothionein expression level is associated with response to chemotherapy. For example, a significant correlation between MT overexpression and response/survival was reported in urothelial transitional cell carcinoma patients [125]. Overexpression of MT has also been observed in bladder tumors from patients that failed cisplatin chemotherapy [126]. In contrast, a study in ovarian tumor biopsies revealed some increases in metallothionein expression, but this did not reach statistical significance [127].

8.6.3 Increased DNA Repair The failure of drug accumulation and inactivation mechanisms to limit the formation of platinum-DNA adducts mandates that cells must either repair or tolerate this damage in order to survive. As DNA is presumed to be the cytotoxic target of platinum complexes, then ability of cells to rapidly repair platinum lesions is a critical process. Studies done with cell lines established from patients with DNA repair deficiencies such as Xeroderma Pigmentosum clearly show a significant level of platinum drug hypersensitivity in a DNA repair-deficient environment. In addition, there evidence indicating that cell lines derived from tumors that are unusually sensitive to cisplatin, such as testicular non-seminomatous germ cell tumors, are deficient in their ability to repair platinum-DNA adducts [128]. However, resistance to DNA damaging agents would represent the opposite: an induction of the capacity to repair lesions. Therefore, one or more components of the repair machinery must be induced/activated to elevated the cell’s overall DNA repair capacity. Evidence

156

of increased repair of platinum-DNA lesions in cisplatin resistant cell lines has been provided for various types of human cancers [129–132] as well as murine leukemia cells [133]. The repair of all types of DNA lesions has been documented including monoadducts, intrastrand- and interstrand-crosslinks. These studies have been done using a variety of repair assays including unscheduled DNA synthesis, host cell reactivation of cisplatin-damaged plasmid DNA, atomic absorption spectrometry, quantitative PCR and renaturing agarose gel electrophoresis. The repair of platinum-DNA adducts occurs predominantly by nucleotide excision repair (NER) and clues to the molecular basis for increased repair activity have emerged. Since the rate-limiting step in this process is platinum-adduct recognition/incision, increased expression of the proteins that control this step are likely to enhance nucleotide excision repair activity. Using an in vitro assay, Ferry et al. [134] demonstrated that the addition of the ERCC1/XPF protein complex increased the platinum-DNA adduct excision activity of an ovarian cancer cell extract. There is also circumstantial evidence that implicates ERCC1 expression with increased NER and cisplatin resistance. For example, expression levels of the ERCC1 and XPA genes have been shown to be higher in malignant tissue from ovarian cancer patients resistant to platinum-based therapy compared with those responsive to treatment [135]. ERCC1 expression has also been shown to correlate with NER activity and cisplatin resistance in human ovarian cancer cells [134]. Increased levels of XPE, a putative DNA repair protein that recognizes many DNA lesions including platinumDNA adducts, has been observed in tumor cell lines resistant to cisplatin [136]. It should be noted, however, that XPE is not a necessary component for the in vitro reconstitution of NER [135, 137]. Inhibiting DNA repair activity in order to enhance platinum drug sensitivity has been an active area of investigation. Selvakumaran et al. [138] showed that down-regulation of ERCC-1 using an antisense approach sensitized a platinum-resistant cell line to cisplatin both in vitro and in vivo. This has also been achieved using siRNA [139]. Unfortunately, there are currently no repair inhibitors that target the recognition/incision step of the NER pathway. Despite this, efforts have been made to inhibit repair at the fill-in step. These include nucleoside analogs such as gemcitabine, fludarabine and cytarabine, the ribonucleotide

D. Roberts et al.

reductase inhibitor, hydroxyurea and the inhibitor of DNA polymerases α and γ, aphidicolin. Since these agents interfere with repair synthesis, they are also likely to effect DNA replication and may not be strictly characterized as repair inhibitors. The potentiation of cisplatin cytotoxicity by treatment with aphidicolin has been studied investigated in human ovarian cancer cell lines. While some studies have demonstrated synergy with this drug combination ([140–141], others have not [142]). In an in vivo mouse model of human ovarian cancer, the combined treatment of cisplatin and aphidicolin glycinate, a water soluble form of the drug, was found to be significantly more effective than cisplatin alone [143].

8.6.4 Increased DNA Damage Tolerance If the repair pathways described above do not sufficiently correct the DNA damage resulting from platinum drug exposure, cells must tolerate this damage in order to survive. Tolerance is a broad term and may involve (1) impaired adduct recognition, (2) attenuated activity of survival and stress signaling pathways, and (3) defects or changes in apoptotic proteins. Thus, influencing the signaling processes from adducts to apoptosis enables cells to ignore the cytotoxic effects of DNA lesions. Platinum-DNA damage tolerance has been observed in both cisplatin-resistant cells derived from chemotherapy-refractory patients and cells selected for primary cisplatin resistance in vitro. The contribution of this mechanism to resistance is significant and it has been shown to correlate strongly with cisplatin resistance as well as resistance to other drugs in two ovarian cancer model systems [130, 144]. It is likely that understanding the basis for the tolerance phenotype will provide new targets for therapy and identify biomarkers to predict response. Sensing the presence of cisplatin-DNA adducts has been proposed to be a function of the DNA mismatch repair (MMR) system. This could provide either a direct cytotoxicity signal or create an environment in which single strand breaks accumulate as a result of futile MMR cycling. Either way, it has been proposed that loss or reduction of the components of this pathway imparts a cisplatin resistance phenotype. There have been studies showing that loss of MMR is associated with low-level cisplatin resistance, and that

8

Platinum Complexes for the Treatment of Cancer

the selection of cells in culture for resistance to this drug often yields cell lines with defective MMR [145]. MSH2 alone, and in combination with MSH6, has been shown to bind to cisplatin 1,2-d(GpG)Pt intrastrand adducts with high efficiency [66, 146]. Additionally, MSH2 and MLH1-containing protein-DNA complexes have been observed when nuclear extracts of MMRproficient cell lines were incubated with DNA preincubated with cisplatin, but not with oxaliplatin. It contrast to these reports, however, Branch et al. [147] found that selecting cells for decreased MLH1 expression, did not result in a predictable degree of cisplatin resistance in a panel of human tumor cell lines. Further studies will be needed to determine whether mismatch repair has a direct effect on drug sensitivity or represents a phenotype that is linked to the emergence of resistance. Another way to ignore or tolerate platinum-DNA damage is to simply replicate DNA past the lesion. Known as replicative bypass, this process has been shown to occur in cisplatin-resistant human ovarian cancer cells [148]. This may also be considered post-replication repair, thus enabling cells to complete S phase and arrest at the G2 checkpoint in order to repair the DNA damage. Chaney and colleagues [149] have carefully studied the ability of individual DNA polymerases to bypass both cisplatin and oxaliplatin adducts. They have shown that oxaliplatin adducts are bypassed with greater efficiency that cisplatin adducts. Analysis of the insertion and extension reactions revealed that both DNA polymerase β and η catalyze this step. The activity of this DNA polymerase β was found to be significantly increased in cells derived from a human malignant glioma resistant to cisplatin compared to its drug sensitive counterpart [132]. Analysis of these markers in tumor biopsies will be necessary to find an association with resistance in vivo. Downstream of platinum-adduct recognition lies a number of signaling events that determine the fate of a tumor cell. These pathways are likely shared by other DNA damaging agents and cytotoxic drugs with other intracellular targets. Thus, tolerance mechanisms in this category may confer a multidrug resistance phenotype. As discussed previously in this chapter, a number of pro- and anti-apoptotic signaling pathways have been implicated in cisplatin sensitivity. One particular signaling pathway that has received significant attention is the JNK/SAPK signaling pathway. The weight of the evidence favors a pro-apoptotic

157

role for both JNK and p38 kinase in tumor cells, while their role in normal cells is more equivocal [150–153]. Paradoxically, c-Jun, a target of JNK, may contribute to cisplatin resistance [154, 155], which indicates the importance of characterizing dimers in the MAP kinase pathway, the composition of which may determine the balance of pro- and anti-apoptotic signaling. Signaling for apoptosis in oxaliplatin-treated cells appears qualitatively different from cisplatin. Variation in the activity of the JNK/p38 pathways is not a determinant of cell death signaling in colon cancer cells, while resistance to oxaliplatin is influenced very markedly by the activity of the NF-κB pathway [156]. In other cells the activity of ATF-2, a substrate for JNK and p38 is also a determinant of resistance [157]. The activity of these signaling pathways on mediators of apoptosis cannot easily be separated form effects on transcription of many of the mediators of detoxication, DNA repair and DNA damage tolerance discussed above, and active research is in progress to test their role in the clinic. With respect to the terminal phase of programmed cell death, the overexpression/activation of antiapoptotic genes or down-regulation/inhibition of proapoptotic genes may influence platinum drug sensitivity and confer a DNA damage tolerance phenotype. Members of the Bcl-2 family of proteins are known to regulate mitochondrial function and serve as a cell survival/cell death rheostat by forming homo- and heterodimers with one another. The anti-apoptotic bcl-2 and bcl-XL proteins are localized in the outer mitochondrial membrane and may be involved in the formation of transmembrane channels. Overexpression of bcl-2 or bcl-XL has been shown to prevent disruption of the mitochondrial transmembrane potential and to prolong cell survival in some cells following exposure to cisplatin and other anticancer drugs [158, 159]. The activity of these proteins is negated, however, in the presence of high levels of the pro-apoptotic protein BAX, another bcl-2 family member. Therefore, the relative intracellular levels or ratio of these proteins may confer resistance to platinum drugs. As discussed earlier in this chapter, disruption of caspase function also has the potential to confer a drug resistant phenotype. Caspase 8 and 9 may be candidates for these effects, however, inhibiting late stage caspases such as caspase-3 or -7 may block the phenotypic features of apoptosis, but not the ultimate death of the cell. Efforts have been made to associate the expression of

158

pro- and anti-apoptotic genes to clinical parameters in patients treated with platinum-based chemotherapy. In a study of 28 ovarian cancer patients, Williams et al. [160] found that Bcl-xL expression in primary tumors was associated with a significantly shorter diseasefree interval as compared to patients whose tumors did not express Bcl-xL (1.6 months as compared to 7.7 months). A number of other studies have also demonstrated an association of Bcl-2 family members and patient response/outcome following platinum treatment [161–165].

References 1. Rosenberg B, VanCamp L, Trosko J, Mansour V (1969) Platinum compounds: a new class of potent antitumor agents, Nature 222:385–386 2. Rosenberg B (1999) Platinum complexes for the treatment of cancer: why the search goes on. In: Lippert B (ed) Cisplatin: chemistry and biochemistry of a leading anticancer drug. Verlag Helvetica Chimica Acta, Zurich, pp 3–27 3. Cvitkovic E, Spaulding J, Bethune V, Martin J, Whitmore W (1977) Improvement of cis-dichlorodiammineplatinum (NSC 119875): therapeutic index in an animal model. Cancer 39:1357–1361 4. Hayes D, Cvitkovic E, Golbey R, Scheiner E, Helson L, Krakoff I (1977) High dose cis-platinum diammine dichloride: amelioration of renal toxicity by mannitol diuresis. Cancer 39:1372–1381 5. O’Dwyer P, Stevenson J, Johnson S (1999) Clinical status of cisplatin, carboplatin and other platinum-based antitumor drugs. In: Lippert B (ed) Cisplatin: chemistry and biochemistry of a leading anticancer drug. Verlag Helvetica Chimica Acta, Zurich, pp 31–69 6. Harrap K (1985) Preclinical studies identifying carboplatin as a viable cisplatin alternative. Cancer Treat Rev 12:A21–A33 7. Harrap K (1995) Initiatives with platinum- and quinazoline-based antitumor molecules – Fourteenth Bruce F. Cain memorial award lecture. Cancer Res 55:2761–2768 8. Calvert A, Newell D, Gumbrell L, O’Reilly S, Burnell M, Boxall F, Siddik Z, Judson I, Gore M, Wiltshaw E (1989) Carboplatin dosage: prospective evaluation of a simple formula based on renal function. J Clin Oncol 7:1748–1756 9. Egorin M, Echo DV, Olman E, Whitaker M, Forrest A, Aisner J (1985) Prospective validation of a pharmacologically based dosing scheme for the cis-diamminedichloroplatinum(II) analog diamminecyclobutanedicarboxylatoplatinum. Cancer Res 45:6502–6506 10. Connors T, Jones M, Ross W, Braddock P, Khokhar A, Tobe M (1972) New platinum complexes with anti-tumour activity. Chem Biol Interact 5: 415–424

D. Roberts et al. 11. Burchenal J, Kalaker K, Dew K, Lokyst L (1979) Rationale for development of platinum analogs. Cancer Treat Rep 63:1493–1498 12. Kidani Y, Inagaki K, Tsukagoshi S (1976) Examination of antitumor activities of platinum complexes of 1,2diaminocyclohexane isomers and their related complexes. Gann 67:921–922 13. Burchenal J, Irani G, Kern K, Lokys L, Turkevich J (1980) 1,2-Diaminocyclohexane platinum derivatives of potential clinical value. Rec Res Cancer Res 74:146–155 14. Rixe O, Ortuzar W, Alvarez M, Parker R, Paull K, Fojo R (1996) Oxaliplatin, tetraplatin, cisplatin, and carboplatin: spectrum of activity in drug-resistant cell lines and in the cell lines of the national cancer institute’s anticancer drug screen panel. Biochem Pharmacol 52:1855–1865 15. Schilder RJ, LaCreta FP, Perez RP, Johnson SW, Brennan JM, Rogatko A, Nash S, McAleer C, Hamilton TC, Roby D et al (1994) Phase I and pharmacokinetic study of ormaplatin (tetraplatin, NSC 363812) administered on a day 1 and day 8 schedule. Cancer Res 54:709–717 16. Chaney SG, Wyrick S, Till GK (1990) In vitro biotransformations of tetrachloro(d,l-trans)-1,2diaminocyclohexaneplatinum(IV) (tetraplatin) in rat plasma. Cancer Res 50:4539–4545 17. Petros WP, Chaney SG, Smith DC, Fangmeier J, Sakata M, Brown TD, Trump DL (1994) Pharmacokinetic and biotransformation studies of ormaplatin in conjunction with a phase I clinical trial. Cancer Chemother Pharmacol 33:347–354 18. Shord SS, Bernard SA, Lindley C, Blodgett A, Mehta V, Churchel MA, Poole M, Pescatore SL, Luo FR, Chaney SG (2002) Oxaliplatin biotransformation and pharmacokinetics: a pilot study to determine the possible relationship to neurotoxicity. Anticancer Res 22:2301–2309 19. Mathe G, Kidani Y, Triana K, Brienza S, Ribaud P, Goldschmidt E, Ecstein E, Despax R, Musset M, Misset JL (1986) A phase I trial of trans-ldiaminocyclohexane oxalato-platinum (l-OHP). Biomed Pharmacother 40:372–376 20. Extra J, Espie M, Calvo F, Ferme C, Mignot L, Marty M (1990) Phase I study of oxaliplatin in patients with advanced cancer. Cancer Chemother Pharmacol 25: 299–303 21. Cvitkovic E, Bekradda M (1999) Oxaliplatin: a new therapeutic option in colorectal cancer. Semin Oncol 26: 647–662 22. Hubbard K, Pazdur R, Ajani J, Braud E, Blaustein A, King M, Llenado-Lee M, Winn R, Levin B, Abbruzzese J (1992) Phase II evaluation of iproplatin in patients with advanced gastric and pancreatic cancer. Am J Clin Oncol 15:524–527 23. Murphy D, Lind M, Prendiville J, Renninson J, Smith D, Thompson G, Ranson M, Crowther B (1992) Phase I/II study of intraperitoneal iproplatin in patients with minimal residual disease following platinum-based systemic therapy for epithelial ovarian carcinoma. Eur J Cancer 28A:870–872 24. Kelland L (1999) The development of orally active platinum drugs. In: Lippert B (ed) Cisplatin: chemistry and biochemistry of a leading anticancer drug. Verlag Helvetica Chimica Acta, Zurich, pp 497–521

8

Platinum Complexes for the Treatment of Cancer 25. Fokkema E, Bauer J, Uges D, Weil C, Smith I (1999) Phase II study of oral platinum drug JM216 as first-line treatment in patients with small-cell lung cancer. J Clin Oncol 17:3822–3827 26. Judson I, Cerny T, Epelbaum R, Dunlop D, Smyth J, Schaefer B, Roelvink M, Kaplan S, Hanauske A (1997) Phase II trial of the oral platinum complex JM216 in nonsmall-cell lung cancer: an EORTC early clinical studies group investigation. Ann Oncol 8:604–606 27. Latif T, Wood L, Connell C, Smith DC, Vaughn D, Lebwohl D, Peereboom D (2005) Phase II study of oral bis (aceto) ammine dichloro (cyclohexamine) platinum (IV) (JM-216, BMS-182751) given daily × 5 in hormone refractory prostate cancer (HRPC). Invest New Drugs 23:79–84 28. Sternberg CN, Whelan P, Hetherington J, Paluchowska B, Slee PH, Vekemans K, Van Erps P, Theodore C, Koriakine O, Oliver T, Lebwohl D, Debois M, Zurlo A, Collette L (2005) Genitourinary Tract Group of the EORTC. Phase III trial of satraplatin, an oral platinum plus prednisone vs. prednisone alone in patients with hormone-refractory prostate cancer. Oncology 68:2–9 29. Holford J, Sharp S, Murrer B, Abrams M, Kelland L (1998) In vitro circumvention of cisplatin resistance by the novel sterically hindered platinum complex AMD473. Br J Cancer 77:366–373 30. Raynaud F, Boxall F, Goddard P, Valenti M, Jones M, Murrer B, Abrams M, Kelland L (1997) cisAmminedichloro(2-methylpyridine) platinum(II) (AMD473), a novel sterically hindered platinum complex: in vivo activity, toxicology, and pharmacokinetics in mice. Clin Cancer Res 3:2063–2074 31. Beale P, Judson I, O’Donnell A, Trigo J, Rees C, Raynaud F, Turner A, Simmons L, Etterley L (2003) A Phase I clinical and pharmacological study of cis-diamminedichloro(2-methylpyridine) platinum II (AMD473). Br J Cancer 88:1128–1134 32. Gelmon KA, Stewart D, Chi KN, Chia S, Cripps C, Huan S, Janke S, Ayers D, Fry D, Shabbits JA, Walsh W, McIntosh L, Seymour LK (2004) A phase I study of AMD473 and docetaxel given once every 3 weeks in patients with advanced refractory cancer: a national cancer institute of Canada-clinical trials group trial, IND 131. Ann Oncol 15:1115–1122 33. Twelves C, Reck M, Anthoney A, Gatzemeier U, Kaye S (2003) A phase I study of ZD0473 combined with paclitaxel for the treatment of solid malignancies. Cancer Chemother Pharmacol 52:277–281 34. Flaherty K, Stevenson J, Redlinger M, Algazy K, Giantonio B, O’Dwyer P (2004) A phase I, doseescalation trial of ZD0473, a novel platinum analog, in combination with gemcitabine. Cancer Chemother Pharmacol 53:404–408 35. Gore ME, Atkinson RJ, Thomas H, Cure H, Rischin D, Beale P, Bougnoux P, Dirix L, Smit WM (2002) A phase II trial of ZD0473 in platinum-pretreated ovarian cancer. Eur J Cancer 38:2416–2420 36. Gelmon KA, Vandenberg TA, Panasci L, Norris B, Crump M, Douglas L, Walsh W, Matthews SJ, Seymour LK (2003) A phase II study of ZD0473 given as a short infusion every 3 weeks to patients with advanced or metastatic

159

37.

38.

39.

40.

41.

42.

43.

44.

45. 46.

47.

48.

49.

50.

51.

breast cancer: a national cancer institute of Canada clinical trials group trial, IND 129. Ann Oncol 14:543–548 Farrell N, Qu Y, Bierbach U, Valsecchi M, Menta E (1999) Structure-activity relationships within di- and trinuclear platinum phase-I clinical anticancer agents. In: Lippert B (ed) Cisplatin: chemistry and biochemistry of a leading anticancer drug. Verlag Helvetica Chimica Acta, Zurich Sessa C, Capri G, Gianni L, Peccatori F, Grasselli G, Bauer J, Zucchetti M, Vigano L, Gatti A, Minoia C, Liati P, Van den Bosch S, Bernareggi A, Camboni G, Marsoni S (2000) Clinical and pharmacological phase I study with accelerated titration design of a daily times five schedule of BBR3464, a novel cationic triplatinum complex. Ann Oncol 11:977–983 Jodrell DI, Evans TR, Steward W, Cameron D, Prendiville J, Aschele C, Noberasco C, Lind M, Carmichael J, Dobbs N, Camboni G, Gatti B, De Braud F (2004) Phase II studies of BBR3464, a novel tri-nuclear platinum complex, in patients with gastric or gastro-oesophageal adenocarcinoma. Eur J Cancer 40:1872–1877 Fojo T, Farrell N, Ortuzar W, Tanimura H, Weinstein J, Myers, TG (2005) Identification of non-cross-resistant platinum compounds with novel cytotoxicity profiles using the NCI anticancer drug screen and clustered image map visualizations. Crit Rev Oncol/Hematol 53:25–34 DeConti R, Toftness B, Lange R, Creasey W (1973) Clinical and pharmacological studies with cis-diamminedichloroplatinum (II). Cancer Res 33:1310–1315 Himmelstein K, Patton T, Belt R, Taylor S, Repta A, Sternson L (1981) Clinical kinetics on intact cisplatin and some related species. Clin Pharmacol Ther 29:658–664 Casper E, Kelsen D, Alcock N, Young C (1979) Platinum concentrations in bile and plasma following rapid and 6-hour infusions of cis-dichlorodiammineplatinum(II). Cancer Treat Rep 63:2023–2025 Duffull S, Robinson B (1997) Clinical pharmacokinetics and dose optimisation of carboplatin. Clin Pharmacokinet 33:161–183 VanderVijgh W (1991) Clinical pharmacokinetics of carboplatin. Clin Pharmacokinet 21:242–261 Graham, MA, Lockwood, GF, Greenslade D, Brienza S, Bayssas M, Gamelin E (2000) Clinical pharmacokinetics of oxaliplatin: a critical review. Clin Cancer Res 6: 1205–1218 Extra J, Marty M, Brienza S, Misset J (1998) Pharmacokinetics and safety profile of oxaliplatin. Semin Oncol 25:13–22 Belt R, Himmelstein K, Patton T, Bannister S, Sternson L, Repta A (1979) Pharmacokinetics of non-proteinbound platinum species following administration of cis-dichlorodiammineplatinum(II). Cancer Treat Rep 63:1515–1521 Vermorken J, Vijgh WVD, Klein I, Hart A, Gall H, Pinedo H (1984) Pharmacokinetics of free and total platinum species after short-term infusion of cisplatin. Cancer Treat Rep 68:505–513 Gormley P, Bull J, LeRoy A, Cysyk R (1979) Kinetics of cis-dichlorodiammineplatinum. Clin Pharmacol Ther 25:351–357 Harland S, Newell D, Siddik Z, Chadwick R, Calvert A, Harrap K (1984) Pharmacokinetics of cis-diammine-1,

160

52.

53.

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

D. Roberts et al. 1-cyclobutane dicarboxylate platinum(II) in patients with normal and impaired renal function. Cancer Res 44: 1693–1697 Gamelin E, Bouil A, Boisdron-Celle M, Turcant A, Cailleux A, Krikorian A, Brienza S, Cvitkovic E, Robert J, Larra F, Allain P (1997) Cumulative pharmacokinetic study of oxaliplatin, administered every three weeks, combined with 5-fluorouracil in colorectal cancer patients. Clin Cancer Res 3:891–899 Evans B, Raju K, Calvert A, Harland S, Wiltshaw E (1983) Phase II study of JM8, a new platinum analog, in advanced ovarian carcinoma. Cancer Treat Rep 67:997–1000 De Gramont A, Banzi M, Navarro M, Tabernero J, Hickish T, Bridgewater J, Rivera F, Figer A, Fountzilas G, Andre T (2003) Oxaliplatin/5-FU/LV in adjuvant colon cancer: results of the international randomized mosaic trial. Proc Am Soc Clin Oncol 22:253 Harder H, Rosenberg B (1970) Inhibitory effects of antitumor platinum compounds on DNA, RNA and protein syntheses in mammalian cells in virtro. Int J Cancer 6:207–216 Howle J, Gale G (1970) Cis-dichlorodiammineplatinum (II). Persistent and selective inhibition of deoxyribonucleic acid synthesis in vivo. Biochem Pharmacol 19: 2757–2762 Reslova S (1971) The induction of lysogenic strains of Escherichia coli by cis-dichloro-diammineplatinum (II). Chem Biol Interact 4:66–70 Poll EHA, Abrahams PJ, Arwert F, Eriksson AW (1984) Host cell reactivation of cis-diamminedichloroplatinum (II)-treated SV40 DNA in normal human, Fanconi anaemia and xeroderma pigmentosum fibroblasts. Mutation Res 132:181–187 Fraval HNA, Rawlings CJ, Roberts JJ (1978) Increased sensitivity of UV-repair deficient human cells to DNA bound platinum products which unlike thymine dimers are not recognized by an endonuclease extracted from Micrococcus luteus. Mutation Res 51: 121–132 Eastman A (1987) The formation, isolation and characterization of DNA adducts produced by anticancer platinum complexes. Pharmacol Ther 34:155–166 Blommaert F, van Kijk-Knijnenburg H, Dijt F, den Engelse L, Baan R, Berends F, Fichtinger-Schepman A (1995) Formation of DNA adducts by the anticancer drug carboplatin: different nucleotide sequence preferences in vitro and in cells. Biochemistry 34:8474–8480 Saris C, van de Vaart P, Rietbroek R, Blommaert F (1996) In vitro formation of DNA adducts by cisplatin, lobaplatin and oxaliplatin in calf thymus DNA in solution and in cultured cells. Carcinogenesis 17:2763–2769 Toney J, Donahue B, Kellett P, Bruhn S, Essigmann J, Lippard S (1989) Isolation of cDNAs encoding a human protein that binds selectively to DNA modified by the anticancer drug cis-diamminedichloroplatinum. Proc Natl Acad Sci USA 86:8328–8332 Bruhn S, Pil P, Essigmann J, Housman D, Lippard S (1989) Isolation and characterization of human cDNA clones encoding a high mobility group box protein that recognizes structural distortions to DNA caused by

65.

66.

67.

68.

69. 70.

71.

72.

73.

74.

75.

76.

77. 78.

79.

binding of the anticancer agent cisplatin. Proc Natl Acad Sci USA 89:2307–2311 Hughes EN, Engelsberg BN, Billings PC (1992) Purification of nuclear proteins that bind to cisplatindamaged DNA. Identity with high mobility group proteins 1 and 2. J Biol Chem 267:13520–13527 Mello J, Acharya S, Fishel R, Essigmann J (1996) The mismatch-repair protein hMSH2 binds selectively to DNA adducts of the anticancer drug cisplatin. Chem Biol 3:579–589 Fink D, Zheng H, Nebel S, Norris P, Aebi S, Lin TP, Nehme A, Christen R, Haas M, MacLeod C, Howell S (1997) In vitro and in vivo resistance to cisplatin in cells that have lost DNA mismatch repair. Cancer Res 57:1841–1845 Fink D, Nebel S, Aebi S, Zheng H, Cenni B, Nehme A, Christen R, Howell S (1996) The role of DNA mismatch repair in platinum drug resistance. Cancer Res 56: 4881–4886 Siddik ZH (2003) Cisplatin: mode of cytotoxic action and molecular basis or resistance. Oncogene 22:7265–7279 Luo Y, Lin FT, Lin WC (2004) ATM-mediated stabilization of hMutL DNA mismatch repair proteins augments p53 activation during DNA damage. Mol Cell Biol 24:6430–6444 Fan S, Smith ML, Rivet DJ, Duba D, Zhan Q, Kohn KW, Fornace AJ Jr, O’Connor PM (1995) Disruption of p53 function sensitizes breast cancer MCF-7 cells to cisplatin and pentoxifylline. Cancer Res 55:1649–1654 Hawkins DS, Demers GW, Galloway DA (1996) Inactivation of p53 enhances sensitivity to multiple chemotherapeutic agents. Cancer Res 56:892–898 Evans D, Dive C (1993) Effects of cisplatin on the induction of apoptosis in proliferating hepatoma cells and nonproliferating immature thymocytes. Cancer Res 53:2133–2139 Sorenson C, Eastman A (1988) Mechansim of cisdiamminedichloroplatinum (II)-induced cytotoxicity: role of G2 arrest and DNA double-strand breaks. Cancer Res 48:4484–4488 Sorenson C, Barry M, Eastman A (1990) Analysis of events associated with cell cycle arrest at G2 phase and cell death induced by cisplatin. J Natl Cancer Inst 82: 749–755 Bunch R, Eastman A (1997) 7-Hydroxystaurosporine (UCN-01) causes redistribution of proliferating cell nuclear antigen and abrogates cisplatin-induced S-phase arrest in Chinese hamster ovary cells. Cell Growth Differ 8:779–788 Wang D, Lippard SJ (2005) Cellular processing of platinum anticancer drugs. Nat Rev Drug Discov 4:307–320 Kondo K, Yamasaki S, Sugie T, Teratani N, Kan T, Imamura M, Shimada Y (2006) Cisplatin-dependent upregulation of death receptors 4 and 5 augments induction of apoptosis by TNF-related apoptosis-inducing ligand against esophageal squamous cell carcinoma. Int J Cancer 118:230–242 Fulda S, Los M, Friesen C, Debatin KM (1998) Chemosensitivity of solid tumor cells in vitro is related to activation of the CD95 system. Int J Cancer 76: 105–114

8

Platinum Complexes for the Treatment of Cancer 80. Brozovic A, Fritz G, Christmann M, Zisowsky J, Jaehde U, Osmak M, Kaina B (2004) Long-term activation of SAPK/JNK, p38 kinase and fas-L expression by cisplatin is attenuated in human carcinoma cells that acquired drug resistance. Int J Cancer 112:974–985 81. Devarajan P, Savoca M, Castaneda MP, Park MS, EstebanCruciani N, Kalinec G, Kalinec F (2002) Cisplatininduced apoptosis in auditory cells: role of death receptor and mitochondrial pathways. Hear Res 174:45–54 82. Park MS, De Leon M, Devarajan P (2002) Cisplatin induces apoptosis in LLC-PK1 cells via activation of mitochondrial pathways. J Am Soc Nephrol 13:858–865 83. Lacour S, Micheau O, Hammann A, Drouineaud V, Tschopp J, Solary E, Dimanche-Boitrel MT (2003) Chemotherapy enhances TNF-related apoptosis-inducing ligand DISC assembly in HT29 human colon cancer cells. Oncogene 22:1807–1816 84. Blanc C, Deveraux QL, Krajewski S, Janicke RU, Porter AG, Reed JC, Jaggi R, Marti A (2000) Caspase-3 is essential for procaspase-9 processing and cisplatin-induced apoptosis of MCF-7 breast cancer cells. Cancer Res 60:4386–4390 85. Kojima H, Endo K, Moriyama H, Tanaka Y, Alnemri ES, Slapak CA, Teicher B, Kufe D, Datta R (1998) Abrogation of mitochondrial cytochrome c release and caspase-3 activation in acquired multidrug resistance. J Biol Chem 273:16647–16650 86. Li P, Nijhawan D, Budihardjo I, Srinivasula SM, Ahmad M, Alnemri ES, Wang X (1997) Cytochrome c and dATP-dependent formation of Apaf-1/caspase-9 complex initiates an apoptotic protease cascade. Cell 91:479–489 87. Srinivasula SM, Ahmad M, Fernandes-Alnemri T, Alnemri ES (1998) Autoactivation of procaspase-9 by Apaf-1-mediated oligomerization. Mol Cell 1:949–957 88. Shimizu S, Narita M, Tsujimoto Y (1999) Bcl-2 family proteins regulate the release of apoptogenic cytochrome c by the mitochondrial channel VDAC. Nature 399: 483–487 89. Verrier F, Deniaud A, Lebras M, Metivier D, Kroemer G, Mignotte B, Jan G, Brenner C (2004) Dynamic evolution of the adenine nucleotide translocase interactome during chemotherapy-induced apoptosis. Oncogene 23: 8049–8064 90. Murata T, Haisa M, Uetsuka H, Nobuhisa T, Ookawa T, Tabuchi Y, Shirakawa Y, Yamatsuji T, Matsuoka J, Nishiyama M, Tanaka N, Naomoto Y (2004) Molecular mechanism of chemoresistance to cisplatin in ovarian cancer cell lines. Int J Mol Med 13:865–868 91. Sheikh-Hamad D, Cacini W, Buckley AR, Isaac J, Truong LD, Tsao CC, Kishore BK (2004) Cellular and molecular studies on cisplatin-induced apoptotic cell death in rat kidney. Arch Toxicol 78:147–155 92. Nachmias B, Ashhab Y, Ben-Yehuda D (2004) The inhibitor of apoptosis protein family (IAPs): an emerging therapeutic target in cancer. Semin Cancer Biol 14: 231–243 93. Li J, Feng Q, Kim JM, Schneiderman D, Liston P, Li M, Vanderhyden B, Faught W, Fung MF, Senterman M, Korneluk RG, Tsang BK (2001) Human ovarian cancer and cisplatin resistance: possible role of inhibitor of apoptosis proteins. Endocrinology 142:370–380

161 94. Dan HC, Sun M, Kaneko S, Feldman RI, Nicosia SV, Wang HG, Tsang BK, Cheng JQ (2004) Akt phosphorylation and stabilization of X-linked inhibitor of apoptosis protein (XIAP). J Biol Chem 279:5405–5412 95. Gately DP, Howell SB (1993) Cellular accumulation of the anticancer agent cisplatin: a review. Br J Cancer 67: 1171–1175 96. Safaei R, Howell SB (2005) Copper transporters regulate the cellular pharmacology and sensitivity to Pt drugs. Crit Rev Oncol Hematol 53:13–23 97. Naredi P, Heath DD, Enns RE, Howell SB (1995) Crossresistance between cisplatin, antimony potassium tartrate, and arsenite in human tumor cells. J Clin Invest 95: 1193–1198 98. Katano K, Kondo A, Safaei R, Holzer A, Samimi G, Mishima M, Kuo YM, Rochdi M, Howell SB (2002) Acquisition of resistance to cisplatin is accompanied by changes in the cellular pharmacology of copper. Cancer Res 62:6559–6565 99. Song IS, Savaraj N, Siddik ZH, Liu P, Wei Y, Wu CJ, Kuo MT (2004) Role of human copper transporter Ctr1 in the transport of platinum-based antitumor agents in cisplatinsensitive and cisplatin-resistant cells. Mol Cancer Ther 3:1543–1549 100. Lin X, Okuda T, Holzer A, Howell SB (2002) The copper transporter CTR1 regulates cisplatin uptake in Saccharomyces cerevisiae. Mol Pharmacol 62:1154–1159 101. Komatsu M, Sumizawa T, Mutoh M, Chen, ZS, Terada K, Furukawa T, Yang XL, Gao H, Miura N, Sugiyama T, Akiyama S (2000) Copper-transporting P-type adenosine triphosphatase (ATP7B) is associated with cisplatin resistance. 60:1312–1316 102. Katano K, Safaei R, Samimi G, Holzer A, Rochdi M, Howell SB (2003) The copper export pump ATP7B modulates the cellular pharmacology of carboplatin in ovarian carcinoma cells. Mol Pharmacol 64:466–473 103. Katano K, Kondo A, Safaei R, Holzer A, Samimi G, Mishima M, Kuo, YM, Rochdi M, Howell SB Acquisition of resistance to cisplatin is accompanied by changes in the cellular pharmacology of copper. Cancer Res 62: 6559–6565 104. Samimi G, Varki, NM, Wilczynski S, Safaei R, Alberts, DS, Howell, SB Increase in the expression of the copper transporter ATP7A during platinum drug-based treatment is associated with poor survival in ovarian cancer patients. Clin Cancer Res 9:5853–5859 105. Borst P, Kool M, Evers R (1997) Do cMOAT (MRP2), other MRP homologues, and LRP play a role in MDR? Semin Cancer Biol 8:205–213 106. Taniguchi K, Wada M, Kohno K, Nakamura T, Kawabe T, Kawakami M, Kagotani K, Okumura K, Akiyama S, Kuwano M (1996) A human canalicular multispecific organic anion transporter (cMOAT) gene is overexpressed in cisplatin-resistant human cancer cell lines with decreased drug accumulation. Cancer Res 56: 4124–4129 107. Koike K, Kawabe T, Tanaka T, Toh S, Uchiumi T, Wada M, Akiyama S, Ono M, Kuwano M (1997) A canalicular multispecific organic anion transporter (cMOAT) antisense cDNA enhances drug sensitivity in human hepatic cancer cells. Cancer Res 57:5475–5479

162 108. Kool M, de Haas M, Scheffer G, Scheper R, van Eijk M, Juijn J, Baas F, Borst P (1997) Analysis of expression of cMOAT (MRP2), MRP3, MRP4, and MRP5, homologues of the multidrug resistance-associated protein gene (MRP1), in human cancer cell lines. Cancer Res 57:3537–3547 109. Arts H, Katsaros D, Vries ED, Massobrio M, Genta F, Danese S, Arisio R, Scheper R, Kool M, Scheffer G, Willemse P, Zee AVD, Suurmeijer A (1999) Drug resistance-associated markers P-glycoprotein, multidrug resistance-associated protein 1, multidrug resistanceassociated protein 2, and lung resistance protein as prognostic factors in ovarian carcinoma. Clin Cancer Res 5:2798–2805 110. Yoh K, Ishii G, Yokose T, Minegishi Y, Tsuta K, Goto K, Nishiwaki Y, Kodama T, Suga M, Ochiai A (2004) Breast cancer resistance protein impacts clinical outcome in platinum-based chemotherapy for advanced non-small cell lung cancer. Clin Cancer Res 10:1691–1697 111. Ishikawa T, Ali-Osman F (1993) Glutathione-associated cis-diamminedichloroplatinum (II) metabolism and ATPdependent efflux from leukemia cells. J Biol Chem 268:20116–20125 112. Mistry P, Loh S, Kelland L, Harrap K (1993) Effect of buthionine sulfoximine on PtII and PtIV drug accumulation and the formation of glutathione conjugates in human ovarian carcinoma cell lines. Int J Cancer 55:848–856 113. Eastman A (1987) Cross-linking of glutathione to DNA by cancer chemotherapeutic platinum coordination complexes. Chem Biol Interact 61:241–248 114. Godwin A, Meister A, O’Dwyer P, Huang C, Hamilton T, Anderson M (1992) High resistance to cisplatin in human ovarian cancer cell lines is associated with marked increase in glutathione synthesis, Proc Natl Acad Sci USA 89:3070–3074 115. Hosking LK, Whelan RDH, Shellard SA, Bedford P, Hill BT (1990) An evaluation of the role of glutathione and its associated enzymes in the expression of differential sensitivities to antitumor agents shown by a range of human tumour cell lines. Biochem Pharmacol 40:1833–1842 116. Mistry P, Kelland L, Abel G, Sidhar S, Harrap K (1991) The relationships between glutathione, glutathione-Stransferase and cytotoxicity of platinum drugs and melphalan in eight human ovarian carcinoma cell lines. Br J Cancer 64:215–220 117. Britten RA, Green JA, Broughton C, Browning PGW, White R, Warenius HM (1991) The relationship between nuclear glutathione levels and resistance to melphalan in human ovarian tumour cells. Biochem Pharmacol 41: 647–649 118. Hamilton T, Winker M, Louie K, Batist G, Behrens B, Tsuruo T, Grotzinger K, McKoy W, Young R, Ozols R (1985) Augmentation of adriamycin, melphalan and cisplatin cytotoxicity in drug-resistant and -sensitive human ovarian cancer cell lines by buthionine sulfoximine mediated glutathione depletion. Biochem Pharmacol 34: 2583–2586 119. Smith E, Brock AP (1988) An in vitro study comparing the cytotoxicity of three platinum complexes with regard to the effect of thiol depletion. Br J Cancer 57: 548–552

D. Roberts et al. 120. Daubeuf S, Leroy P, Paolicchi A, Pompella A, Wellman M, Galteau MM, Visvikis A (2002) Enhanced resistance of HeLa cells to cisplatin by overexpression of gammaglutamyltransferase. Biochem Pharmacol 15:207–216 121. Pattanaik A, Bachowski G, Laib J, Lemkuil D, Shaw CR, Petering D, Hitchcock A, Saryan L (1992) Properties of the reaction of cis-dichlorodiammineplatinum(II) with metallothionein. J Biol Chem 267:16121–16128 122. Kelley S, Basu A, Teicher B, Hacker M, Hamer D, Lazo J (1988) Overexpression of metallothionein confers resistance to anticancer drugs. Science 241:1813–1815 123. Kondo Y, Woo ES, Michalska AE, Choo KHA, Lazo JS (1995) Metallothionein null cells have increased sensitivity to anticancer drugs. Cancer Res 55:2021–2023 124. Kojima M, Kikkawa F, Oguchi H, Mizuno K, Maeda O, Tamakoshi K, Ishikawa H, Kawai M, Suganuma N, Tomoda Y (1994) Sensitisation of human ovarian carcinoma cells to cis-diamminedichloroplatinum (II) by amphotericin B in vitro and in vivo. Eur J Cancer 30A:773–778 125. Siu L, Banerjee D, Khurana F, Pan X, Pflueger R, Tannock I, Moore M (1998) The prognostic role of p53, metallothionein, P-glycoprotein, and MIB-1 in muscle-invasive urothelial transitional cell carcinoma. Clin Cancer Res 4:559–565 126. Wood D, Klein E, Fair W, Chaganti R (1993) Metallothionein gene expression in bladder cancer exposed to cisplatin. Mod Pathol 6:33–35 127. Wrigley E, Verspaget HW, Jayson GC, McGown AT (2000) Metallothionein expression in epithelial ovarian cancer: effect of chemotherapy and prognostic significance. J Cancer Res Clin Oncol 126:717–721 128. Koberle B, Grimaldi K, Sunters A, Hartley J, Kelland L, Masters J (1997) DNA repair capacity and cisplatin sensitivity of human testis tumour cells. Int J Cancer 70:551–555 129. Johnson S, Perez R, Godwin A, Yeung A, Handel L, Ozols R, Hamilton T (1994) Role of platinum-DNA adduct formation and removal in cisplatin resistance in human ovarian cancer cell lines. Biochem Pharmacol 47:689–697 130. Johnson S, Swiggard P, Handel L, Brennan J, Godwin A, Ozols R, Hamilton T (1994) Relationship between platinum-DNA adduct formation and removal and cisplatin cytotoxicity in cisplatin-sensitive and -resistant human ovarian cancer cells. Cancer Res 54:5911–5916 131. Yen L, Woo A, Christopoulopoulos G, Batist G, Panasci L, Roy R, Mitra S, Alaoui-Jamali M (1995) Enhanced host cell reactivation capacity and expression of DNA repair genes in human breast cancer cells resistant to bi-functional alkylating agents. Mutat Res 337:179–189 132. Ali-Osman F, Berger M, Rairkar A, and Stein D (1994) Enhanced repair of a cisplatin-damaged reporter chloramphenicol-O-acetyltransferase gene and altered activities of DNA polymerases α and β, and DNA ligase in cells of a human malignant glioma following in vivo cisplatin therapy. J Cell Biochem 54:11–19 133. Eastman A, Schulte N (1988) Enhanced DNA repair as a mechanism of resistance to cis-diamminedichloroplatinum(II). Biochemistry 27:4730–4734 134. Ferry K, Hamilton T, Johnson S (2000) Increased nucleotide excision repair in cisplatin-resistant ovarian

8

Platinum Complexes for the Treatment of Cancer

135.

136.

137.

138.

139.

140.

141.

142.

143.

144.

145.

146.

147.

148.

cancer cells: role of ERCC1-XPF. Biochem Pharmacol 60:1305–1313 Dabholkar M, Vionnet J, Bostick-Bruton F, Yu J, Reed E (1994) Messenger RNA levels of XPAC and ERCC1 in ovarian cancer tissue correlate with response to platinumbased chemotherapy. J Clin Invest 94:703–708 Chu G, Chang E (1990) Cisplatin-resistant cells express increased levels of a factor that recognizes damaged DNA. Proc Natl Acad Sci USA 87:3324–3328 Mu D, Park C-H, Matsunaga T, Hsu D, Reardon J, Sancar A (1995) Reconstitution of human DNA repair excision nuclease in a highly defined system. J Biol Chem 270:2415–2418 Selvakumaran M, Piscarcik, DA, Bao R, Yeung AT, Hamilton TC (2003) Enhanced cisplatin cytotoxicity by disturbing the nucleotide excision repair pathway in ovarian cancer cell lines. Cancer Res 63:1311–1316 Chang IY, Kim MH, Kim HB, Lee Do Y, Kim SH, Kim HY, You HJ (2005) Small interfering RNA-induced suppression of ERCC1 enhances sensitivity of human cancer cells to cisplatin. Biochem Biophys Res Commun 327:225–233 Masuda H, Tanaka T, Matsuda H, Kusaba I (1990) Increased removal of DNA-bound platinum in a human ovarian cancer cell line resistant to cis-diamminedichloroplatinum (II). Cancer Res 50:1863–1866 Katz E, Andrews P, Howell S (1990) The effect of DNA polymerase inhibitors on the cytotoxicity of cisplatin in human ovarian carcinoma cells. Cancer Comm 2:159–164 Dempke WCM, Shellard SA, Fichtinger-Schepman AMJ, Hill BT (1991) Lack of significant modulation of the formation and removal of platinum-DNA adducts by aphidicolin glycinate in two logarithmically-growing ovarian tumour cell lines in vitro. Carcinogenesis 12:525–528 O’Dwyer P, Moyer J, Suffness M, Harrison S, Cysyk R, Hamilton T, Plowman J (1994) Antitumor activity and biochemical effects of aphidicolin glycinate (NSC 303812) alone and in combination with cisplatin in vivo. Cancer Res 54:724–729 Johnson S, Laub P, Beesley J, Ozols R, Hamilton T (1997) Increased platinum-DNA damage tolerance is associated with cisplatin resistance and cross-resistance to various chemotherapeutic agents in unrelated human ovarian cancer cell lines. Cancer Res 57:850–856 Aebi S, Kurdi-Haidar B, Gordon R, Cenni B, Zheng H, Fink D, Christen R, Boland C, Koi M, Fishel R, Howell S (1996) Loss of DNA mismatch repair in acquired resistance to cisplatin. Cancer Res 56:3087–3090 Duckett D, Drummond J, Murchie A, Reardon J, Sancar A, Lilley D, Modrich P (1996) Human MutSa recognizes damaged DNA base pairs containing 06-methylguanine, O4-methylthymine, or the cisplatin-d(GpG)adduct. Proc Natl Acad Sci USA 93:6443–6447 Branch P, Masson M, Aquilina G, Bignami M, Karran P (2000) Spontaneous development of drug resistance: mismatch repair and p53 defects in resistance to cisplatin in human tumor cells. Oncogene 19:3138–3145 Mamenta E, Poma E, Kaufmann W, Delmastro D, Grady H, Chaney S (1994) Enhanced replicative bypass of platinum-DNA adducts in cisplatin-resistant human ovarian carcinoma cell lines. Cancer Res 54:3500–3505

163 149. Chancy, SG, Campbell, SL, Bassett E, Wu Y (2005) Recognition and processing of cisplatin- and oxaliplatinDNA adducts. Crit Rev Oncol Hematol 53:3–11 150. Zanke B, Boudreau K, Rubie E, Winnett E, Tibbles L, Zon L, Kyriakis J, Liu F-F, and Woodgett J (1996) The stressactivated protein kinase pathway mediates cell death following injury induced by cis-platinum, UV irradiation or heat. Curr Biol 6:606–613 151. Sanchez-Perez I, Murguia J, Perona R (1998) Cisplatin induces a persistent activation of JNK that is related to cell death. Oncogene 16:533–540 152. Vasilevskaya I, O’Dwyer PJ (2003) Role of Jun and Jun kinase in resistance of cancer cells to therapy. Drug Resist Updates 6:147–156 153. Vasilevskaya IA, Rakitinam TV, O’Dwyer PJ (2004) Quantitative effects on c-jun N-terminal protein kinase signaling determine synergistic interaction of cisplatin and 17-allylamino-17-demethoxygeldanamycin in colon cancer cell lines. Mol Pharmacol 65:235–243 154. Pan B, Yao K-S, Monia BP, Dean NM, McKay RA, Hamilton TC, O’Dwyer PJ (2002) Reversal of cisplatin resistance by a c-jun antisense oligodeoxynucleotide (ISIS 10582): evidence for the role of transcription factor overexpression in determining resistant phenotype. Biochem Pharmacol 63:1699–1707 155. Hayakawa J, Ohmichi M, Kurachi H, Ikegami H, Kimura A, Matsuoka T, Jikihara H, Mercola D, Murata Y (1999) Inhibition of extracellular signal-regulated protein kinase or c-Jun N-terminal protein kinase cascade, differentially activated by cisplatin, sensitizes human ovarian cancer cell line. J Biol Chem 274:31648–31654 156. Rakitina TV, Vasilevskaya IA, O’Dwyer PJ (2003) Additive interaction of oxaliplatin and 17-allylamino-17demethoxygeldanamycin in colon cancer cell lines results from inhibition of nuclear factor kappaB signaling. Cancer Res 63:8600–8605 157. Hayakawa J, Depatie C, Ohmichi M, Mercola D (2003) The activation of c-Jun NH2-terminal kinase (JNK) by DNA-damaging agents serves to promote drug resistance via activating transcription factor 2 (ATF2)-dependent enhanced DNA repair. J Biol Chem 278:20582–20592 158. Miyashita T, Reed JC (1993) Bcl-2 oncoprotein blocks chemotherapy-induced apoptosis in a human leukemia cell line. Blood 81:151–157 159. Minn A, Rudin C, Boise L, Thompson C (1995) Expression of Bcl-xL can confer a multidrug resistance phenotype. Blood 86:1903–1910 160. Williams J, Lucas PC, Griffith KA, Choi M, Fogoros S, Hu YY, Liu JR (2005) Expression of Bcl-xL in ovarian carcinoma is associated with chemoresistance and recurrent disease. Gynecol Oncol 96:287–295 161. Geisler JP, Geisler HE, Miller GA, Wiemann MC, Zhou Z, Crabtree W (2000) p53 and bcl-2 in epithelial ovarian carcinoma: their value as prognostic indicators at a median follow-up of 60 months. Gynecol Oncol 77: 278–282 162. Kupryjanczyk J, Szymanska T, Madry R, Timorek A, Stelmachow J, Karpinska G et al (2003) Evaluation of clinical significance of TP53, BCL-2, BAX and MEK1 expression in 229 ovarian carcinomas treated with platinum-based regimen. Br J Cancer 88:848–854

164 163. Baekelandt M, Holm R, Nesland JM, Trope CG, Kristensen GB (2000) Expression of apoptosis-related proteins is an independent determinant of patient prognosis in advanced ovarian cancer. J Clin Oncol 18: 3775–3781 164. Baekelandt M, Kristensen GB, Nesland JM, Trope CG, Holm R (1999) Clinical significance of apoptosis-related

D. Roberts et al. factors p53, Mdm2, and Bcl-2 in advanced ovarian cancer. J Clin Oncol 17:2061 165. Sagarra RA, Andrade LA, Martinez EZ, Pinto GA, Syrjanen KJ, Derchain SF (2002) P53 and Bcl-2 as prognostic predictors in epithelial ovarian cancer. Int J Gynecol Cancer 12:720–727

Chapter 9

Hormonal Therapy in Cancer Soe T. Maunglay, Julia A. Cogburn, and Pamela N. Munster

9.1 Introduction

9.2 Hormonal Therapy in Breast Cancer

Endocrine manipulation as systemic therapy for two of the most common human cancers, breast cancer in women and prostate cancer in men, continues to evolve. In the treatment of breast cancer in postmenopausal women, the development of third generation aromatase inhibitors has had a large impact in the adjuvant setting, building on the success of these agents in the treatment of metastatic disease. Hormone-sensitive disease, in general, portends a better prognosis and higher likelihood of response to treatment in both breast and prostate cancer patients. Cancers of the female reproductive tract organs (ovaries, endometrium and uterus) respond to endocrine manipulation to varying degrees, and hormonal treatment may be valuable in second-line or palliative settings. Malignancies associated with the overproduction of hormones (ectopic ACTH syndrome, neuroendocrine tumors and pituitary adenomas) may often be countered by hormonal antagonists and analogs. The role of hormonal therapy and their potential risks and benefits for each of the prescribed settings will be discussed in further detail for each tumor type.

Selective estrogen receptor modulators (SERMs) and selective estrogen receptor down-regulators (SERDs) bind to the estrogen receptor, and thereby inhibit estrogen-mediated signaling [2]. Compounds in the SERM family include tamoxifen, raloxifene, toremifene, GW5638, GW7604 (the active metabolite of GW5638), idoxifene, bazedoxifene, EM-800, lasofoxifene, arzoxifene, and acolbifene (the active metabolite of EM-800). The SERDs include the recently approved fulvestrant, as well as ZK-703, ZK253, and RU 58668 [3]. TAS-108, a tissue-selective antiestrogen, is currently under development [4]. An alternative strategy to inhibit estrogen mediated signaling is to decrease estrogen levels in the target tissues by blocking the conversion of precursor molecules to estrogen using an aromatase inhibitor (AI). Oophorectomy remains a surgical alternative to blocking estrogen receptor signaling by eliminating the major source of estrogen in premenopausal women. Several studies are currently underway to compare ovarian function suppression in combination SERMs or AIs vs. the standard treatment with a SERM alone as adjuvant therapy for premenopausal women (Table 9.1).

P.N. Munster () Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center, Experimental Therapeutics and Breast Medical Oncology, 12902 Magnolia Dr, Tampa, FL 33612, USA e-mail: [email protected] B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_9, © Springer Science+Business Media B.V. 2011

165

166 Table 9.1 Select hormonal agents used in breast cancer

S.T. Maunglay et al. Anti-estrogens

SERMs Tamoxifen, raloxifene, toremifene SERD Fulvestrant Aromatase inhibitors (AI) Steroidal AIs Exemestane (aromatase inactivator) Formestane Nonsteroidal inhibitors Aminoglutethimide∗ , letrozole, anastrozole, fadrozole, and vorozole Androgen substrate Androstenedione Progestational agents Megestrol acetate and intramuscular medroxyprogesterone acetate Progesterone receptor Antagonists Onapristone and mifepristone Androgens Danazol, testosterone, fluoxymesterone, testolactone and fluoxymesterone SERMs Selective estrogen receptor modulators, SERD Selective Estrogen receptor down regulator, AIs Aromatase Inhibitors. [∗ ]; Nonselective AI

9.2.1 Selective Estrogen Receptor Modulators (SERMs) 9.2.1.1 Tamoxifen The majority of human breast cancers are hormone receptor positive (express estrogen receptors and/or progesterone receptors), and tumor cell growth and proliferation may at least in part be stimulated by endogenous or exogenous estrogen and progesterone. The hormone-mediated effects involve signaling through the estrogen receptors (ERs) and progesterone receptors (PgRs) located in the nucleus of the cell. For many years, tamoxifen has been the mainstay of treatment in early stage and metastatic hormonereceptor positive breast cancers and has an additional role in prevention of hormone-receptor positive breast cancer in high-risk patients. Several meta-analyses showed an unequivocal benefit in patients with hormone-receptor positive cancers early stage breast cancer receiving adjuvant tamoxifen therapy for 5 years, regardless of menopausal status [5]. The use of adjuvant tamoxifen reduced the annual breast cancer death rate by 31%, and the benefits of 5 years of therapy were maintained over 15 years of study follow-up [6]. Tamoxifen was also shown to reduce the risk of developing contralateral breast recurrance [7]. Tamoxifen was associated with a 32% reduction in osteoporotic fractures, but it imparts

a higher risk for thromboembolic events, including strokes, as well as endometrial cancer [8, 9]. Whereas tamoxifen may be replaced by aromatase inhibitors in postmenopausal women, it remains the treatment of choice outside the participation in a clinical trial in premenopausal women as well as in men. Tamoxifen has not shown a benefit in patients with hormone receptor negative tumors.

9.2.1.2 Raloxifene Raloxifene, a nonsteroidal benzothiophene, is a newer SERM that has been studied mainly in the prevention and treatment of osteoporosis. It has been shown to lower serum low-density lipoprotein (LDL) cholesterol levels and, unlike tamoxifen, is not associated with endometrial stimulation in postmenopausal women [10–13]. In long-term follow-up however, thromboembolic events were more frequently seen with raloxifene when compared to placebo but no increased risk in endometrial cancer was observed [12, 13]. In addition to its use in osteoporosis, the potential role of raloxifene in the prevention of breast cancer was evaluated in the Multiple Outcomes of Raloxifene Evaluation (MORE) trial. In this multi-center, randomized, double-blinded study, breast cancer was diagnosed in 13 out of 5129 women assigned to the raloxifene group compared to 27 out of 2576 women

9

Hormonal Therapy in Cancer

who received placebo during 40 months of follow-up. The overall risk of developing invasive breast cancer was decreased by 76% during 3 years of treatment with raloxifene [12]. The Continuing Outcomes Relevant to R (CORE) trial was conducted as a continuaEvista tion of the MORE trial for an additional 4 years [14]. This trial confirmed the findings of the MORE trial, reporting a 66% reduction in the incidence of invasive breast cancer in the treatment group with a 76% reduction in ER-positive invasive breast cancer. Data from the RUTH (Raloxifene Use for the Heart) trial, a randomized study of 10,101 postmenopausal women at increased risk of coronary events suggested that raloxifene reduced the relative risk of developing invasive breast cancer by 44% (40 vs. 70 events; hazard ratio, 0.56; 95% confidence interval, 0.38–0.83), with an absolute risk reduction of 1.2 invasive breast cancers per 1000 women treated for 1 year [15]. These promising early data prompted the initiation of a prospective study to compare the benefits of raloxifene in preventing breast cancer to those seen with tamoxifen in the Study of Tamoxifen and Raloxifene (STAR). Treatment with raloxifene resulted in a similar reduction of developing invasive breast cancer compared to tamoxifen, however there was a numerically but not statistically higher number of noninvasive breast cancers in the raloxifene group. Raloxifene was further associated with a lower incidence of thromboembolic events, cataracts and uterine cancer [16]. Data from several thousands of postmenopausal women suggest that raloxifene is a feasible alternative to tamoxifen for the prevention of invasive breast cancer, and this compound is now approved by the U.S. Food and Drug Administration (FDA) not only for osteoporosis but also for the prevention of breast cancer in high-risk postmenopausal women.

9.2.1.3 Toremifene The efficacy of toremifene, a newer SERM, in comparison to tamoxifen in tamoxifen-naïve patients was evaluated in several studies. Toremifene appeared comparable to tamoxifen in both efficacy and toxicity profile in postmenopausal women with hormone receptor positive or hormone receptor unknown breast cancer [17, 18], however toremifene was not effective as a secondline therapy after tamoxifen failure, possibly due to cross resistance [19].

167

9.2.2 Estrogen Receptor Down-Regulators The selective estrogen receptor down-regulators, such fulvestrant, not only inhibit the estrogen receptor but induce its down-regulation [20]. Unlike the SERMs, the SERDs, e.g. fulvestrant are pure anti-estrogens without evidence of estrogen agonist activity [21]. Fulvestrant was compared to tamoxifen as first-line therapy but was not found to be superior to tamoxifen [22]. In smaller studies, fulvestrant has shown activity as second-line therapy in hormone-sensitive advanced breast cancer, after progression on tamoxifen or toremifene [23, 24]. As second-line therapy, fulvestrant was as effective as anastrozole in postmenopausal women with advanced breast carcinoma, showing similar overall survival [25] (see Table 9.2). Fulvestrant has activity in breast cancer patients who progressed after treatment with aromatase inhibitors (AIs) with a 35 and 37% clinical benefits rate (objective response and stable disease >24 weeks) [26, 27]. The convenience of monthly intramuscular injections may render this agent an attractive alternative to the daily oral dosing of most other hormonal therapies.

9.2.3 Aromatase Inhibitors 9.2.3.1 Aromatase Inhibitors for Advanced Breast Cancer Aromatase inhibitors (AIs) effectively suppress plasma estrogen levels by inhibiting or inactivating the aromatase enzyme thereby preventing the conversion of androstenedione to estrone and testosterone to estradiol [28]. Aromatase inhibitors are only approved for postmenopausal women. The third-generation AIs have been shown to be more effective than tamoxifen in postmenopausal women with advanced breast in the first-line setting (Table 9.2), and remain effective as second-line therapy in tamoxifen-resistant disease. The AIs have also proven useful following 5 years of adjuvant tamoxifen [29]. Furthermore, the selective AIs are superior to tamoxifen for adjuvant therapy either as initial therapy or after 2–3 years of tamoxifen in postmenopausal women (see Table 9.3). As discussed previously, tamoxifen for 5 years remains the standard adjuvant hormonal treatment in premenopausal

56% vs. 56% (p = 0.787) 59% vs. 46% (p = 0.098) 83% vs. 56% (p < 0.001) 50% vs. 38% (p = 0.004) 57% vs. 42%

Phase III

Phase III

Phase III

Phase III optional cross-over Phase II open label efficacy study

41% vs. 17%

30% vs. 20% (p =0.0002)

43% vs. 31% (p = 0.172)

21% vs. 17% (p = 0.005)

33% vs. 33%

Studies with AIs as second line after tamoxifen Vorozole 2.5 mg (n = 225) vs. Phase III 24% vs. 27% 9.7% vs.6.8% MA 40 mg (n = 227) (p = 0.24) (p = 0.24) Fulvestrant 250 mg Combined data of 43.5% vs.40.9% 19.2% vs. 16.5% monthly;(n =428) vs. two similarly (95% CI, – 4.42 to (95.14% CI, Anastrozole 1 mg daily, designed Phase III 9.36; p = 0.51) −2.27 to 9.05; (n =423) trials p = 0.31)

Studies with AIs as first line Anastrozole 1 mg (n = 340) vs. Tamoxifen 20 mg (n = 328) Anastrozole 1 mg (n = 511) vs. Tamoxifen 20 mg (n = 510) Anastrozole 1 mg (n = 121) vs. Tamoxifen 40 mg (n = 117) Letrozole 2.5 mg (n = 453) vs. Tamoxifen 20 mg (n = 454) Exemestane 25 mg (n =61) vs. Tamoxifen 20 mg (n = 59)

5.5 vs. 4.1 (HR, 0.95; 95.14% CI, 0.82–1.10; P = 0.48)

Goss et al. [35]

Paridaens et al. [34]

Mouridsen et al. [33]

Milla-Santos et al. [32]

Nabholtz et al. [31]

Bonneterre et al. [30]

27.4 vs. 27.7 (p = 0.809) Howell et al. [25]

2.6 vs.3.3 (p = 0.56) NS 26 vs. 29 (p = 0.94) NS

Median response duration were 16 (95% CI 11–38 months) vs. 22 (95% CI 12–36 months)

9.4 vs. 6.0 (p<0.001)

34 vs. 30 NS median follow-up of 32 months Not reported in this efficacy study

Not Reported Median follow up 17.7 months 17.4 vs. 16 (p = 0.003)

11.1 vs. 5.6 (p = 0.005)

18.0 vs. 7.0 (p < 0.01)

Not Reported Median follow up 19 months

Median Overall survival in month Authors

8.2 vs. 8.3 (p = 0.941)

Table 9.2 Select randomized controlled trials of aromatase inhibitors or inactivators in advanced/metastatic breast cancer Design, daily dosage and Overall response rate Median time to tumor number of patients Phase II or III Clinical benefit (%) progression in months

168 S.T. Maunglay et al.

42% vs. 40% and 40%

37.4% vs. 34.6%

Not reported

Not reported

Two Phase III trials

Phase III

Phase III

Phase III

6.6% (95% CI 3.8–10.6%) and 12.1% (95% CI, 5.0–23.3%).

16% vs. 21% and 15%

23.6% vs. 12.8% (p = 0.004) and 16.4% (p = 0.04)

3.675 and 2.175

Median survival could not be estimated

6 vs. 3 (p = 0.074) and 3 33 vs. 29 (p = 0.189) (p = 0.044) and 26 (p = 0.03)

12.5% vs. 12.5% and 4.8 vs. 5.3 and 4.6 12.2%

15.0% vs. 12.4%

Median Overall survival in month Authors

Lonning et al. [40]

Buzdar et al. [39]

Buzdar et al. [36] 26.7 vs. 25.5 (p = 0.025) and 22.5 (p = 0.09)NS Median follow up 31.2 months 5.08 vs. 4.15 (p = 0.037) Median survival was not Kaufmann et al. reached yet for [37] exemestane but superior to MA (>29.5∗ vs. 28.7 months) 5.6 vs. 5.1 (p = 0.02) 25.3 vs. 21.5 (p = 0.03) Dombernowsky and 5.5 (p = 0.05) NS and 21.5 (p = 0.4) et al. [38] Median 45 months follow up

Overall response rate Median time to tumor (%) progression in months

AI aromatase inhibitors; CR complete response; PR partial response; NC no change; CB clinical benefit (CB =CR+PR+ NC >6 months; NS Not significant; PD progressive disease; CI Confidence Interval ; HR hazard ratio

24.3% (95% CI, 19.0–30.2%) and 1.7% (95% CI, 0.0–9.2%).

Clinical benefit

Phase II or III

AIs as second line after initial first line AI failure Phase II efficacy trial. Exemestane 25 mg Patients with (n = 241) and dose progressive disease escalation of (PD) after treatment exemestane 100 mg with a nonsteroidal (n = 58) upon PD aromatase inhibitor.

Letrozole 2.5 mg. (n = 174) vs. Letrozole 0.5 mg (n = 188) vs. MA 160 mg (n = 189) Letrozole 2.5 mg (n = 199) vs. Letrozole 0.5 mg (n = 202) vs. MA 40 mg (n = 201)

Anastrozole 1 mg (n = 263) vs. Anastrozole 10 mg (n = 248) vs. MA 40 mg (n = 253) Exemestane 25 mg (n = 366) vs. MA 40 mg (n = 403)

Table 9.2 (continued) Design, daily dosage and number of patients

9 Hormonal Therapy in Cancer 169

170

S.T. Maunglay et al.

Table 9.3 Phase III randomized trials of aromatase inhibitors as single- agent upfront, sequential, or extended adjuvant hormonal therapy in postmenopausal women Trial DFS OS Contralateral breast cancer ATAC (Arimidex, Tamoxifen Alone or in Combination) [53] (n = 9366) Anastrozole Tamoxifen Tamoxifen + anastrozole∗ BIG 1–98 or BIG FEMTA (Breast International Group 1–98) [54] (Letrozole first n = 4003; tamoxifen first n = 4007) Letrozole ---------------> Tamoxifen -------------> Letrozole -> Tamoxifen Tamoxifen -> Letrozole

Significantly favors anastrozole Trend favors anastrozole (HR (HR 0.87 [95% CI 0.97 [95% CI 0.85–1.12, 0.78–0.97, p = 0.01]) p = 0.7])

Significantly favors anastrozole (35 vs. 59 cases [42% relative reduction, p = 0.01])

Trend favors letrozole (166 Trend favors letrozole (16 5-year DFS estimates = deaths in letrozole group [0.4%] vs. 27 [0.7%] cases) Overall = [4.1%] vs. 192 deaths in Significantly favors letrozole tamoxifen group [4.8%]) (84%) over tamoxifen (81.4%) (HR 0.81 [95% CI 0.70–0.93, p = 0.003]) Subgroups = Node-positive = 77.9% (letrozole) vs. 71.4% (tamoxifen) Node-negative = 88.7% in both groups Significantly favors exemestane Trend favors exemestane (222 Significantly favors exemestane IES (Intergroup Exemestane (56% relative reduction) (OR deaths in exemestane group (unadjusted HR 0.76 [95% Study) [55] 0.44 [95% CI 0.20–0.98, vs. 261 deaths in tamoxifen CI 0.66–0.88, p = 0.0001]) Tamoxifen -> Exemestane p = 0.04]) group) (HR 0.85 [95% CI with an absolute benefit of (n = 2352) 0.71–1.02, p = 0.08]) 3.3% by the end of treatment Tamoxifen ----------------> Subgroup analysis excluding (n = 2372) 122 patients with estrogen receptor-negative disease significantly favors exemestane (HR 0.83 [95% CI 0.69–1.00, p = 0.05) 4-year DFS estimates = MA-17 (National Cancer Trend favors letrozole (17 vs. 4-year OS estimates = Significantly favors letrozole Institute of Canada Clinical 28 cases) (HR 0.63 [95% CI Trend favors letrozole (94.4%) over placebo Trials Group MA-17 Study) 0.18–2.21, p = 0.12]) (95.4%) over placebo (95%) (89.8%) (HR 0.58 [95% CI [29] (HR 0.82 [95% CI 0.45–0.76, p = < 0.001]) Tamoxifen -> Letrozole 0.57–1.19, p = 0.3]) (n = 2593) Subgroup = Tamoxifen -> Placebo Significantly favors letrozole (n = 2594) among lymph node-positive patients (HR 0.61 [95% CI 0.38–0.98, p = 0.04) Meta-analysis of three clinical Significantly favors anastrozole Significantly favors anastrozole Anastrozole = 14 cases vs. (HR 0.59 [95% CI (HR 0.71 [95% CI tamoxifen = 22 cases (1% trials[56] (ABCSG 8, ARNO 0.48–0.74, p < 0.0001]) 0.52–0.98, p = 0.04]) incidence rate in both 95 and ITA) [56] groups) Tamoxifen -> anastrozole (n = 2009) Tamoxifen ---------------> (n = 1997) NSABP B-33 (National Trend favors exemestane (91%) No difference between groups Exemestane = 2 cases vs. Surgical Adjuvant Breast over placebo (89%) (RR (exemestane = 16 deaths and placebo = 8 cases and Bowel Project) [57] 0.68, p = 0.07) placebo = 13 deaths) (n = 1598)∗∗ (RR = 1.2, p = 0.63) Tamoxifen -> Exemestane Tamoxifen -> Placebo DFS disease-free survival; OS Overall survival; HR hazard ratio; OR odds ratio; CI confidence interval; ABCSG Austrian Breast and Colorectal Cancer Study Group; ARNO Arimidex-Nolvadex study; ITA Italian Tamoxifen Anastrozole study; ∗ indicates that this arm was closed and unblinded after the first interim analysis showed its equivalence to tamoxifen; ∗∗ indicates that this trial was electively closed early for accrual, after the results from MA-17 were reported

9

Hormonal Therapy in Cancer

women. The role of AIs in premenopausal women in any setting is still unknown and is currently being evaluated in randomized trials in combination with ovarian suppression. Aminoglutethimide (AG) is a nonselective, nonsteroidal anti-adrenal first-generation aromatase inhibitor. In contrast to its use in ectopic ACTH syndrome and against adrenal steroidogenesis, a lower dose was effective for breast cancer treatment [41, 42]. While initial studies showed that AG was not superior to tamoxifen, AG was shown to be beneficial in patients after progressing on tamoxifen. The combination of tamoxifen and AG did not convey additional benefits to either agent given alone. Due to its undesirable toxicity profile, AG is now rarely used. Formestane and fadrozole are members of the second generation steroidal and nonsteroidal AIs. These agents are selective inhibitors of the aromatase enzyme and do not block other adrenal gland steroidogenesis. Fadrozole showed similar efficacy when compared to tamoxifen as first-line treatment in postmenopausal patients with advanced breast cancer [43]. It was found to be a significantly better tolerated alternative to tamoxifen. Another trial found fadrozole to be useful as first-line treatment, although complete response rate and duration of objective response were significantly better in the patients treated with tamoxifen [44]. It was found to be comparable to tamoxifen for both efficacy and tolerability as first-line therapy [45]. However, neither drug is currently commercially available in the United States. The third generation selective aromatase inhibitors include anastrozole, letrozole, exemestane and vorozole, with the first three being approved agents. Anastrozole was found to have a longer time to progression when compared to tamoxifen in an randomized Phase III trial performed in North America [31], however this was not seen in a similar trial performed outside the United States [30]. Neither trial suggested an overall survival benefit when compared to tamoxifen in the treatment of metastatic breast cancer in postmenopausal women, but anastrozole was associated with a lower incidence of thromboembolic events and vaginal bleeding [30–32, 46]. Letrozole was initially shown to be effective when studied as third-line hormonal therapy in women with metastatic breast cancer [47]. Letrozole was compared to tamoxifen as first-line therapy in postmenopausal

171

women with locally advanced or metastatic breast cancer and in this study cross-over was allowed. Although the difference in median survival was not statistically significant between the groups, those patients who started in the letrozole arm had both a longer time to progression (median, 16 months and 9.4 months respectively) and a longer time before chemotherapy was initiated when compared to those patients who started in the tamoxifen arm (median, 9 months and 6 months respectively) [48]. Vorozole was found to be as effective as megestrol acetate as secondline hormonal therapy in postmenopausal women with advanced breast cancer who had disease progression following tamoxifen treatment [35]. In contrast to the non-steroidal AIs, letrozole and anastrozole, exemestane is a steroidal selective aromatase inhibitor [49] with irreversible inactivation of the aromatase enzyme. When compared to megestrol acetate in tamoxifen failure, exemestane showed prolonged overall survival, time to tumor progression, and time to treatment failure [37]. Exemestane has shown activity in the setting of primary tamoxifen resistance, as well as in patients who progressed on a non-steroidal aromatase inhibitor, e.g. anastrozole or letrozole [40, 50, 51]. A meta-analysis of 25 clinical trials enrolling a total of 8504 patients found third-generation AIs to have a statistically significant survival benefit over both tamoxifen and secondgeneration AIs in women with metastatic breast cancer. Their efficacy, in addition to their favorable toxicity profile, has rendered the third generation AIs the firstline choice of hormonal therapy in postmenopausal women with hormone receptor positive or unknown advanced breast cancer [52].

9.2.3.2 Aromatase Inhibitors for Early Stage Breast Cancer The AIs have been compared to tamoxifen as upfront adjuvant, sequential and extended adjuvant hormonal treatment in postmenopausal women in large randomized trials (Table 9.3, Fig. 9.1). The ATAC trial (Arimidex, Tamoxifen Alone or in Combination) evaluated 9366 postmenopausal women randomized into three arms of adjuvant hormonal therapy for 5 years (anastrozole, tamoxifen or the combination). Due to inferior efficacy, the combination arm was later closed to accrual. The results significantly favored anastrozole

172 Fig. 9.1 Aromatase inhibitors for early stage breast cancer. Abbreviations: ATAC = Arimidex, Tamoxifen Alone or in Combination study; IES = Intergroup Exemestane Study; MA-17 = National Cancer Institute of Canada Clinical Trials Group MA-17 Study; BIG 1–98 or BIG FEMTA = Breast International Group 1–98 study; ABCSG = Austrian Breast and Colorectal Cancer Study Group; ARNO = ArimidexNolvadex study; ITA = Italian Tamoxifen Anastrozole study; NSABP B-33 = National Surgical Adjuvant Breast and Bowel Project B-33 study. PLAC = Placebo; LET = Letrozole; R = Randomization

S.T. Maunglay et al. 5 years

tamoxifen

ATAC

R

anastrozole tamoxifen + anastrozole

tamoxifen

tamoxifen

3-2 years

R

2-3 years

IES

exemestane

tamoxifen

letrozole MA-17

letrozole

R

tamoxifen 5 years

(PLAC) Placebo (PLAC)

R (PLAC-LET)

5 years

BIG 1.98 (BIG FEMTA)

R

tamoxifen letrozole letrozole tamoxifen tamoxifen letrozole 2 years

ARNO, ITA ABCSG

R

tamoxifen

tamoxifen

tamoxifen

anastrozole

exemestane NSABP B33

tamoxifen 5 years

R placebo 2 years

in terms of disease-free survival and the development of a contralateral breast cancer. The overall survival trend favored anastrozole, but was not statistically significant [53]. The BIG 1–98 (Breast International Group 1–98) or BIG FEMTA trial evaluated 8010 postmenopausal women randomized into four arms of adjuvant hormonal therapy; letrozole or tamoxifen for 5 years, letrozole for 2 years followed by tamoxifen for 3 years or tamoxifen for 2 years followed by letrozole for 3 years. The data was analyzed based on 2 groups of patients – those who initially received tamoxifen (n = 4007) and those who initially received letrozole (n = 4003). The data revealed a statistically significant improvement in disease-free survival in the women treated with letrozole first, with a striking benefit seen in the node-positive subgroup. The overall survival trend, as well as the incidence of developing a

contralateral breast cancer, favored letrozole but neither endpoint reached statistical significance [54]. The Intergroup Exemestane Study (IES) evaluated 4724 postmenopausal women who received adjuvant tamoxifen for 2–3 years and were then randomly assigned to either switch to exemestane or to continue on tamoxifen for the remainder of the 5 years of adjuvant hormonal therapy. The results significantly favored the switch to exemestane in terms of diseasefree survival, with an absolute benefit of 3.3% by the end of treatment. The overall survival trend favored the switch to exemestane, and reached statistical significance in the subgroup analysis excluding patients with ER-negative tumors. The development of contralateral breast cancer was significantly reduced in the exemestane group (relative reduction of 56%) [55]. The MA-17 trial (National Cancer Institute of Canada Clinical Trials Group) evaluated 5187

9

Hormonal Therapy in Cancer

postmenopausal women who received tamoxifen for 5 years and were then randomized to extended adjuvant therapy with letrozole for 5 years vs. placebo. The results of this study significantly favored the letrozole group in terms of disease-free survival, with an absolute benefit of 4.6% at 4 years. The overall survival and incidence of contralateral breast cancer trends favored letrozole, and the subgroup of lymph-node positive patients receiving letrozole did show a statistically significant overall survival benefit. A further benefit was seen in the patients who were originally treated with placebo group, but then opted to received letrozole after the trial was unblinded [29]. The meta-analysis of three clinical trials (ABCSG 8, ARNO 95 and ITA) evaluated a total of 4006 postmenopausal women who received adjuvant tamoxifen for 2–3 years and were then randomized to anastrozole or to continue tamoxifen to complete 5 years of adjuvant hormonal therapy. The disease-free survival and overall survival significantly favored the switch to anastrozole, while the incidence rate of contralateral breast cancer was similar between the groups (1%) [56]. The NSABP B-33 trial (National Surgical Adjuvant Breast and Bowel Project) evaluated 1598 postmenopausal women who received adjuvant tamoxifen for 5 years and were then randomized to extended adjuvant therapy with exemestane vs. placebo, initially for 2 years (the protocol was amended in 2002 to extend exemestane or placebo for 5 years). When the substantial benefit of extended adjuvant therapy with letrozole following 5 years of tamoxifen was reported from the MA-17 trial in 2003, the NSABP B-33 trial was electively closed short of its patient accrual goal of 3000 women. The study was unblinded, and exemestane was offered to those patients who had been randomized to the placebo group, with 344 of 779 women opting to cross over to the exemestane group. The early results from the NSABP B-33 trial with a median follow-up of 30 months indicated that there was a trend toward a benefit in diseasefree survival in the exemestane group, translating into an absolute 2% difference between the groups. There was no difference noted in overall survival between the two groups. There were fewer contralateral breast cancers diagnosed in the exemestane group when compared to placebo (2 cases vs. 8 cases respectively) [57].

173

9.2.4 Ovarian Function Suppression (OFS) With or Without SERMs in Premenopausal Women Ovarian suppression by oophorectomy in premenopausal women was one of the first therapeutic interventions in the treatment of breast cancer dating back to more than 100 years ago [1]. Ovarian suppression may alternatively be induced by radiation to the ovaries or by chemical means with the use of LHRH agonists [58, 59]. It has not been clearly established whether the addition of ovarian ablation to chemotherapy and/or hormonal therapy is necessary and whether it provides an additional benefit. Premenopausal women with ER-positive early stage breast cancer who were treated with adjuvant chemotherapy and developed chemotherapy-induced amenorrhea were found to have a significant improvement in outcomes [9]. Ovarian suppression combined with tamoxifen has clearly been shown to be superior to ovarian ablation alone [60]. In contrast, the benefits of ovarian ablation in addition to tamoxifen compared to tamoxifen alone in premenopausal women with ERpositive and/or PgR-positive tumors have been shown in some studies [61–63] but were not observed in others [64] and most studies were limited in numbers or in follow up times. A trial of chemotherapy (CMF = cyclophosphamide, methotrexatee and 5-fluorouracil) vs. chemical ovarian ablation as adjuvant therapy in premenopausal women with ER-positive and nodepositive early stage breast cancer suggested that ovarian suppression may as effective but associated with better quality of life (QOL) measures [65]. However, the chemotherapy used in this trial is now rarely used and the patients in neither group received tamoxifen, rendering the value of these findings difficult to assess. In particular as it is felt that ovarian suppression alone may not be the best treatment option for hormonesensitive early stage breast cancer in premenopausal women [66]. The benefits of optimal hormonal therapy in premenopausal women are currently being addressed in several large, randomized studies, including the International Breast Cancer Study Group (IBCSG) trials [67] ,the Suppression of Ovarian Function Trial (SOFT), the Tamoxifen and Exemestane Trial (TEXT)

174

S.T. Maunglay et al.

and the recently closed Premenopausal Endocrine Responsive Chemotherapy Trial (PERCHE). The details of these trials are summarized in Table 9.4 and Fig. 9.2.

9.2.5 Progestational Agents Megestrol acetate (MA) and intramuscular medroxyprogesterone acetate while active in second-line treatment, these drugs have been replaced upon the introduction of AIs [72]. AIs showed superior activity when compared to MA in multiple settings, and progestational agents are more commonly used in later stages of the disease (Table 9.2).

9.2.6 Progesterone Receptor Antagonists Onapristone and mifepristone are progesterone antagonists that have been evaluated in small studies for the treatment of breast cancer. Onapristone was studied as first-line therapy in 18 patients, benefits were seen in 67% patients with a median duration of benefits of 70 weeks. However, the development of onapristone was stopped due to unacceptable liver toxicity [73, 74]. Mifepristone was studied in 28 patients with PgRpositive recurrent breast cancer who had received no prior therapy, but it showed only minimal activity with a 11% overall response rate.

Table 9.4 Select large trials on ovarian function suppression Trial Patient population Design Studies without tamoxifen ZEBRA Kaufmann et al. [68]

IBCSG VIII IBCSG [66]

Studies with tamoxifen ABCSG Jakesz et al. [69] ZIPP Rutqvist et al. [70]

N+; ER+/−

CMF × 6 months (n = 823). G × 2 years (n = 817)

N−; ER+/−

CMF × 6 (n = 360) G × 24 months (n = 346) CMF × 6 G × 18 months (n = 357)

Node+/−, ER+ (N = 1034)

CMF × 6 G × 3 years + tamoxifen for 5 years G × 2 years tamoxifen for 2 years. G × 2 years+ tamoxifen for 2 years. No adjuvant treatment CAF CAF + G × 5 years CAF + G + Tamoxifen × 5 years

Node+/−, ER+/− (N = 2631)

Node+, ER+ (N = 1504)

Results ER-positive = [DFS = HR = 1.05; 95% CI, 0.88 to 1.24; P = .6] ER negative = CMF > G ER+ = CMF = G [DFS = HR = 0.97; 95% CI, 0.66–1.42; P = 0.86] CMF G = G [DFS = HR = 0.84; 95% CI, 0.56–1.26; P = 0.40] CMF G = CMF [DFS = HR = 0.80; 95% CI, 0.54–1.19; P = 0.26] CMF < G + Tamoxifen for = [DFS = HR = 1.40; 95% CI, 1.06 to 1.87; P = .017] G > no G = [DFS = HR = 0.77; 95% CI, 0.66 to 0.89; P < .001]

CAF + G = CAF = [DFS = HR = 0.93; 95% CI, 0.76 to 1.14; P = .25] CAF + G + Tamoxifen > CAF + G = [DFS = HR = 0.73; 95% CI, 0.59 to 0.90; P < .01] <, worse than; >, better than; =, equal to. HR hazard ratio; ZEBRA Zoladex Early Breast Cancer Research Association; CMF cyclophosphamide, methotrexate, fluorouracil; N− node negative; G goserelin; ER estrogen receptor; DFS disease-free survival; IBCSG International Breast Cancer Study Group; N+ node positive; OA ovarian ablation; OS overall survival. ABCSG Austrian Breast and Colorectal Cancer Study Group; ZIPP Zoladex in Premenopausal Patients; INT North American Breast Cancer Intergroup Trial; CAF cyclophosphamide, doxorubicin, fluorouracil; IBCSG International Breast Cancer Study Group; BIG Breast International Group

INT-0101 Davidson et al. [71]

9

Hormonal Therapy in Cancer

175 SOFT [IBCSG 24-02, BIG 2-02] Strata

ER ≥ 10% and/or PgR ≥ 10%

Any CT

Patients with estradiol (E2) in the premenopausal range either after CT or without CT

No CT

R A N D O M I Z E

T x 5y OFS + T x 5y OFS + E x 5y

TEXT [IBCSG 25-02, BIG 3-02]

ER ≥ 10% and/or PgR ≥ 10% Candidates to begin GnRH analogue (triptorelin) from the start of adjuvant therapy

Strata** Any CT

No CT

R A N D O M I Z E

GnRH+ Tamoxifen* x 5y +/-CT** GnRH+ Exemestane* x 5y +/-CT**

* to begin at least 6 weeks after start of triptorelin or after CT, whichever is later. ** choice of +/-CT may be made by previous randomization in the PERCHE trial.

PERCHE [IBCSG 26-02, BIG 4-02] Strata

ER ≥ 10% and/or PgR ≥ 10% Patients for whom CT is considered to be a randomized option (lower risk)

Type of chemotherapy Type of OFS TEXT or T or E

R A N D O M I Z E

OFS + TEXT x 5y or T or E x 5y

OFS + any CT+TEXT x5y or T or E x 5y

Fig. 9.2 Hormonal therapy in premenopausal women. Abbreviations: CT=chemotherapy; OFS=ovarian function suppression using triptorelin × 5 years or surgical oophorectomy or radiation; T=tamoxifen; E=exemestane; GnRH

analogue=triptorelin × 5 years (but oophorectomy or radiation is allowed after 6 months; TEXT=randomized trial comparing tamoxifen vs. exemestane (recommended strata)

9.2.7 Androgens

9.2.8 Estrogens

Androgens including danazol, testosterone, fluoxymesterone, testolactone and fluoxymesterone have been studied in breast cancer, but these agents are now rarely used due to their low efficacy and poor side effect profile. Danazol was studied in 41 patients with responses seen in seven patients (17%), but the high dose was associated with significant adverse side effects [75]. Fluoxymesterone was studied in combination with tamoxifen vs. tamoxifen alone in 541 ER-positive postmenopausal women with resected early breast cancer. The combination failed to show an improvement over tamoxifen alone [76].

Diethylstilbestrol (DES) was studied in postmenopausal women with advanced breast cancer after developing resistance to estrogen deprivation [77]. In this study of 32 patients, eight patients discontinued due to side effects in the absence of progression. Five patients had an objective response, and one patient maintained stable disease lasting for 1 year. DES however is no longer commercially available in the United States due to its teratogenic effects. In postmenopausal women, AIs are most commonly recommended as first line for both, adjuvant

176

or metastatic disease whereas tamoxifen remains the treatment of choice in premenopausal woman. The SERDs, progestin analogues or estrogens are offered only after multiple hormonal therapy failures.

9.3 Hormonal Therapy in Ovarian Cancer Ovarian cancer is often diagnosed in its advanced stages, due to a lack of specific symptoms or a paucity of clinical findings in early stage disease. Platinum-based chemotherapy is considered front-line treatment, and hormonal therapies have been evaluated for their role in this illness. Tamoxifen has been studied as second-line therapy in platinum-refractory ovarian cancer and yielded an objective response rate of 13% [78] Mifepristone was studied in cisplatinand paclitaxel-resistant ovarian cancer, yielding a 27% response rate, including a 9% complete response rate [79]. The potential benefit of SERMs in the prevention of ovarian cancer was suggested in a small retrospective single institution study of 152 tamoxifentreated breast cancer patients undergoing oophorectomies. Ovarian cancer was found in none of the 53 tamoxifen treated patients where 10 of 99 (17.8%) patients in the untreated group were found to have ovarian cancer [80]. It has been well-established that oral contraceptives may play a preventive role in the development of ovarian cancer. The Cancer and Steroid Hormone Study concluded that the use of oral contraceptives decreases the risk of epithelial ovarian cancer [81, 82]. A report on a quantitative assessment of 20 studies of oral contraceptive (OC) use revealed a 36% reduction in ovarian cancer risk, with a 10% decrease in risk after 1 year of OC use and an approximately 50% decrease after 5 years of OC use [83]. However, given the still not completely resolved debate on whether OCs increase the risk for breast cancer and other adverse events, the use of these agents should be considered on an individual patient basis.

9.4 Hormonal Therapy in Endometrial Cancer The staging and initial management of endometrial cancer generally involves surgical intervention.

S.T. Maunglay et al.

Total extrafascial hysterectomy with bilateral salpingooophorectomy is routinely offered except when the tumor is limited to the endometrium and fertilitypreservation is a concern. This group of patient may benefit from hormonal manipulation with progestin until child-bearing is completed, followed by surgery. High-risk organ-confined disease will benefit from radiation therapy, but extra-uterine disease will typically require systemic therapy. At 5 years, 92% of women with early stage disease were disease free compared to only 41% of women with aortic node metastases or gross laparotomy findings [84]. While cytoreductive surgery appears beneficial for most local recurrences [85], central pelvic recurrence may require pelvic exenteration. This procedure carries a high operative morbidity, limiting the surgery to good surgical candidates, and only 20% to 45% of women were reported to survive beyond 5 years [86, 87]. Hormonal therapy is an acceptable first-line systemic treatment in women with inoperable tumors. The various progestational agents have been shown to have similar efficacy. When megestrol acetate was compared with hydroxyprogesterone caproate, an objective response was seen in 15% of the patients and 7% of patients achieved a complete response [88]. In this study, tumors that recurred more than 3 years from initial diagnosis had a superior response rate when compared to tumors that recurred within 3 years of initial diagnosis (33% vs. 8% respectively). A Gynecologic Oncology Group (GOG) study showed that in contrast to its use in breast cancer, high-dose megestrol acetate was not superior to low-dose megestrol acetate [89]. This study showed a 24% response rate with 6% complete responses, and an additional 22% of women in the trial maintained stable disease. Low-grade lesions had a superior response rate of 37%, compared to only 8% in the poorly-differentiated tumors. It has been shown that progesterone receptor (PR) status correlates with response to progestational agents [90]. In a GOG study, 37% of PR-positive tumors responded to progestational agents, compared to only 8% in the PR-negative group [89]. Selective estrogen receptor modulators (SERMs) play a lesser role in the treatment of endometrial cancer as compared to progestational agents. Tamoxifen as a single-agent or in combination with a progestin, in the setting of progestin failure, may have some utility in women who may not tolerate more intensive systemic chemotherapy. A

9

Hormonal Therapy in Cancer

GOG study showed a 10% response rate with tamoxifen with 4% complete responses [91]. An Eastern Cooperative Oncology Group (ECOG) study failed to demonstrate superiority of the combination of tamoxifen and progestin over progestin alone when used as initial hormonal therapy (19% vs. 20% response rate respectively), and more toxicity was noted in the combination group [92]. A comparison between oral tamoxifen and intramuscular medroxyprogesterone in advanced endometrial carcinoma of stage III and IV disease showed similar response rates of 53% vs. 56% respectively were seen [93] What was more encouraging in this study was initial non responders of medroxyprogesterone were given combination of the two therapies and 48% responded A comparison between oral tamoxifen and intramuscular medroxyprogesterone in advanced endometrial carcinoma of stage III and IV disease showed similar response rates of 53% vs. 56% respectively were seen [93]. What was more encouraging in this study was initial non responders of medroxyprogesterone were given combination of the two therapies and 48% responded. Additional SERMs are emerging as possible treatment options in advanced endometrial cancer. In a phase II study, arzoxifene showed a 31% overall response rate [94]. The responders included hormone receptor-positive women previously treated with progestins. Thus, as in breast cancer, there is a high likelihood that hormone receptor-positive tumors may also respond to newer generation SERMs. The AIs have shown only minimal activity in the treatment of endometrial cancer. Studies of letrozole and anastrozole as single-agents in patients previously treated with progestin achieved 10% and 9% response rates respectively [95, 96]. A preliminary report on exemestane use in women heavily pretreated with chemotherapy and radiation therapy showed a poor response to treatment [97]. A case report of two women who wished to preserve their fertility described the reversion of well-differentiated endometrialconfined tumors to normal endometrium after treatment with the combination of anastrozole and progestin [98]. GnRH agonists have been evaluated as a means of hormonal blockade but generally yielded poor results. In a phase II study, triptorelin achieved a 9% response rate, but no responses were seen in the previously irradiated or progestin-treated women [99]. Goserelin acetate was studied in a separate

177

GOG study, achieving a 12% response rate [100]. Leuprolide was studied in a primarily pre-treated population and also failed to show any response [101]. The current hormonal therapies used in the treatment of endometrial cancer include progestational agents, employed primarily in the setting of metastatic disease. Additional considerations for the use of progestins include women with disease limited to the endometrium who wish to delay surgery for possible child-bearing and women with PR-positive, lowgrade, well-differentiated tumors with a late recurrence beyond 3 years. High-dose progestins failed to provide a superior response when compared to lower doses, thus megestrol acetate 200 mg once a day is most commonly prescribed [102]. The addition of tamoxifen to progestins may be considered but has been associated with a worse toxicity profile. The addition of tamoxifen to progestins may be considered but has been associated with a worse toxicity profile [92, 94].

9.5 Hormonal Therapy in Uterine Sarcomas Uterine sarcomas are categorized as endometrial stromal sarcoma (ESS), undifferentiated sarcoma (highgrade endometrial stromal sarcoma) or pure heterologous sarcoma and leiomyosarcoma. Similar to breast and endometrial cancers, uterine sarcomas express hormone receptors. A study of 43 cases revealed that 56% of tumors expressed estrogen receptor (ER) and 56% of tumors expressed progesterone receptor (PR) [103]. In a separate study of 60 cases, 48% were found to be ER-positive, and 30% were PR-positive [104] of all the varieties of uterine sarcomas, the ESS subtype appears to have the most benefit from hormonal therapy. Hormone therapy may be indicated in medically inoperable endometrial stromal sarcomas in the settings of either limited to uterus or recurrent advanced disease. A retrospective study of a small group of women showed that those who received progestins as adjuvant therapy had fewer recurrences than those who did not receive progestins (31% vs. 67%). The majority of patients who do recur seem to benefit from subsequent progestin therapy, which resulted in stable disease (38%) or complete response (50%) [105]. Megestrol acetate is the most commonly utilized progestin in the clinical setting. AIs may also play a role

178

in second-line therapy following the use of progestins [106, 107]. However data on AIs as either first-line [106, 108, 109] or second-line hormonal therapy is sparse [110].

9.6 Hormonal Therapy in Meningioma The management of meningiomas is based on the size and location of the tumor and associated clinical symptoms. The majority of cases are followed over time with serial imaging studies, as these tumors tend to have an indolent course. Surgery or stereotactic radiosurgery (SRS) may be employed, particularly in the event of a symptomatic tumor. Malignant meningiomas may require radiation therapy following surgical resection, and approximately 19% of resected meningiomas will recur following surgery [111]. The recurrence rate varies based on the tumor location and ease of resectability, but multiple attempts at surgical resection may be possible [112]. Radiation therapy may also play a role in the setting of recurrent disease. Systemic treatment options for unresectable meningiomas or malignant meningiomas are limited. Meningiomas tend to be progesterone receptorpositive rather than estrogen receptor-positive [113]. Mifepristone is a progesterone receptor antagonist with antiglucocorticoid receptor activity. Mifepristone was shown to have a 25% objective response rate in an earlier study [114]. A more recent study of 28 patients with a median duration of treatment of 35 months showed improvement in automated visual field examination or improved CT or MRI scans in 8 patients (28%), 7 of whom were either male patients or premenopausal female patients [115]. However, more data is necessary to determine the optimal hormonal manipulations in this disease.

9.7 Hormonal Therapy for Ectopic ACTH Syndrome The most common causes of ectopic corticotropin (ACTH) syndrome are small-cell carcinomas, bronchial carcinoids, and islet cell tumors. Surgical excision of the tumor generally offers the best chance

S.T. Maunglay et al.

of cure [116–118], but in many cases the tumor is unresectable or there is evidence of metastatic disease. When the liver is the only site of metastatic disease in neuroendocrine tumors, resection of hepatic metastases, cryoablation and liver transplantation are all practical options in selected patients [119, 120]. Adrenal enzyme inhibitors such as aminoglutethimide and ketoconazole, alone or combination with metyrapone, may be used to control symptoms of hypercortisolism. To prevent acute adrenal insufficiency, exogenous glucocorticoids should be coadministered as needed [121]. Etomidate has also been used with success when intravenous administration is necessary [122, 123]. Somatostatin analogues such as octreotide reduce ectopic ACTH secretion [124, 125] and are especially effective when somatostatin receptor scintigraphy is positive [126]. Mifepristone is a progesterone and glucocorticoid receptor antagonist that may be used for Cushing’s syndrome secondary to ectopic ACTH secretion [127]. Adrenelectomy, followed by life-long glucocorticoid and mineralocorticoid replacement, may sometimes be required when the adrenal enzyme inhibitors fail to control hypercortisolism [128].

9.8 Hormonal Therapy in Neuroendocrine Tumors Metastatic carcinoid tumors are capable of causing carcinoid syndrome through the secretion of serotonin and other vasoactive substances. Cytoreductive surgical resection or hepatic artery embolization should be considered as therapeutic options. Octreotide and lanreotide are somatostatin analogs that have yielded good biochemical and symptomatic responses by acting on somatostatin receptors in the neuroendocrine tumors. A small number of patients has been reported to have tumor regression in addition to biochemical response [129]. In a study of 25 patients with advanced neuroendocrine tumors treated with lanreotide, objective partial responses were seen in 2 patients (8%), both with midgut carcinoids, and an additional 10 patients (40%) had tumor stabilization [130]. Somatostatin analogs have been combined with interferon alfa (IFNa), but a recent randomized trial failed to prove superiority of the combination over octreotide alone [131]. On

9

Hormonal Therapy in Cancer

the basis of previous studies, it may be reasonable to add IFNa to octerotide when octreotide alone fails to control the disease [132, 133].

9.9 Hormonal Therapy in Pituitary Adenoma Pituitary adenomas tend to be asymptomatic until they exceed 10 millimeters in size, at which point they are classified as macroadenomas. Gonadotroph adenomas, the most common type of macroadenoma, are typically non-functioning and may be managed with surgery, or rarely with radiation. In select asymptomatic cases, they may be followed without any intervention. Hormonal manipulation with dopamine agonists may result in a decline in follicular stimulating hormones but has not been shown to reduce tumor size [134, 135]. Thyrotroph adenomas may be clinically non-functioning when only thyroid stimulating hormone subunits are secreted, but increased thyroid stimulating hormone secretion may result in hyperthyroidism. Corticotroph adenomas often cause Cushing’s disease by ACTH production, and primary therapy includes surgery and radiation. In relapsed or inoperable cases, medical adrenalectomy with mitotane may be used in conjunction with pituitary irradiation followed by hormone replacement therapy for each hormone deficient condition. Lactotroph adenomas secrete prolactin (PRL), which leads to hyperprolactinemia and the development of hypogonadism in both men and women. Dopamine agonists are considered the first line of treatment in this condition. Bromocriptine is an ergot derivative with the longest track record, but it requires twice daily administration. Bromocriptine exists in a long-acting formulation with good efficacy data, but this agent is not currently available in the United States [136]. Cabergoline is a long-acting dopamine agonist, specific for the D2 receptor, that can be given once or twice weekly and is associated with less gastrointestinal side effects than bromocriptine [137]. Cabergoline has shown good activity in tumors that previously failed bromocriptine [138, 139]. Pergolide is another drug used for the treatment of hyperprolactinemia, but it was recently withdrawn from the market in the United States due to its association with valvular heart disease [140, 141]. Cabergoline also seemed to carry

179

the same risk in these studies. The long-acting nonergot dopamine agonist quinoglide (CV 205–502) has good efficacy data but is not currently available for clinical use [135, 142]. Estrogen and progestin may have a role in woman with hypogonadism secondary to hyperprolactinemia. Somatotroph adenomas are typically growth hormone (GH) releasing tumors. GH excess occurring before the fusion of the epiphyseal growth plates results in gigantism, whereas GH excess occurring after complete epiphyseal fusion results in acromegaly. Transphenoidal surgery is the treatment of choice with the intention to cure. Cranial irradiation could be considered, but it is associated with panhypopituitarism, especially in a developing child. For this reason, in relapsed and unresectable cases, hormonal manipulation plays a significant role. Bromocriptine was found to be effective at lowering GH levels and controlling disease, particularly when concomitant prolactin over secretion is present [143, 144]. Cabergoline, the long acting dopamine agonist, is traditionally more effective and better tolerated than bromocriptine, and is also especially advantageous when the tumor over secretes both GH and PRL [145]. The somatostatin analogs, octerotide and lanreotide, are commonly used with good success, seldomly in combination with a dopamine agonist. In some cases, infusional octerotide may be required if subcutaneous depot formulations are not effective [146]. It may be possible to switch over to long-acting lanreotide once the disease becomes controlled [147]. Pegvisomant, a GH receptor antagonist has shown good activity in both adults and children, and it may be used when the tumor is not responding to other treatments. Elevated liver enzymes were reported in some patients and thus need to be monitored closely during treatment [148–150].

9.10 Hormonal Therapy in Cancer Anorexia, Cachexia and for Hematopoietic Recovery An Eastern Cooperative Oncology Group (ECOG) study revealed that weight loss may correlate with a significantly shorter median survival, a lower response rate to chemotherapy and may influence the performance status in most cancers [151]. In this study,

180

weight loss also correlated with more advanced disease. Corticosteroids and progestins are commonly used for the treatment of cancer anorexia and cachexia. Oral methylprednisolone (MP) was evaluated in a randomized, double-blind crossover trial, in which one group of patients received MP for 14 days and the other group of patients received placebo the both groups were given MP for 20 days. There was less pain, lower analgesic use and less depressive symptoms observed in the majority of patients who were on MP [152]. Intravenous MP for 8 weeks was evaluated in a study of terminally-ill women. The MP group reported significant quality of life improvement, but there was no effect on overall mortality rates or time to death [153]. Steroid use for symptom improvement may be best utilized in the setting of palliative treatment of terminally-ill patients with short life expectancy due to its side effects. Megestrol acetate (MA) is the most studied hormonal drug for anorexia and cachexia. It has been approved for this indication in the setting of AIDS since 1993. A recent review of fifty-five studies also concluded that both progestins and corticosteroids are beneficial in anorexia [154]. MA is superior to fluoxymesterone, an anabolic corticosteroid, and it seems to have a better toxicity profile [155]. It has been noted that MA does have a higher rate of deep venous thrombosis than dexamethasone (5% vs. 1%). In addition to fluoxymesterone, oxandrolone is another anabolic steroid that has been studied with final efficacy data not yet reported. Recombinant human growth hormone (rHGH) has been studied in prolonged critical illnesses, but high doses of growth hormone have been associated with an increase in mortality. The group treated with rHGH had a higher relative risk of death of 1.9 and 2.4 in two separate studies [156]. The use of physiological doses of human growth hormone was studied in a recent randomized trial of patients with hematologic malignancies who were receiving intensive chemotherapy. The patients who received rHGH showed significantly faster recovery of platelets when compared to the arm that received placebo, and time to relapse did not differ significantly between the arms [157]. The benefits of physiologic or high normal doses of rHGH for cancer anorexia and cachexia remain to be determined.

S.T. Maunglay et al.

9.11 Hormonal Therapy in Prostate Cancer The dependence of prostate cancer on androgens, the male sex steroids, is well-described in the literature. The androgen receptor is a nuclear transcription factor which plays a key regulatory role in the development and progression of prostate cancer. Androgens are produced mainly in the testes, and to a lesser extent in the adrenal glands. In prostate tissue, testosterone and adrenal androgens are converted by 5-alpha reductase to dihydrotestosterone, which acts as the primary ligand for the androgen receptor [158].

9.11.1 Androgen-Deprivation Therapy Androgen-deprivation therapy (ADT) has played a fundamental role in the treatment of advanced prostate cancer since its palliative use was first described in the 1940s by Huggins and Hodges [159]. The goal of ADT in prostate cancer is to reduce levels of circulating androgens, which are felt to drive the malignant transformation and growth of the tumor. Bilateral orchiectomy results in a rapid decline in serum testosterone within hours of surgery, but it is irreversible and may have a considerable negative psychological impact on the patient. The first alternative to orchiectomy was diethylstilbestrol, an estrogen agonist [160]. Luteinizing hormone-releasing hormone (LHRH) or gonadotropin-releasing hormone (GnRH) agonists have also been used to induce medical castration. All three methods of ADT were shown to have similar survival rates in a meta-analysis of men with locally advanced or metastatic prostate cancer [161]. Androgen-deprivation therapy is associated with a number of distinct side effects, including decreased libido and erectile dysfunction, loss of bone mineral density, weight gain and loss of muscle mass, cognitive dysfunction, hot flashes, fatigue, depression and anemia. Additionally, a recent observational study of men treated with a LHRH agonist showed an increased risk of developing diabetes and cardiovascular disease in this group of patients. Men who underwent orchiectomies were observed to be at greater risk for

9

Hormonal Therapy in Cancer

developing diabetes, but not cardiovascular disease [162].

9.11.2 The Estrogen Agonists The estrogen agonists, including diethylstilbestrol, suppress the secretion of LHRH by the hypothalamus, resulting in decreased LH levels and testosterone synthesis by the testes. It may take 3 weeks or longer to achieve castrate levels of testosterone with diethylstilbestrol [163]. A meta-analysis of the Veteran’s Affairs Cooperative Urologic Research Group (VACURG) study in 1988 showed prolonged survival in patients with advanced prostate cancer who received treatment with diethylstilbestrol 1 mg daily compared with lower or higher doses or placebo [164]. A major drawback of the estrogen agonists is the associated risk of cardiovascular disease, including thromboembolic events, myocardial infarction and stroke. Diethylstilbestrol is no longer commercially available in the United States [165]. Currently, estrogen therapy is rarely used to treat prostate cancer.

9.11.3 The LHRH Agonists The LHRH agonists include leuprolide, goserelin and triptorelin. These drugs bind continuously to LHRH receptors on pituitary gonadotrope-producing cells. This leads to an initial stimulation of LH release, resulting in a testosterone surge and possible tumor flare. After about one week, the LHRH receptors are downregulated, leading to reduced production of LH and therefore, decreased synthesis of testosterone by the testes. Significant reductions in serum LH and castrate testosterone levels are not seen for up to three to four weeks after initiating therapy with a LHRH agonist [166–168]. Therapy with a LHRH agonist is considered the first-line pharmacologic approach to treating advanced or metastatic prostate cancer. Treatment is considered palliative, not curative, but the Medical Research Council Prostate Cancer Working Party Investigators Group did show a modest prolongation in survival and decreased risk of major complications (pathologic fracture, spinal cord compression, urinary tract obstruction and extraskeletal metastasis)

181

when treatment is started early and not delayed until the onset of symptoms [169]. Due to the initial testosterone surge and potential tumor flare associated with the LHRH agonists, the temporary use of an antiandrogen in combination with the LHRH agonist is recommended in certain at-risk patients (i.e. men with severe ureteral obstruction or severe, painful vertebral metastases) [167, 168, 170]. In patients with node-positive disease who have undergone radical prostatectomy and lymph node dissection, immediate treatment with ADT is associated with a significant overall and prostate-cancer-specific survival benefit and progression-free survival benefit, when compared to delayed treatment at the time of disease progression [171]. Biochemical relapse (rising PSA level alone) is a common situation, occurring in up to 20–40% of men within 10 years of definitive treatment with radiation therapy or radical prostatectomy [172]. A large retrospective review examining this group of patients found that in the subgroup of men with high-risk disease (Gleason > 8, PSA doubling time < 12 months), early ADT provided a clinical disease-free survival benefit [173]. Intermittent androgen-deprivation therapy refers to cyclic administration of LHRH agonists and antiandrogens, with the goal of attenuating some of the treatment-associated adverse effects. Usually there is either a fixed interval defined for induction treatment with ADT (i.e. 9–12 months), or treatment is given until maximal PSA response. This is followed by a period of observation of the PSA level off ADT, and once a predefined rise in PSA level is noted, reinitiation of ADT is begun. Apart from the benefits of minimizing adverse side effects and lowering cost, intermittent ADT may also potentially delay the emergence of androgen-independent tumor growth [163, 174–177]. Currently there is insufficient evidence to support the routine use of intermittent ADT, but a number of clinical trials are ongoing to address this issue [178]. A number of randomized trials of radiation therapy alone vs. radiation therapy and ADT showed a significant clinical benefit for the combination treatment in patients with high-risk (i.e. Gleason score 8 to 10, PSA >20 ng/mL), locally advanced prostate cancers. Androgen-deprivation therapy should begin at least two months prior to starting radiation therapy, and continue at least through the course of radiation [179].

182

9.11.4 The LHRH Antagonists The LHRH antagonists include abarelix, cetrorelix, ganirelix, antarelix and detirelix. These drugs directly block the LHRH receptors on pituitary gonadotropeproducing cells, inhibiting LH release and resulting in rapid suppression of testosterone production without the tumor flare associated with the LHRH agonists [160, 180]. Unlike LHRH agonists, significant reductions in serum testosterone levels may be seen as early as a few days after starting therapy with a LHRH antagonist [181]. Abarelix was approved in the United States in 2003 for initial treatment of advanced prostate cancer, but the drug was withdrawn from the market in May 2005 due to poor sales and a higher than expected rate of severe allergic reactions [170].

9.11.5 Anti-Androgens Anti-androgens include both non-steroidal (flutamide, bicalutamide, and nilutamide) and steroidal (cyproterone acetate and megestrol acetate) formulations. These drugs compete with dihydrotestosterone by binding to the androgen receptor and blocking its action [172]. In addition, the steroidal anti-androgens inhibit LHRH secretion, resulting in suppression of LH and testosterone. Single-agent use of the non-steroidal anti-androgens is not considered androgen-deprivation therapy, because these drugs raise rather than lower serum testosterone levels. Bicalutamide monotherapy is well-tolerated and has a more favorable toxicity profile (better sexual function and improved bone density) when compared to LHRH agonists or bilateral orchiectomy alone [182]. A common side effect of the anti-androgens is gynecomastia, and the diarrhea associated with flutamide may impact its compliance rate and clinical use. The Early Prostate Cancer trial program comprises a pooled analysis of three studies of high dose bicalutamide (150 mg daily) vs. placebo after standard treatment (watchful waiting, prostatectomy or radiation) in patients with localized or locally advanced nonmetastatic prostate cancer. A significant progressionfree survival benefit was noted in the subgroup of patients with locally advanced, but not early stage, disease who received bicalutamide [183]. Two studies of patients with locally advanced or metastatic disease

S.T. Maunglay et al.

comparing high dose bicalutamide (150 mg daily) to castration showed overall similar survival outcomes between the groups and better tolerability with bicalutamide [164, 184]. At the present time, anti-androgens are not approved as monotherapy to treat prostate cancer in the United States, Canada or Europe. Combined androgen blockade (CAB) involves either surgical or medical castration (traditionally with a LHRH agonist) combined with an anti-androgen, with the goal of blocking both testicular and adrenal androgens. A number of meta-analyses of the randomized controlled trials comparing CAB with orchiectomy or LHRH agonist alone in men with advanced prostate cancer suggest a small 5-year survival advantage (0–5%). This survival benefit may be offset by concerns regarding increased adverse side effects and cost [110, 185–187]. The largest meta-analysis, conducted by the Prostate Cancer Trialists’ Collaborative Group, showed no overall survival benefit between CAB and castration alone at 2 or 5 years. However, subgroup analysis did show a 3% absolute survival benefit at 5 years for CAB with the use of a nonsteroidal anti-androgen. The use of the steroidal antiandrogen, cyproterone, in CAB was associated with a 3% absolute increased risk of death at 5 years [185] (Table 9.5). At the present time, CAB may be considered in select patients, but should be recommended under careful consideration of the patient’s underlying medical and social circumstances as well as the tumors molecular make-up and biology [178]. An exception may be the previously mentioned temporary use of CAB when starting treatment in certain at-risk patients to minimize tumor flare and clinical symptoms.

9.11.6 Secondary Hormonal Manipulations Men who develop an increase in PSA or clinical disease progression while receiving ADT, in the presence of castrate levels of testosterone (less than 20 ng/dL), are noted to have androgen-independent prostate cancer. The treatment options for these patients include secondary hormonal manipulations and systemic chemotherapy. Secondary hormonal manipulations typically start with the addition of an antiandrogen to LHRH agonist monotherapy or, if the patient is already receiving CAB, the discontinuation

9

Hormonal Therapy in Cancer

183

Table 9.5 Largest meta-analysis data from 27 randomized clinical trials involving 8275 patients; comparison between monotherapy (medical or surgical castration) vs. combined Treatment 5-year survival

Monotherapy Combined Androgen blockade Survival difference

23.6% 25.4%

androgen blockade (castration plus anti-androgen) in patients with locally advanced or metastatic prostate cancer [185] 5-yr survival = Subgroup receiving steroidal anti-androgen (cyproterone acetate) 18.1% 15.4%

5-yr survival = Subgroup receiving non-steroidal anti-androgen (nilutamide and flutamide) 24.7% 27.6%

1.8% − 2.8% 2.9% [SE 1.3]; logrank 2p = 0.11 [SE 2.4]; logrank 2p = 0.04 [SE 1.3]; logrank 2p = 0.005 adverse

of the anti-androgen agent [188, 189]. Additional strategies include the use of a different anti-androgen agent, estrogens, cytochrome P450 enzyme inhibitors (i.e. ketoconazole), and corticosteroids. The phenomenon of a decline in PSA and occasional symptomatic improvement seen with the withdrawal of an anti-androgen was first described in 1993 [190]. Approximately 20% of patients failing CAB have a PSA response (>50% decline in PSA) when the anti-androgen is discontinued, although the response duration is typically short, in the range of four to six months. Another option is utilizing a different anti-androgen agent, which is based on the premise that specific anti-androgens interact differently with the androgen receptor [191]. For all men with androgen-independent prostate cancer, continuation of the primary testicular androgen deprivation (i.e. LHRH agonist) to maintain castrate levels of testosterone is recommended, as data suggest that there may be a persistent population of tumor cells that remain hormone sensitive despite tumor progression [192]. Ketoconazole is an anti-fungal agent which, at high doses, inhibits the cytochrome P450 enzyme and blocks 17,20-lyase, a crucial enzyme in the testicular and adrenal steroid synthesis pathways [193]. It also exerts a direct cytotoxic effect on prostate cancer cells in vitro and is capable of lowering testosterone levels into castrate range within 24 h [193, 194]. Common side effects associated with ketoconazole include nausea and vomiting, skin rash, fatigue and gynecomastia. Due to the lack of specificity of ketoconazole, concurrent administration of hydrocortisone is necessary to treat the resulting adrenal insufficiency. Several small trials of patients receiving ketoconazole and hydrocortisone as a secondary hormonal manipulation report

PSA responses (>50% decline in PSA) in the 20– 60% range, with duration of response from 3–8 months [195–197].

9.12 Summary Despite the improvements in systemic chemotherapy and the development of targeted agents such as trastuzumab, hormonal therapy remains a central part of therapy in breast cancer. The aromatase inhibitors have moved tamoxifen to the second line setting in the postmenopausal women with advanced as well as those with early stage disease. The potential role of AI’s in combination with ovarian ablation is currently being studied for premenopausal women. The introduction of newer SERMs and SERDs has increased the arsenal of effective hormonal agents for breast cancer. The recent approval of raloxifene as preventive therapy in high-risk postmenopausal women is a positive step toward reducing the development of invasive breast cancer. The ovarian function suppression trials will shed light on our management of premenopausal women with hormone receptor-positive breast cancer. Although prostate cancer is the most common cancer and one of the leading causes of cancer mortality in men, hormonal therapies remain limited mainly to ADT, utilizing medical or surgical castration with or without anti-androgens. Th use of combined hormonal ablation is guided by careful risk assessment of the disease and the individual tolerability and acceptability of treatment-induced short- and longterm sequealae. Hormonal manipulations may play a role in many other diseases but may be of lesser importance than in breast and prostate cancer and may offer predominantly palliative benefits. Further studies are

184

needed to optimize the integration of hormonal strategies for the treatment and prevention.

References 1. Beatson CT (1896) On the treatment of inoperable cases of carcinomas of the mamma: suggestions for a new method of treatment, with illustrative cases. Lancet 2: 104–107 2. Jensen EV et al (1967) Estrogen-receptor interactions in target tissues. Arch Anat Microsc Morphol Exp 56(3):547–569 3. Ariazi EA et al (2006) Estrogen receptors as therapeutic targets in breast cancer. Curr Top Med Chem 6(3): 181–202 4. Buzdar AU (2005) TAS-108: a novel steroidal antiestrogen. Clin Cancer Res 11(2 Pt 2):906s–908s 5. Tamoxifen for early breast cancer. Cochrane Database Syst Rev 2001(1):CD000486 6. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) (2005) Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 365(9472):1687–1717 7. Fisher B et al (2002) Tamoxifen, radiation therapy, or both for prevention of ipsilateral breast tumor recurrence after lumpectomy in women with invasive breast cancers of one centimeter or less. J Clin Oncol 20(20):4141–4149 8. Fisher B et al (2005) Tamoxifen for the prevention of breast cancer: current status of the national surgical adjuvant breast and bowel project P-1 study. J Natl Cancer Inst 97(22):1652–1662 9. Colleoni M et al (2006) Tamoxifen after adjuvant chemotherapy for premenopausal women with lymph node-positive breast cancer: international breast cancer study group trial 13–93. J Clin Oncol 24(9):1332–1341 10. Delmas PD et al (1997) Effects of raloxifene on bone mineral density, serum cholesterol concentrations, and uterine endometrium in postmenopausal women. N Engl J Med 337(23):1641–1647 11. Johnston CC Jr et al (2000) Long-term effects of raloxifene on bone mineral density, bone turnover, and serum lipid levels in early postmenopausal women: three-year data from 2 double-blind, randomized, placebo-controlled trials. Arch Intern Med 160(22):3444–3450 12. Cummings SR et al (1999) The effect of raloxifene on risk of breast cancer in postmenopausal women: results from the MORE randomized trial. Multiple outcomes of raloxifene evaluation. JAMA 281(23):2189–2197 13. Ettinger B et al (1999) Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple outcomes of raloxifene evaluation (MORE) investigators. JAMA 282(7):637–645 14. Martino S et al (2004) Continuing outcomes relevant to Evista: breast cancer incidence in postmenopausal osteoporotic women in a randomized trial of raloxifene. J Natl Cancer Inst 96(23):1751–1761

S.T. Maunglay et al. 15. Barrett-Connor E et al (2006) Effects of raloxifene on cardiovascular events and breast cancer in postmenopausal women. N Engl J Med 355(2):125–137 16. Vogel VG et al (2006) Effects of tamoxifen vs raloxifene on the risk of developing invasive breast cancer and other disease outcomes: the NSABP study of tamoxifen and raloxifene (STAR) P-2 trial. JAMA 295(23):2727–2741 17. Hayes DF et al (1995) Randomized comparison of tamoxifen and two separate doses of toremifene in postmenopausal patients with metastatic breast cancer. J Clin Oncol 13(10):2556–2566 18. Pyrhonen S et al (1999) Meta-analysis of trials comparing toremifene with tamoxifen and factors predicting outcome of antiestrogen therapy in postmenopausal women with breast cancer. Breast Cancer Res Treat 56(2):133–143 19. Vogel CL et al (1993) Multicenter phase II efficacy trial of toremifene in tamoxifen-refractory patients with advanced breast cancer. J Clin Oncol 11(2):345–350 20. Dauvois S, White R, Parker MG (1993) The antiestrogen ICI 182780 disrupts estrogen receptor nucleocytoplasmic shuttling. J Cell Sci 106(Pt 4):1377–1388 21. DeFriend DJ et al (1994) Investigation of a new pure antiestrogen (ICI 182780) in women with primary breast cancer. Cancer Res 54(2):408–414 22. Howell A et al (2004) Comparison of fulvestrant versus tamoxifen for the treatment of advanced breast cancer in postmenopausal women previously untreated with endocrine therapy: a multinational, double-blind, randomized trial. J Clin Oncol 22(9):1605–1613 23. Howell A, Robertson J (1995) Response to a specific antioestrogen (ICI 182780) in tamoxifen-resistant breast cancer. Lancet 345(8955):989–990 24. Watanabe T et al (2004) Fulvestrant for the treatment of advanced breast cancer in postmenopausal women: a Japanese study. Anticancer Res 24(2C):1275–1280 25. Howell A et al (2005) Fulvestrant versus anastrozole for the treatment of advanced breast carcinoma: a prospectively planned combined survival analysis of two multicenter trials. Cancer 104(2):236–239 26. Ingle JN et al (2006) Fulvestrant in women with advanced breast cancer after progression on prior aromatase inhibitor therapy: north central cancer treatment group trial N0032. J Clin Oncol 24(7):1052–1056 27. Perey L et al (2007) Clinical benefit of fulvestrant in postmenopausal women with advanced breast cancer and primary or acquired resistance to aromatase inhibitors: final results of phase II Swiss group for clinical cancer research trial (SAKK 21/00). Ann Oncol 18(1):64–69 28. Smith IE, Dowsett M (2003) Aromatase inhibitors in breast cancer. N Engl J Med 348(24):2431–2442 29. Goss PE et al (2005) Randomized trial of letrozole following tamoxifen as extended adjuvant therapy in receptorpositive breast cancer: updated findings from NCIC CTG MA.17. J Natl Cancer Inst 97(17):1262–1271 30. Bonneterre J et al (2000) Anastrozole versus tamoxifen as first-line therapy for advanced breast cancer in 668 postmenopausal women: results of the tamoxifen or arimidex randomized group efficacy and tolerability study. J Clin Oncol 18(22):3748–3757 31. Nabholtz JM et al (2000) Anastrozole is superior to tamoxifen as first-line therapy for advanced breast cancer

9

Hormonal Therapy in Cancer

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

in postmenopausal women: results of a North American multicenter randomized trial. Arimidex study group. J Clin Oncol 18(22):3758–3767 Milla-Santos A et al (2003) Anastrozole versus tamoxifen as first-line therapy in postmenopausal patients with hormone-dependent advanced breast cancer: a prospective, randomized, phase III study. Am J Clin Oncol 26(3):317–322 Mouridsen H et al (2001) Superior efficacy of letrozole versus tamoxifen as first-line therapy for postmenopausal women with advanced breast cancer: results of a phase III study of the international letrozole breast cancer group. J Clin Oncol 19(10):2596–2606 Paridaens R et al (2003) Mature results of a randomized phase II multicenter study of exemestane versus tamoxifen as first-line hormone therapy for postmenopausal women with metastatic breast cancer. Ann Oncol 14(9): 1391–1398 Goss PE et al (1999) Randomized phase III trial comparing the new potent and selective third-generation aromatase inhibitor vorozole with megestrol acetate in postmenopausal advanced breast cancer patients. North American vorozole study group. J Clin Oncol 17(1): 52–63 Buzdar AU et al (1998) Anastrozole versus megestrol acetate in the treatment of postmenopausal women with advanced breast carcinoma: results of a survival update based on a combined analysis of data from two mature phase III trials. Arimidex study group. Cancer 83(6):1142–1152 Kaufmann M et al (2000) Exemestane is superior to megestrol acetate after tamoxifen failure in postmenopausal women with advanced breast cancer: results of a phase III randomized double-blind trial. The exemestane study group. J Clin Oncol 18(7):1399–1411 Dombernowsky P et al (1998) Letrozole, a new oral aromatase inhibitor for advanced breast cancer: double-blind randomized trial showing a dose effect and improved efficacy and tolerability compared with megestrol acetate. J Clin Oncol 16(2):453–461 Buzdar A et al (2001) Phase III, multicenter, double-blind, randomized study of letrozole, an aromatase inhibitor, for advanced breast cancer versus megestrol acetate. J Clin Oncol 19(14):3357–3366 Lonning PE et al (2000) Activity of exemestane in metastatic breast cancer after failure of nonsteroidal aromatase inhibitors: a phase II trial. J Clin Oncol 18(11):2234–2244 Smith IE et al (1982) Tamoxifen versus aminoglutethimide versus combined tamoxifen and aminoglutethimide in the treatment of advanced breast carcinoma. Cancer Res 42(8 Suppl):3430s–3433s Bonneterre J et al (1985) Aminoglutethimide in advanced breast cancer: clinical results of a French multicenter randomized trial comparing 500 mg and 1 g/day. Eur J Cancer Clin Oncol 21(10):1153–1158 Thurlimann B et al (1996) First-line fadrozole HCI (CGS 16949A) versus tamoxifen in postmenopausal women with advanced breast cancer. Prospective randomised trial of the Swiss group for clinical cancer research SAKK 20/88. Ann Oncol 7(5):471–479

185 44. Falkson CI, Falkson HC (1996) A randomised study of CGS 16949A (fadrozole) versus tamoxifen in previously untreated postmenopausal patients with metastatic breast cancer. Ann Oncol 7(5):465–469 45. Perez Carrion R et al (1994) Comparison of the selective aromatase inhibitor formestane with tamoxifen as firstline hormonal therapy in postmenopausal women with advanced breast cancer. Ann Oncol 5(Suppl 7):S19–S24 46. Nabholtz JM et al (2003) Anastrozole (Arimidex) versus tamoxifen as first-line therapy for advanced breast cancer in postmenopausal women: survival analysis and updated safety results. Eur J Cancer 39(12):1684–1689 47. Ingle JN et al (1997) A randomized phase II trial of two dosage levels of letrozole as third-line hormonal therapy for women with metastatic breast carcinoma. Cancer 80(2):218–224 48. Mouridsen H et al (2003) Phase III study of letrozole versus tamoxifen as first-line therapy of advanced breast cancer in postmenopausal women: analysis of survival and update of efficacy from the international letrozole breast cancer group. J Clin Oncol 21(11):2101–2109 49. Lonning PE et al (1997) Exemestane experience in breast cancer treatment. J Steroid Biochem Mol Biol 61 (3–6):151–155 50. Kvinnsland S et al (2000) High activity and tolerability demonstrated for exemestane in postmenopausal women with metastatic breast cancer who had previously failed on tamoxifen treatment. Eur J Cancer 36(8):976–982 51. Bertelli G et al (2005) Sequential treatment with exemestane and non-steroidal aromatase inhibitors in advanced breast cancer. Oncology 69(6):471–477 52. Mauri D et al (2006) Survival with aromatase inhibitors and inactivators versus standard hormonal therapy in advanced breast cancer: meta-analysis. J Natl Cancer Inst 98(18):1285–1291 53. Howell A et al (2005) Results of the ATAC (arimidex, tamoxifen, alone or in combination) trial after completion of 5 years’ adjuvant treatment for breast cancer. Lancet 365(9453):60–62 54. Thurlimann B et al (2005) A comparison of letrozole and tamoxifen in postmenopausal women with early breast cancer. N Engl J Med 353(26):2747–2757 55. Coombes RC et al (2007) Survival and safety of exemestane versus tamoxifen after 2–3 years’ tamoxifen treatment (intergroup exemestane study): a randomised controlled trial. Lancet 369(9561):559–570 56. Jonat W et al (2006) Effectiveness of switching from adjuvant tamoxifen to anastrozole in postmenopausal women with hormone-sensitive early-stage breast cancer: a metaanalysis. Lancet Oncol 7(12):991–996 57. Mamounas E, Wickerham L et al (2006) Benefit from exemestane (EXE) as extended adjuvant therapy after 5 years of tamoxifen (TAM): intent-to-treat analysis of NSABP B-33. [Abstract] Breast Cancer Res Treat 100(Suppl 1):A-49, S22 58. Clarke MJ (1998) Ovarian ablation in breast cancer, 1896 to 1998: milestones along hierarchy of evidence from case report to Cochrane review. BMJ 317(7167):1246–1248 59. Tan SH, Wolff AC (2007) Luteinizing hormone-releasing hormone agonists in premenopausal hormone receptorpositive breast cancer. Clin Breast Cancer 7(6):455–464

186 60. Klijn JG et al (2001) Combined tamoxifen and luteinizing hormone-releasing hormone (LHRH) agonist versus LHRH agonist alone in premenopausal advanced breast cancer: a meta-analysis of four randomized trials. J Clin Oncol 19(2):343–353 61. Davidson NE et al (2005) Chemoendocrine therapy for premenopausal women with axillary lymph node-positive, steroid hormone receptor-positive breast cancer: results from INT 0101 (E5188). J Clin Oncol 23(25):5973–5982 62. De Placido S et al (2005) A randomised factorial trial of sequential doxorubicin and CMF vs CMF and chemotherapy alone vs chemotherapy followed by goserelin plus tamoxifen as adjuvant treatment of node-positive breast cancer. Br J Cancer 92(3):467–474 63. Baum M et al (2006) Adjuvant goserelin in premenopausal patients with early breast cancer: results from the ZIPP study. Eur J Cancer 42(7):895–904 64. Adjuvant Breast Cancer Trials Collaborative Group (2007) Ovarian ablation or suppression in premenopausal early breast cancer: results from the international adjuvant breast cancer ovarian ablation or suppression randomized trial. J Natl Cancer Inst 99(7):516–525 65. Jonat W et al (2002) Goserelin versus cyclophosphamide, methotrexate, and fluorouracil as adjuvant therapy in premenopausal patients with node-positive breast cancer: the Zoladex early breast cancer research association study. J Clin Oncol 20(24):4628–4635 66. Castiglione-Gertsch M et al (2003) Adjuvant chemotherapy followed by goserelin versus either modality alone for premenopausal lymph node-negative breast cancer: a randomized trial. J Natl Cancer Inst 95(24):1833–1846 67. Dellapasqua S et al (2005) Adjuvant endocrine therapy for premenopausal women with early breast cancer. J Clin Oncol 23(8):1736–1750 68. Kaufmann M et al (2003) Survival analyses from the ZEBRA study. goserelin (Zoladex) versus CMF in premenopausal women with node-positive breast cancer. Eur J Cancer 39(12):1711–1717 69. Jakesz R et al (2002) Randomized adjuvant trial of tamoxifen and goserelin versus cyclophosphamide, methotrexate, and fluorouracil: evidence for the superiority of treatment with endocrine blockade in premenopausal patients with hormone-responsive breast cancer – Austrian breast and colorectal cancer study group trial 5. J Clin Oncol 20(24):4621–4627 70. Rutqvist, Zoladex and tamoxifen as adjuvant therapy in premenopausal breast cancer: a randomized trial by the cancer research campaign (C.R.C.) breast cancer trials group, the stockholm breast cancer study group, the South-East Sweden Breast Cancer Group & the Gruppo Interdisciplinare Valutazione Interventi in Oncologia (G.I.V.I.O). Proc Am Soc Clin Oncol 18:67a, 1999 (abstr 251) 71. Davidson N, Vukov A et al (1999) Effect of chemohormonal therapy in premenopausal node positive, receptor positive breast cancer: an eastern cooperative oncology group phase III intergroup trial (E5188. INT-0101). Proc Am Soc Clin Oncol 18:67a (abstr 249) 72. Mattsson W (1983) Current status of high dose progestin treatment in advanced breast cancer. Breast Cancer Res Treat 3(2):231–235

S.T. Maunglay et al. 73. Robertson JF et al (1999) Onapristone, a progesterone receptor antagonist, as first-line therapy in primary breast cancer. Eur J Cancer 35(2):214–218 74. Klijn JG, Setyono-Han B, Foekens JA (2000) Progesterone antagonists and progesterone receptor modulators in the treatment of breast cancer. Steroids 65(10–11):825–830 75. Coombes RC et al (1983) Danazol treatment for advanced breast cancer. Cancer Chemother Pharmacol 10(3): 194–195 76. Ingle JN et al (2006) Randomized trial of tamoxifen alone or combined with fluoxymesterone as adjuvant therapy in postmenopausal women with resected estrogen receptor positive breast cancer. North central cancer treatment group trial 89–30–52. Breast Cancer Res Treat 98(2): 217–222 77. Lonning PE et al (2001) High-dose estrogen treatment in postmenopausal breast cancer patients heavily exposed to endocrine therapy. Breast Cancer Res Treat 67(2): 111–116 78. Markman M et al (1996) Tamoxifen in platinumrefractory ovarian cancer: a gynecologic oncology group ancillary report. Gynecol Oncol 62(1):4–6 79. Rocereto TF et al (2000) Phase II study of mifepristone (RU486) in refractory ovarian cancer. Gynecol Oncol 77(3):429–432 80. McGonigle KF et al (1999) Ovarian histopathology in breast cancer patients receiving tamoxifen. Gynecol Oncol 73(3):402–406 81. (1987) The reduction in risk of ovarian cancer associated with oral-contraceptive use. The cancer and steroid hormone study of the centers for disease control and the national institute of child health and human development. N Engl J Med 316(11):650–655 82. (1983) Oral contraceptive use and the risk of ovarian cancer. The centers for disease control cancer and steroid hormone study. JAMA 249(12):1596–1599 83. Hankinson SE et al (1992) A quantitative assessment of oral contraceptive use and risk of ovarian cancer. Obstet Gynecol 80(4):708–714 84. Morrow CP et al (1991) Relationship between surgicalpathological risk factors and outcome in clinical stage I and II carcinoma of the endometrium: a gynecologic oncology group study. Gynecol Oncol 40(1):55–65 85. Bristow RE et al (2006) Salvage cytoreductive surgery for recurrent endometrial cancer. Gynecol Oncol 103(1): 281–287 86. Morris M et al (1996) Treatment of recurrent adenocarcinoma of the endometrium with pelvic exenteration. Gynecol Oncol 60(2):288–291 87. Barakat RR et al (1999) Pelvic exenteration for recurrent endometrial cancer. Gynecol Oncol 75(1):99–102 88. Piver MS et al (1980) Medroxyprogesterone acetate (Depo-Provera) vs. hydroxyprogesterone caproate (Delalutin) in women with metastatic endometrial adenocarcinoma. Cancer 45(2):268–272 89. Lentz SS et al (1996) High-dose megestrol acetate in advanced or recurrent endometrial carcinoma: a gynecologic oncology group study. J Clin Oncol 14(2):357–361 90. Utsunomiya H et al (2003) The correlation between the response to progestogen treatment and the expression of

9

Hormonal Therapy in Cancer

91.

92.

93.

94.

95.

96.

97.

98.

99.

100.

101.

102.

103. 104.

105. 106.

progesterone receptor B and 17beta-hydroxysteroid dehydrogenase type 2 in human endometrial carcinoma. Clin Endocrinol (Oxf) 58(6):696–703 Thigpen T et al (2001) Tamoxifen in the treatment of advanced or recurrent endometrial carcinoma: a gynecologic oncology group study. J Clin Oncol 19(2): 364–367 Pandya KJ et al (2001) Megestrol and tamoxifen in patients with advanced endometrial cancer: an eastern cooperative oncology group study (E4882). Am J Clin Oncol 24(1):43–46 Rendina GM et al (1984) Tamoxifen and medroxyprogesterone therapy for advanced endometrial carcinoma. Eur J Obstet Gynecol Reprod Biol 17(4):285–291 McMeekin DS et al (2003) A phase II trial of arzoxifene, a selective estrogen response modulator, in patients with recurrent or advanced endometrial cancer. Gynecol Oncol 90(1):64–69 Ma BB et al (2004) The activity of letrozole in patients with advanced or recurrent endometrial cancer and correlation with biological markers – a study of the national cancer institute of Canada clinical trials group. Int J Gynecol Cancer 14(4):650–658 Rose PG et al (2000) A phase II trial of anastrozole in advanced recurrent or persistent endometrial carcinoma: a gynecologic oncology group study. Gynecol Oncol 78(2):212–216 Nordstrom B et al (2006) Exemestane in advanced and recurrent endometrial carcinoma. A phase II study. J Clin Oncol (Meeting Abstracts) 24: 5042 Burnett AF, Bahador A, Amezcua C (2004) Anastrozole, an aromatase inhibitor, and medroxyprogesterone acetate therapy in premenopausal obese women with endometrial cancer: a report of two cases successfully treated without hysterectomy. Gynecol Oncol 94(3): 832–834 Lhomme C et al (1999) A multicenter phase II study with triptorelin (sustained-release LHRH agonist) in advanced or recurrent endometrial carcinoma: a French anticancer federation study. Gynecol Oncol 75(2):187–193 Asbury RF et al (2002) Goserelin acetate as treatment for recurrent endometrial carcinoma: a gynecologic oncology group study. Am J Clin Oncol 25(6):557–560 Covens A et al (1997) A phase II study of leuprolide in advanced/recurrent endometrial cancer. Gynecol Oncol 64(1):126–129 Thigpen JT et al (1999) Oral medroxyprogesterone acetate in the treatment of advanced or recurrent endometrial carcinoma: a dose-response study by the gynecologic oncology group. J Clin Oncol 17(6):1736–1744 Sutton GP et al (1986) Estrogen and progesterone receptors in uterine sarcomas. Obstet Gynecol 68(5):709–714 Wade K et al (1990) Uterine sarcoma: steroid receptors and response to hormonal therapy. Gynecol Oncol 39(3):364–367 Chu MC et al (2003) Low-grade endometrial stromal sarcoma: hormonal aspects. Gynecol Oncol 90(1):170–176 Pink D et al (2006) Harm or benefit of hormonal treatment in metastatic low-grade endometrial stromal sarcoma: single center experience with 10 cases and review of the literature. Gynecol Oncol 101(3):464–469

187 107. Maluf FC et al (2001) Endometrial stromal sarcoma: objective response to letrozole. Gynecol Oncol 82(2): 384–388 108. Leunen M et al (2004) Low-grade endometrial stromal sarcoma treated with the aromatase inhibitor letrozole. Gynecol Oncol 95(3):769–771 109. Spano JP et al (2003) Long-term survival of patients given hormonal therapy for metastatic endometrial stromal sarcoma. Med Oncol 20(1):87–93 110. Samson DJ et al (2002) Systematic review and metaanalysis of monotherapy compared with combined androgen blockade for patients with advanced prostate carcinoma. Cancer 95(2):361–376 111. Adegbite AB et al (1983) The recurrence of intracranial meningiomas after surgical treatment. J Neurosurg 58(1):51–56 112. Mirimanoff RO et al (1985) Meningioma: analysis of recurrence and progression following neurosurgical resection. J Neurosurg 62(1):18–24 113. Grunberg SM et al (1991) Treatment of unresectable meningiomas with the antiprogesterone agent mifepristone. J Neurosurg 74(6):861–866 114. Koide SS (1998) Mifepristone. Auxiliary therapeutic use in cancer and related disorders. J Reprod Med 43(7): 551–560 115. Grunberg SM et al (2006) Long-term administration of mifepristone (RU486): clinical tolerance during extended treatment of meningioma. Cancer Invest 24(8):727–733 116. Aniszewski JP et al (2001) Cushing syndrome due to ectopic adrenocorticotropic hormone secretion. World J Surg 25(7):934–940 117. Ilias I et al (2005) Cushing’s syndrome due to ectopic corticotropin secretion: twenty years’ experience at the national institutes of health. J Clin Endocrinol Metab 90(8):4955–4962 118. Isidori AM et al (2006) The ectopic adrenocorticotropin syndrome: clinical features, diagnosis, management, and long-term follow-up. J Clin Endocrinol Metab 91(2): 371–377 119. Miller CA, Ellison EC (1998) Therapeutic alternatives in metastatic neuroendocrine tumors. Surg Oncol Clin N Am 7(4):863–879 120. Lehnert T (1998) Liver transplantation for metastatic neuroendocrine carcinoma: an analysis of 103 patients. Transplantation 66(10):1307–1312 121. Winquist EW et al (1995) Ketoconazole in the management of paraneoplastic Cushing’s syndrome secondary to ectopic adrenocorticotropin production. J Clin Oncol 13(1):157–164 122. Krakoff J et al (2001) Use of a parenteral propylene glycol-containing etomidate preparation for the longterm management of ectopic Cushing’s syndrome. J Clin Endocrinol Metab 86(9):4104–4108 123. Drake WM et al (1998) Emergency and prolonged use of intravenous etomidate to control hypercortisolemia in a patient with Cushing’s syndrome and peritonitis. J Clin Endocrinol Metab 83(10):3542–3544 124. Hearn PR et al (1988) Lung carcinoid with Cushing’s syndrome: control of serum ACTH and cortisol levels using SMS 201–995 (sandostatin). Clin Endocrinol (Oxf) 28(2):181–185

188 125. Bertagna X et al (1989) Suppression of ectopic adrenocorticotropin secretion by the long-acting somatostatin analog octreotide. J Clin Endocrinol Metab 68(5): 988–991 126. Krenning EP et al (1993) Somatostatin receptor scintigraphy with [111In-DTPA-D-Phe1]- and [123I-Tyr3]octreotide: the Rotterdam experience with more than 1000 patients. Eur J Nucl Med 20(8):716–731 127. Nieman LK et al (1985) Successful treatment of Cushing’s syndrome with the glucocorticoid antagonist RU 486. J Clin Endocrinol Metab 61(3):536–540 128. Vella A et al (2001) Laparoscopic adrenalectomy for adrenocorticotropin-dependent Cushing’s syndrome. J Clin Endocrinol Metab 86(4):1596–1599 129. Leong WL, Pasieka JL (2002) Regression of metastatic carcinoid tumors with octreotide therapy: two case reports and a review of the literature. J Surg Oncol 79(3):180–187 130. Ricci S et al (2000) Long-acting depot lanreotide in the treatment of patients with advanced neuroendocrine tumors. Am J Clin Oncol 23(4):412–415 131. Arnold R et al (2005) Octreotide versus octreotide plus interferon-alpha in endocrine gastroenteropancreatic tumors: a randomized trial. Clin Gastroenterol Hepatol 3(8):761–771 132. Frank M et al (1999) Combination therapy with octreotide and alpha-interferon: effect on tumor growth in metastatic endocrine gastroenteropancreatic tumors. Am J Gastroenterol 94(5):1381–1387 133. Janson ET, Oberg K (1993) Long-term management of the carcinoid syndrome. Treatment with octreotide alone and in combination with alpha-interferon. Acta Oncol 32(2):225–229 134. Berezin M et al (1984) Reduction of follicle-stimulating hormone (FSH) secretion in FSH-producing pituitary adenoma by bromocriptine. J Clin Endocrinol Metab 59(6):1220–1223 135. Vance ML, Ridgway EC, Thorner MO (1985) Folliclestimulating hormone- and alpha-subunit-secreting pituitary tumor treated with bromocriptine. J Clin Endocrinol Metab 61(3):580–584 136. Beckers A et al (1992) Treatment of macroprolactinomas with the long-acting and repeatable form of bromocriptine: a report on 29 cases. J Clin Endocrinol Metab 75(1):275–280 137. Webster J et al (1994) A comparison of cabergoline and bromocriptine in the treatment of hyperprolactinemic amenorrhea. Cabergoline comparative study group. N Engl J Med 331(14):904–909 138. Biller BM et al (1996) Treatment of prolactin-secreting macroadenomas with the once-weekly dopamine agonist cabergoline. J Clin Endocrinol Metab 81(6):2338–2343 139. Verhelst J et al (1999) Cabergoline in the treatment of hyperprolactinemia: a study in 455 patients. J Clin Endocrinol Metab 84(7):2518–2522 140. Schade R et al (2007) Dopamine agonists and the risk of cardiac-valve regurgitation. N Engl J Med 356(1):29–38 141. Zanettini R et al (2007) Valvular heart disease and the use of dopamine agonists for Parkinson’s disease. N Engl J Med 356(1):39–46 142. van der Lely AJ, Brownell J, Lamberts SW (1991) The efficacy and tolerability of CV 205–502 (a nonergot

S.T. Maunglay et al.

143.

144.

145.

146.

147.

148.

149.

150.

151.

152.

153.

154.

155.

156.

157.

158.

159.

dopaminergic drug) in macroprolactinoma patients and in prolactinoma patients intolerant to bromocriptine. J Clin Endocrinol Metab 72(5):1136–1141 Bassetti M et al (1986) Morphological studies on mixed growth hormone (GH)- and prolactin (PRL)-secreting human pituitary adenomas. Coexistence of GH and PRL in the same secretory granule. J Clin Endocrinol Metab 62(6):1093–1100 Ritzen EM et al (1985) Management of pituitary gigantism. The role of bromocriptine and radiotherapy. Acta Paediatr Scand 74(5):807–814 Abs R et al (1998) Cabergoline in the treatment of acromegaly: a study in 64 patients. J Clin Endocrinol Metab 83(2):374–378 Nanto-Salonen K et al (1999) Suppression of GH secretion in pituitary gigantism by continuous subcutaneous octreotide infusion in a pubertal boy. Acta Paediatr 88(1):29–33 Morange I et al (1994) Slow release lanreotide treatment in acromegalic patients previously normalized by octreotide. J Clin Endocrinol Metab 79(1):145–151 Rix M et al (2005) Pegvisomant therapy in pituitary gigantism: successful treatment in a 12-year-old girl. Eur J Endocrinol 153(2):195–201 van der Lely AJ et al (2001) Long-term treatment of acromegaly with pegvisomant, a growth hormone receptor antagonist. Lancet 358(9295):1754–1759 Trainer PJ et al (2000) Treatment of acromegaly with the growth hormone-receptor antagonist pegvisomant. N Engl J Med 342(16):1171–1177 Dewys WD et al (1980) Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern cooperative oncology group. Am J Med 69(4):491–497 Bruera E et al (1985) Action of oral methylprednisolone in terminal cancer patients: a prospective randomized double-blind study. Cancer Treat Rep 69(7–8):751–754 Popiela T, Lucchi R, Giongo F (1989) Methylprednisolone as palliative therapy for female terminal cancer patients. The methylprednisolone female preterminal cancer study group. Eur J Cancer Clin Oncol 25(12):1823–1829 Yavuzsen T et al (2005) Systematic review of the treatment of cancer-associated anorexia and weight loss. J Clin Oncol 23(33):8500–8511 Loprinzi CL et al (1999) Randomized comparison of megestrol acetate versus dexamethasone versus fluoxymesterone for the treatment of cancer anorexia/cachexia. J Clin Oncol 17(10):3299–3306 Takala J et al (1999) Increased mortality associated with growth hormone treatment in critically ill adults. N Engl J Med 341(11):785–792 Sirohi B et al (2007) Use of physiological doses of human growth hormone in haematological patients receiving intensive chemotherapy promotes haematopoietic recovery: a double-blind randomized, placebo-controlled study. Bone Marrow Transplant 39(2):115–120 Dehm SM, Tindall DJ (2007) Androgen receptor structural and functional elements: role and regulation in prostate cancer. Mol Endocrinol 21(12):2855–2863 Huggins C, Hodges CV (1972) Studies on prostatic cancer. I. The effect of castration, of estrogen and androgen

9

Hormonal Therapy in Cancer

160. 161.

162.

163.

164.

165.

166.

167.

168.

169.

170. 171.

172.

173.

174.

175.

injection on serum phosphatases in metastatic carcinoma of the prostate. CA Cancer J Clin (reprint from 1941) 22(4):232–240 Debruyne F (2002) Hormonal therapy of prostate cancer. Semin Urol Oncol 20(3 Suppl 1):4–9 Seidenfeld J et al (2000) Single-therapy androgen suppression in men with advanced prostate cancer: a systematic review and meta-analysis. Ann Intern Med 132(7):566–577 Keating NL, O’Malley AJ, Smith MR (2006) Diabetes and cardiovascular disease during androgen deprivation therapy for prostate cancer. J Clin Oncol 24(27):4448–4456 Lin BJ et al (1994) The time for serum testosterone to reach castrate level after bilateral orchiectomy or oral estrogen in the management of metastatic prostatic cancer. Urology 43(6):834–837 Byar DP, Corle DK (1988) Hormone therapy for prostate cancer: results of the veterans administration cooperative urological research group studies. NCI Monogr 7: 165–170 Higano C (2006) Androgen deprivation therapy: monitoring and managing the complications. Hematol Oncol Clin North Am 20(4):909–923 Chrisp P, Sorkin EM (1991) Leuprorelin. A review of its pharmacology and therapeutic use in prostatic disorders. Drugs Aging 1(6):487–509 Labrie F et al (1984) Simultaneous administration of pure antiandrogens, a combination necessary for the use of luteinizing hormone-releasing hormone agonists in the treatment of prostate cancer. Proc Natl Acad Sci USA 81(12):3861–3863 Thorpe SC et al (1996) A prospective, randomised study to compare goserelin acetate (Zoladex) versus cyproterone acetate (Cyprostat) versus a combination of the two in the treatment of metastatic prostatic carcinoma. Eur Urol 29(1):47–54 (1997) Immediate versus deferred treatment for advanced prostatic cancer: initial results of the medical research council trial. The medical research council prostate cancer working party investigators group. Br J Urol 79(2): 235–246 Brawer MK (2006) Hormonal therapy for prostate cancer. Rev Urol 8(Suppl 2):S35–S47 Messing EM et al (2006) Immediate versus deferred androgen deprivation treatment in patients with nodepositive prostate cancer after radical prostatectomy and pelvic lymphadenectomy. Lancet Oncol 7(6):472–479 Moul JW, Ward JF (2006) Management of the patient with a rising PSA alone. Hematol Oncol Clin North Am 20(4):897–908 Moul JW et al (2004) Early versus delayed hormonal therapy for prostate specific antigen only recurrence of prostate cancer after radical prostatectomy. J Urol 171(3):1141–1147 Grossfeld GD et al (2001) Intermittent androgen deprivation: update of cycling characteristics in patients without clinically apparent metastatic prostate cancer. Urology 58(2):240–245 de Leval J et al (2002) Intermittent versus continuous total androgen blockade in the treatment of patients with advanced hormone-naive prostate cancer: results of a

189

176.

177.

178.

179.

180.

181. 182.

183.

184.

185.

186.

187.

188.

189.

190.

191.

192.

193.

prospective randomized multicenter trial. Clin Prostate Cancer 1(3):163–171 Hurtado-Coll A et al (2002) Intermittent androgen suppression in prostate cancer: the Canadian experience. Urology 60(3 Suppl 1):52–56; discussion 56 Higano CS et al (1996) Intermittent androgen suppression with leuprolide and flutamide for prostate cancer: a pilot study. Urology 48(5):800–804 Loblaw DA et al (2007) Initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2006 update of an American society of clinical oncology practice guideline. J Clin Oncol 25(12):1596–1605 Lee AK, Frank SJ (2006) Update on radiation therapy in prostate cancer. Hematol Oncol Clin North Am 20(4):857–878 Msaouel P et al (2007) Luteinising hormone-releasing hormone antagonists in prostate cancer therapy. Expert Opin Emerg Drugs 12(2):285–299 Trachtenberg J (2001) Emerging pharmacologic therapies for prostate cancer. Rev Urol 3(Suppl 3):S23–S28 Wellington K, Keam SJ (2007) Spotlight on bicalutamide 150 mg in the treatment of locally advanced prostate cancer. Drugs Aging 24(2):169–171 McLeod DG et al (2006) Bicalutamide 150 mg plus standard care vs standard care alone for early prostate cancer. BJU Int 97(2):247–254 Tyrrell CJ et al (1998) A randomised comparison of ‘Casodex’ (bicalutamide) 150 mg monotherapy versus castration in the treatment of metastatic and locally advanced prostate cancer. Eur Urol 33(5):447–456 (2000) Maximum androgen blockade in advanced prostate cancer: an overview of the randomised trials. Prostate cancer trialists’ collaborative group. Lancet 355(9214): 1491–1498 Schmitt BBC, Seidenfeld J, Samson D, Wilt T (1999) Maximal androgen blockade for advanced prostate cancer. Cochrane Database Syst Rev 2(CD001526). doi:10.1002/14651858.CD001526 Klotz L, Schellhammer P, Carroll K (2004) A reassessment of the role of combined androgen blockade for advanced prostate cancer. BJU Int 93(9):1177–1182 Labrie F et al (1988) Benefits of combination therapy with flutamide in patients relapsing after castration. Br J Urol 61(4):341–346 Kucuk O et al (2001) Phase II trial of bicalutamide in patients with advanced prostate cancer in whom conventional hormonal therapy failed: a southwest oncology group study (SWOG 9235). Urology 58(1): 53–58 Kelly WK, Scher HI (1993) Prostate specific antigen decline after antiandrogen withdrawal: the flutamide withdrawal syndrome. J Urol 149(3):607–609 Joyce R et al (1998) High dose bicalutamide for androgen independent prostate cancer: effect of prior hormonal therapy. J Urol 159(1):149–153 Taylor CD, Elson P, Trump DL (1993) Importance of continued testicular suppression in hormone-refractory prostate cancer. J Clin Oncol 11(11):2167–2172 De Coster R et al (1986) Effects of high dose ketoconazole therapy on the main plasma testicular and adrenal

190 steroids in previously untreated prostatic cancer patients. Clin Endocrinol (Oxf) 24(6):657–664 194. Eichenberger T et al (1989) Ketoconazole: a possible direct cytotoxic effect on prostate carcinoma cells. J Urol 141(1):190–191 195. Harris KA et al (2002) Low dose ketoconazole with replacement doses of hydrocortisone in patients with progressive androgen independent prostate cancer. J Urol 168(2):542–545

S.T. Maunglay et al. 196. Small EJ et al (2004) Antiandrogen withdrawal alone or in combination with ketoconazole in androgen-independent prostate cancer patients: a phase III trial (CALGB 9583). J Clin Oncol 22(6):1025–1033 197. Small EJ et al (1997) Ketoconazole retains activity in advanced prostate cancer patients with progression despite flutamide withdrawal. J Urol 157(4):1204–1207

Chapter 10

Effects of Cancer Chemotherapy on Gonadal Function Angela R. Bradbury and Richard L. Schilsky

10.1 Introdution During the past 20 years, major strides have been made in the treatment of neoplastic disease with cytotoxic chemotherapy. Progress in understanding tumor cell biology and mechanisms of drug resistance, the introduction of new, effective antineoplastic drugs and technological advances that allow for more detailed and complete pharmacogenetic studies have all contributed to the successful application of cancer chemotherapy. Many patients with Hodgkin’s disease, acute leukemia, non-Hodgkin’s lymphoma, testicular cancer and other tumors now regularly achieve sustained clinical remissions and cures. Moreover, adjuvant chemotherapy is now commonly employed for treatment of micrometastatic disease in clinically well patients with breast cancer, colorectal cancer, lung cancer and soft tissue sarcoma and decreases the relapse rate and prolongs survival for many individuals. Thus many more patients currently receive chemotherapy than ever before and, of greater significance, many more individuals are cured of their tumors and survive to experience the potential late adverse effects of such treatment. Among these, infertility and mutagenesis are often of particular concern to cancer survivors who have new hopes and expectations for a return to normal life style. This chapter will review the effects of cancer chemotherapy on the gonadal function, sexuality and progeny of patients treated for malignant disease.

A.R. Bradbury () Department of Medicine, Fox Chase Cancer Center, Philadelphia, PA 19111, USA e-mail: [email protected]

10.2 Effects of Cancer Chemotherapy on Gonadal Function Neoplastic disease and its treatment can potentially interfere with any of the cellular, anatomic, physiologic or behavioral processes that comprise normal sexual function. The nature of the patient’s illness, the extent of necessary surgery or radiation therapy, and the patient’s relationship with spouse and family may all play an important role in reestablishing normal sexual interest and function following treatment for cancer. Further, many drugs used in the treatment of malignant disease have profound and often lasting effects on the testis and ovary. Germ cell production and endocrine function may both be altered, with the magnitude of the effect related to the age, pubertal status and menstrual status of the patient as well as to the particular drug, dosage or combination administered.

10.2.1 Chemotherapy Effects in Men The normal adult testis is an organ composed of diverse and highly specialized cell types, which may vary in their sensitivity to cytotoxic drugs. The exocrine function of the gland, spermatogenesis, proceeds in the seminiferous tubules, while the interstitial cells of Leydig carry out the primary endocrine function of the testis, testosterone production [1]. The seminiferous tubules, which constitute 75% of the testicular mass, are lined by stratified epithelium composed of two cell types: spermatogenic cells and Sertoli cells. The spermatogenic cells are arranged in an orderly fashion; spermatogonia lie

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_10, © Springer Science+Business Media B.V. 2011

191

192

directly on the tubular basement membrane, while primary and secondary spermatocytes, spermatids, and maturing spermatozoa progress centrally toward the tubular lumen. Sertoli cells also lie on the basement membrane and serve to regulate the release of mature spermatozoa from the germinal epithelium as well as to maintain the integrity of the blood-testis barrier. Spermatogenesis is a dynamic and complex process which may be divided into three phases: (1) proliferation of spermatogonia to produce spermatocytes and to renew the germ cell pool; (2) meiotic division of spermatocytes to reduce the chromosome number in the germ cells by half; and (3) maturation of the spermatids to become spermatozoa [2]. Cytotoxic drugs could potentially effect this process in a number of ways: (1) a specific cell type within the germinal epithelium might be selectively damaged or destroyed; (2) the proliferative and meiotic phases of spermatogenesis might proceed normally, but sperm maturation might be abnormal, leading to functionally incompetent mature spermatozoa; or (3) chemotherapy might damage Sertoli cells, Leydig cells or other supportive or nutritive constituents of the testis in such a way as to alter the particular microenvironment necessary for normal germ cell production.

A.R. Bradbury and R.L. Schilsky

after doxorubicin administration revealed an absence of pachytene primary spermatocytes, indicating that type A2 (primitive) spermatogonia are most sensitive to injury by that drug [3]. Similar analysis after cisplatin administration demonstrated that intermediate spermatogonia are most sensitive to cisplatin and that at high doses (10 mg/kg), even late-stage spermatids may be affected, suggesting the occurrence of Sertoli cell damage at this dose level [4]. Following administration of 5-fluorouricil (5-FU), spermatogonial damage is not seen; rather arrest of spermatid development is noted [5]. Failure of sperm release from the germinal epithelium has been observed after the administration of 5-FU, cisplatin, doxorubicin, or methotrexate (MTX), suggesting Sertoli cell damage by all these agents [5]. Serial mating studies, whereby animals are mated at varying intervals after drug administration and the onset of infertility is noted, can provide similar, though less precise information. In the rat, an infertile mating occurring six to seven weeks after drug treatment implies that spermatocytes were primarily affected by the drug in question, whereas infertility occurring ten weeks after drug treatment reflects spermatogonial destruction [6, 7].

10.2.3 Clinical Assessment 10.2.2 Animal Models With knowledge of the normal histology of the germinal epithelium and of the kinetics of spermatogenesis, it is possible to estimate the specific site of a drug’s effect, either by examining the testis microscopically or by performing sperm counts or mating studies at some interval after administration of the drug. The morphology of the spermatids can be used to define the stage of the germinal epithelial cycle at the time of biopsy, and the presence or absence of cells expected to occur in association with those spermatids can be noted. Flow cytometry can also be used to examine the DNA content and cell-cycle progression of spermatogenic cells obtained from animals injected with bromodeoxyurdine. Known kinetic parameters can then be used to determine precisely which spermatogenic cell was destroyed by drug administration. For example, examination of mouse testes 11 days

Testicular function in patients receiving cancer chemotherapy can be adequately evaluated with a careful physical examination, semen analysis and determination of serum gonadotropin and testosterone levels (Table 10.1). Occasionally, testicular biopsy is necessary to complete the evaluation. Since the seminiferous tubules comprise such a large portion of the testicular mass, damage to the germinal epithelium frequently results in testicular atrophy, which is readily detected on physical exam. Impaired spermatogenesis is also manifest as a decrease in the number and/or motility of sperm present in the ejaculate and, since pituitary gonadotropin secretion is under feedback control by the testis, an increase in serum follicle stimulating hormone (FSH) level [8, 9]. Leydig cell dysfunction may also occur and is detected by an increase in serum luteinizing hormone (LH) level, and if uncompensated, a fall in serum testosterone level. Subclinical

10 Effects of Cancer Chemotherapy on Gonadal Function Table 10.1 Evaluation of the patient with germinal aplasia Normal Germinal aplasia Testicular Size Length × width (cm) Volume (cc) Sperm count (106/ml) FSH (mIU/ml) LH (mIU/ml) LH response to LH-RH Testosterone (ng/dl)

5.0 × 3.0 16–30 20–100 4–25 4–20 Normal 250–1200

3.7 × 2.3 8–15 0 25–90 8–25 Exaggerated 200–700

abnormalities of Leydig cell function may occasionally be demonstrated by administration of LH releasing hormone. An excessive rise in serum LH levels in this provocative test suggests the presence of abnormal Leydig cell function [10–13].

10.2.4 Drug Effects on Spermatogenesis Following cytotoxic chemotherapy, there appear to be common histopathologic changes that occur in the testis, independent of the type of drug employed but related to the total dose administered. The primary testicular lesion caused by all antitumor agents studied thus far is depletion of the germinal epithelium lining the seminiferous tubules [14–18]. Testicular biopsy in most patients reveals complete germinal aplasia with only Sertoli cells left lining the tubular lumens. Occasionally, scattered spermatogonia, spermatocytes or spermatids may be seen or there may be evidence for maturation arrest occurring at the spermatocyte stage. This latter finding appears most often in patients receiving short courses of chemotherapy with antimetabolites [19]. 10.2.4.1 Drugs Highly Toxic to the Germinal Epithelium Among the anticancer drugs, alkylating agents most consistently caused male infertility. In particular, chlorambucil and cyclophosphamide deplete the testicular germinal epithelium in a dose-related fashion. Progressive oligospermia occurs in men with lymphoma who are treated with up to 400 mg of chlorambucil [18], and those patients receiving cumulative doses in excess of 400 mg are uniformly azoospermic.

193

Similarly, decreased sperm counts may occur in men treated with 50–100 mg of cyclophosphamide daily for courses as brief as 2 months, although azoospermia and germinal aplasia are infrequent until higher doses have been administered. Rivkees and Crawford found that 80% of men treated with more than 300 mg/kg of single-agent cyclophosphamide developed gonadal dysfunction [20]. Despite a high incidence of damage to the germinal epithelium, partial or full recovery of gonadal function may be possible for some individuals [21, 22]. One study reported that 40% of men treated with cyclophosphamide-based regimens for sarcoma had recovery of spermatogenesis at 5 years, but only 10% had recovery when cumulative doses exceeded 7.5 g/m2 [23]. Several studies have suggested that procarbazine is particularly damaging to the germinal epithelium [24, 25]. Animal studies have shown that procarbazine is severely toxic to the germinal epithelium in adult male monkeys and rats [26, 27]. Human studies evaluating germinal damage after combination chemotherapy also suggest that procarbazine plays an important role in the development of chemotherapy-related infertility [24, 25]. Several other newer chemotherapy drugs have been recently evaluated with conflicting results. While one group suggested that ifosfamide may be less toxic to the germinal epithelium than cyclophosphamide [28], Longhi et al. evaluated the effect of ifosfamidebased regimens in men with osteosarcoma and found a higher rate of azoospermia with ifosfamide-based regimens when compared to combinations that did not include ifosfamide [29]. In addition, the incidence of azoospermia was related to the total ifosfamide dose. These studies suggest that ifosfamide, like other alkylating agents, has a dose-dependent effect on gonadal function. The effects of cisplatin alone on testicular function are difficult to discern, as the majority of men with testicular cancer have impaired spermatogenesis prior to therapy. While early studies suggested that patients with testicular cancer treated with cisplatin-based combination chemotherapy uniformly become severely oligospermic or azoospermic soon after chemotherapy is initiated [30–35], subsequent studies have suggested that higher doses of cisplatin, or more cycles of chemotherapy, are associated with more profound and persistent decreases in sperm counts [36, 37]. In a review of 5 published studies, DeSantis et al. determined that cumulative cisplatin doses less

194

than 400 mg/m2 were unlikely to cause azoospermia, while patients who received higher doses, or more than 4 cycles of chemotherapy, had a higher risk of impaired spermatogenesis when compared to controls [28]. Several groups have recently evaluated the gonadal toxicity of carboplatin. While animal studies suggested a dose-related effect on spermatogenesis similar to cisplatin [38], recent human studies suggest less effect on spermatogenesis with carboplatin-based regimens [39, 40]. Although single agent vincristine was thought to cause only temporary and reversible damage to the germinal epithelium and to have an additive effect when combined with other highly gonadotoxic agents, a recent multivariate analysis suggests that vincristine itself may have a significant effect on fertility [41]. Vincristine is rarely administered as a single-agent, and is often administered with other highly gonadotoxic agents, such as procarbazine. For this reason, it is difficult to assess the germinal toxicity of vincristine in humans.

10.2.4.2 Drugs with Low Toxicity to Male Germ Cells

A.R. Bradbury and R.L. Schilsky Table 10.2 Toxicity of single agents to male germ cells References Drugs highly toxic to male germ cells Chlorambucil Cyclophosphamide Ifosfamide Procarbazine Cisplatin Vincristine

[18, 21] [20, 22, 23] [28, 29] [24–27] [28, 30–40, 264, 265] [41]

Drugs with low toxicity to male germ cells Methotrexate Doxorubicin Interferon alpha-2β

[43, 46] [3, 42, 44, 45, 47–49] [266]

severe or irreversible testicular injury occurs. As newer agents are incorporated into standard cancer treatment programs, additional studies need to be completed to assess their effects on fertility.

10.2.5 Combination Chemotherapy and Disease-Specific Considerations 10.2.5.1 Lymphoma

Antimetabolites in conventional doses seem to have relatively few effects on spermatogenesis, although one study suggested that high-dose methotrexate (MTX 250 mg/kg) may produce transient oligospermia in some patients [42]. This modest effect of MTX on spermatogenesis may be due to the presence of a significant barrier to MTX passage from blood to seminiferous tubule [43]. While doxorubicin produces severe germinal epithelial injury in both the mouse [3] and the rat [44, 45], several reports have suggested that doxorubicin may be less toxic to the human testis than expected based on animal studies, with reversible testicular injury noted in the majority of patients under age 40 [46–49]. In considering individual agents, these data suggest that chemotherapeutic agents vary in toxicity to the germinal epithelium (Table 10.2). In addition, there appears to be a threshold dose for the development of testicular germinal aplasia for each particular drug. However, prospective studies of testicular function in large numbers of men receiving a variety of antitumor agents are needed to provide more reliable information concerning the threshold drug dose above which

As might be expected, combination chemotherapy regimens that include alkylating agents produce germinal aplasia and infertility in the majority of patients. This is clear in Hodgkin’s disease, where the effects of MOPP (nitrogen mustard, vincristine, procarbazine and prednisone) and a related regimen, MVPP (in which vinblastine replaces vincristine) have been extensively investigated. Sherins and DeVita first reported azoospermia or severe oligospermia in 3 of 16 men with lymphoma in complete remission 2 months to 7 years after MOPP, CVP (cyclophosphamide, vincristine and prednisone), or cyclophosphamide alone [50]. Subsequent studies have confirmed that at least 80% of men receiving MOPP combination chemotherapy develop azoospermia, germinal aplasia, testicular atrophy and elevated FSH levels [13, 51–54]. Patients who receive COPP (cyclophosphamide, vinblastine, procarbazine and prednisone) or ChlVPP (chlorambucil, vincristine, procarbazine and prednisolone) have significant gonadal dysfunction as well [55, 56]. Likewise, Chapman et al. found that all 74 men who received cyclic combination chemotherapy for

10 Effects of Cancer Chemotherapy on Gonadal Function

Hodgkin’s disease were azoospermic after treatment, and only four of 74 recovered spermatogenesis after a median follow-up of 27 months. A decline in libido and decreased sexual activity also occurred during therapy and only partially recovered after treatment [52]. Interpretation of this data is complicated by pretreatment azoospermia that occurs in at least 50% of men with advanced Hodgkin’s disease [52, 57]. While reversibility of gonadal dysfunction has been known to occur with single agent therapy, patients who receive combination chemotherapy are likely to develop long-lasting and frequently permanent infertility. Sherins and DeVita [50] noted azoospermia and testicular germinal aplasia in patients as long as 4 years after completion of MOPP chemotherapy. Others have confirmed these findings, and it seems reasonable to conclude that only about 10% of patients receiving MOPP or MVPP will ultimately have a return of spermatogenesis [58, 59]. A number of alternative combination chemotherapy regimens to MOPP have now been developed for the treatment of advanced Hodgkin’s disease. Among these ABVD (Adriamycin, bleomycin, vinblastine, dacarbazine) has been shown to be more efficacious and less toxic than the MOPP regimen. A comparison of these regimens revealed that azoospermia occurs in 100% of patients treated with MOPP, but in only 35% of patients receiving ABVD. In addition, recovery of spermatogenesis occurs rarely in MOPP-treated patients but nearly always in those treated with ABVD [60–62]. Hybrid regimens of MOPP or COPP and ABVD also produce persistent testicular dysfunction, with 60–80% of patients experiencing prolonged germinal damage [57, 61]. Unlike patients with Hodgkin’s disease, those with non-Hodgkin’s lymphoma often have normal pretreatment sperm counts and motility [63]. Regimens containing modest doses of cyclophosphamide such as MACOP-B (MTX-leucovorin, Adriamycin, cyclophosphamide, vincristine, prednisone and bleomycin) or VACOP-B (including vinblastine rather than MTX) have produced only transient azoospermia, with recovery of spermatogenesis in 100% of patients at a mean of 28 months after completion of chemotherapy [63]. However, with the standard cyclophosphamide-based regimens, sperm counts recovered in only two-thirds of patients at 7 years. [64]. A small study evaluating 14 patients who received VAPEC-B (vincristine,

195

doxorubicin, prednisolone, etoposide, cyclophosphamide and bleomycin) for either Hodgkin’s disease or non-Hodgkin’s lymphoma reported only 1 case of azoospermia in a patient who also received pelvic radiation therapy [65]. As new regimens are developed, they will need to be compared to standard regimens for efficacy. In addition, larger studies are necessary to confirm and compare the effects on spermatogenesis. This information may play an important role in treatment planning for young men with Hodgkin’s disease and non-Hodgkin’s lymphoma who are concerned about preservation of fertility during and after treatment.

10.2.5.2 Testicular Cancer Like patients with Hodgkin’s disease, patients with testicular cancer have a high rate of oligospermia prior to treatment. Studies have shown that up to 50% of men with testicular cancer have oligospermia at diagnosis [40, 66, 67]. Patients with testicular cancer treated with cisplatin-based combination chemotherapy uniformly become severely oligospermic or azoospermic soon after chemotherapy is initiated [30–35, 68]. Despite this immediate gonadal injury, there appears to be a high degree of reversibility of testicular dysfunction, with as many as 50% of patients demonstrating resumption of spermatogensis within 2 years of completing chemotherapy. Among 98 patients with testicular germ cell tumors, 28 were treated with cisplatinbased chemotherapy and had profound decreases in sperm counts 1 year later, but a return to pretreatment levels 3 years after completion of chemotherapy [69], paralleled by a normalization of FSH values. In a study with a median follow-up of 5 years, 27% of men who received PVB (cisplatin, vincristine and bleomycin) were azoospermic. While many studies suggest that recovery of spermatogenesis is rare after 2 years [33, 70], there have been reports of recovery of spermatogenesis and fertility long after completion of treatment [71, 72]. Higher doses of chemotherapy generally induce longer-lasting oligospermia [36]. As described above, patients who receive carboplatinbased therapy are more likely to recover spermatogenesis when compared to those who receive cisplatinbased therapy. Other predictors of recovery include normospermia prior to therapy and less than 5 cycles of chemotherapy [40].

196

10.2.5.3 High-Dose Chemotherapy and Bone Marrow Transplantation More information is now available regarding the impact of bone marrow transplantation conditioning regimens on fertility. In general, conditioning regimens involving total body irradiation appear to severely affect fertility, while gonadal recovery occurs in a portion of patients receiving chemotherapy-only conditioning regimens. In men receiving a preparative regimen of high-dose cyclophosphamide alone, potential for recovery of spermatogenesis is reasonably high. In 72 men who received this treatment in Seattle, 65% had a normal FSH and normal sperm counts, and 94% had normal serum LH and testosterone levels [73]. Recovery of spermatogenesis was not agerelated in this population. Recent studies evaluating different conditioning regimens found that 61–90% of men regain spermatogenesis within 3 years after single agent cyclophosphamide [74, 75]. Recovery of spermatogenesis was significantly lower in two studies that employed a busulfan-cyclophosphamide (Bu-Cy) conditioning regimen. While early studies using 200 mg/kg of cyclophosphamide reported a recovery rate of only 17% [74], more recent studies using a lower dose of cyclophosphamide (120 mg/kg + 16 mg/kg busulfan) have reported higher rates of recovery, ranging from 50–84% [75, 76]. Conditioning regimens combining cyclophosphamide with total body irradiation appear to severely affect gonadal function with only 17% of patients recovering spermatogenesis and never earlier than 4 years pos-treatment [75].

10.2.5.4 Leukemia There have been relatively few studies evaluating the gonadal effects of combination chemotherapy for acute lymphoblastic leukemia (ALL). An early study of 44 boys with ALL reported impaired spermatogenesis in 40% of patients and found that combinations including cyclophosphamide and cytosine arabinoside were associated with a higher likelihood of gonadal damage [77]. Quigley et al. also found severe germinal damage in 13 of 25 boys with ALL who received the modified LSA2 L2 protocol, a regimen including both cyclophosphamide and cytosine arabinoside [78]. Despite these discouraging results, other ALL

A.R. Bradbury and R.L. Schilsky

regimens have been associated with lower rates of gonadal damage. An aggressive eight-drug regimen, that did not contain procarbazine was used in the treatment of adult ALL and was associated with preservation of fertility in the majority of patients [79]. More recently, Wallace et al. evaluated 37 men who received combination chemotherapy for ALL in childhood. Only 6 men had evidence of severe germinal damage at a median follow-up of 10 years. In addition, all six had received either cyclophosphamide or cyclophosphamide and cytosine arabinoside [80], supporting the hypothesis that ALL regimens that exclude cyclophosphamide and cytosine arabinoside are less likely to cause permanent germinal aplasia.

10.3 Chemotherapy Effects in Women Oogenesis is the process of maturation of the primitive female germ cell to the mature ovum. This process occurs primarily during intrauterine life and involves multiple mitotic divisions to increase the number of germ cells, followed by the beginning of the first meiotic division, which will eventually reduce the diploid chromosome number to half before fertilization. At the time of birth, the oocytes are in the long prophase of their first meiotic division, and they remain in that state until the formation of a mature follicle before ovulation [81]. In the postnatal ovary, most of the ongoing cellular growth and replication is related to the growth and development of follicles. Primordial follicles develop during gestation and consist of a primary oocyte covered by a layer of mesenchymal cells called granulosa cells. At the time of birth, the ovary may contain 150,000–500,000 primordial follicles, many of which subsequently become atretic. From childhood to menopause, follicular growth occurs as a continuous process, with ovulation occurring in a cyclic fashion [82]. The granulosa cells surrounding the primary oocyte proliferate, follicular fluid accumulates, and the ovum completes its first meiotic division to become a secondary oocyte. At this time, the follicle is known as a secondary or graafian follicle. The follicle continues to enlarge until the time of ovulation. Those follicles not undergoing ovulation become atretic and regress. During the reproductive life of a woman, only

10 Effects of Cancer Chemotherapy on Gonadal Function

300–400 oocytes mature and are extruded in the process of ovulation; the remainder undergo some form of atresia.

10.3.1 Assessment of Ovarian Function The evaluation of chemotherapy effects on ovarian function is hampered by the relative inaccessibility of the ovary to biopsy. There is no readily available direct measurement of the female germ cell population analogous to sperm counts in men. Animal models have only recently been developed to assess the effects of cytotoxic drugs on ovarian function. Thus, one must rely primarily on menstrual and reproductive history and on determinations of serum hormone levels to assess the functional status of the ovary. Follicular growth and maturation and estradiol production are under regulatory control of the pituitary and hypothalamus. Pituitary FSH stimulates granulosa cells to replicate and produce estradiol. The midcycle LH surge promotes ovulation and the ruptured follicle becomes the corpus luteum, which produces progesterone thereby suppressing further LH secretion [83]. Drug-induced ovarian failure interrupts this delicate hormonal balance and results in abnormally low serum levels of estradiol and progesterone, markedly elevated levels of FSH and LH, amenorrhea and symptoms of estrogen deficiency. The primary histologic lesion noted in the ovaries of women receiving antineoplastic chemotherapy is ovarian fibrosis and follicle destruction [84, 85]. Clinically, amenorrhea ensues and is accompanied by elevation of serum FSH and LH levels and a fall in serum estradiol. Vaginal epithelial atrophy and endometrial hypoplasia occur, and patients may complain of menopausal symptoms such as vaginal dryness and dyspareunia.

197

follicle diameter, and a fall in serum estradiol and progesterone levels in rats receiving the drug [86]. Incubation of mouse oocytes with doxorubicin results in a series of morphologic and biochemical events resembling apoptosis. Indeed, functional bax protein appears to be necessary for doxorubicin-induced cell death to occur [87]. An in vitro model of cisplatin effects on primordial follicles found swelling of the pregranulosa cells and nuclei followed by disappearance of the lumen and oocyte. In addition, there was evidence of apoptosis in chemotherapy treated primordial follicles, but not in controls [88]. Evaluation of human ovaries after chemotherapy treatment reveals a decreased number of oocytes and diffuse fibrosis [85, 89]. These findings are similar to the changes observed in post-menopausal ovaries. Therefore, chemotherapy may reduce the population of oocytes available for follicular recruitment, resulting in progressive, irreversible ovarian failure, as ovarian germ cells can not be regenerated [90]. Others have suggested that there may be impairment of follicular maturation, depletion of primordial follicles, inhibition of pregranulosa cell proliferation or reduced granulosa cell steroid production in primordial follicles that could contribute to ovarian failure [84, 91, 92]. Improved understanding of the molecular events surrounding chemotherapyinduced ovarian failure might permit the development of strategies to prevent this complication of treatment.

10.3.3 Drug Effects on Ovarian Function The onset and duration of amenorrhea seem to be both dose and age-related. Generally, younger patients are able to tolerate larger cumulative drug doses before amenorrhea occurs and have a greater likelihood of resumption of menses when therapy is discontinued.

10.3.2 Animal Studies

10.3.4 Drugs Highly Toxic to Germ Cells

Although the exact mechanism of chemotherapy induced ovarian failure is unclear, it is likely to be the process of follicular growth and maturation that is most affected by cytotoxic chemotherapy. Cyclophosphamide has been noted to cause a doserelated depletion of antral follicles, a decrease in

Among the anticancer drugs, alkylating agents are the most frequent cause of ovarian dysfunction (Table 10.3). During the early clinical trials of busulfan, amenorrhea was a common side effect. Several investigators noted the onset of permanent amenorrhea among patients receiving busulfan in doses varying

198

A.R. Bradbury and R.L. Schilsky

Table 10.3 Toxicity of single agents to female germ cells. References Drugs highly toxic to female germ cells Busulfan Cyclophosphamide Melphalan

[93, 94] [95–97, 101] [267]

Drugs with moderate to low toxicity to female germ cells Methotrexate 5-FU Etoposide/vinca alkaloids Doxorubicin Cisplatin

[42] [101, 267] [106, 109] [107] [108–111]

form 0.5 to 14.0 mg/day for at least 3 months [93, 94]. The effects of cyclophosphamide on ovarian function in humans were first noted in the rheumatology literature, as early cessation of menses and menopausal symptoms developed in six of 33 patients treated for rheumatoid arthritis with daily cyclophosphamide for 6–40 months [95]. Subsequently, several investigators documented the occurrence of amenorrhea in at least 50% of premenopausal women receiving 40–120 mg of cyclophosphamide daily for an average of 18 months [96, 97]. Ovarian biopsy in some patients demonstrated arrest of follicular maturation and absence of ova. Studies of the use of adjuvant chemotherapy for the prevention of recurrence of breast cancer suggest that the onset of amenorrhea and the resumption of menses after cyclophosphamide are related to the age of the patient during chemotherapy and to the total dose administered [98–100]. Amenorrhea developed in 17 of 18 women treated with adjuvant cyclophosphamide for 13–14 months postoperatively [101]. Permanent cessation of menses occurred after a mean total dose of 5.2 g in all patients 40 years of age and older. Amenorrhea also developed in four of five women younger than age 40, but only after a mean cyclophosphamide dose of 9.3 g had been administered. Menses subsequently returned in two of these patients within 6 months of discontinuing therapy. Time to the development of amenorrhea also appears to be age-related after adjuvant treatment with alkylating agents [91, 102–105]. In women younger than 35 who received cyclophosphamide, methotrexate and 5-FU (CMF), mean time to the onset of amenorrhea is 5.54 months; for women aged 35–45 years, the mean time is 2.31 months, and in women older than age 45, amenorrhea

develops very quickly, with a mean onset of 1.01 months [102]. It seems, then, that alkylating agent chemotherapy accelerates the onset of menopause, particularly in older patients, whereas younger patients may tolerate higher total doses before amenorrhea becomes irreversible.

10.3.5 Drugs with Moderate to Low Toxicity to Germ Cells While many other chemotherapeutic agents have been evaluated for long-term ovarian toxicity, the majority of evidence comes from studying the effects of combination chemotherapy regimens. Therefore, it is often difficult to determine the contribution of individual agents. In general, chemotherapeutic agents that are cell cycle specific appear to have low gonadotoxicity in women. While many of these agents are toxic to reproductive germ cells in men, they do not have the same toxicity in women. This is likely because there is constant cell division during spermatogenesis, while in women, there is intermittent cell division involving only a small number of primary oocytes with each menstrual cycle. Among the antimetabolites, high-dose methotrexate and 5-fluorouracil (5-FU) have been evaluated and appear to have no immediate ovarian toxicity [42]. A study of single-agent 5-FU in nine breast cancer patients found no evidence of ovarian failure [101]. The effects of oral etoposide on ovarian function were evaluated in one study of 22 patients receiving this agent. Age-related oligo- or amenorrhea occurred in 41% of patients after a mean cumulative etoposide dose of 5 g [106]. Doxorubicin administration does not appear to have profound ovarian ablative effects [107]. Although platinum chemotherapeutic agents have notable gonadal toxicity in men, the data in women are limited and contradictory. Many studies suggest that the majority of women who receive platinum based chemotherapy have temporary amenorrhea, but resume normal menstrual function [108, 109], while other groups have reported persistent menstrual dysfunction after the administration of cisplatin-based therapies [110, 111]. The inconsistencies in the literature may be explained by differences in defining treatment related ovarian failure, the duration of follow-up, dose received and age at administration. It is clear that further studies are needed to determine the true impact

10 Effects of Cancer Chemotherapy on Gonadal Function

of platinum-based therapy on fertility. Although taxanes have become widely used in the treatment of breast cancer, there is little data regarding the ovarian toxicity of this class of chemotherapeutics. Early results of the BCIRG 001 trial reported that 51% of patients receiving TAC (docetaxel, Adriamycin, cyclophosphamide) developed amenorrhea∗ . These results are preliminary, follow-up is short and the definition of amenorrhea used in the study is unclear. Therefore, further studies are needed to draw definitive conclusions regarding the incidence of treatment related ovarian failure following taxane therapy.

10.3.6 Combination Chemotherapy and Disease-Specific Considerations 10.3.6.1 Breast Cancer Studies of adjuvant chemotherapy for breast cancer have yielded important information regarding the effects of dose and treatment duration on menstrual cycles. Evaluation of 95 premenopausal women who received cyclophosphamide, MTX, 5-FU, vincristine, and prednisone documented permanent amenorrhea in 70.5% of patients [112]. Women receiving chemotherapy for 12 weeks had a 55% incidence of amenorrhea, whereas 83% of women receiving a 36-week regimen were rendered amenorrheic. Breast cancer recurrence and mortality rates in women who experienced amenorrhea were lower than in those who continued to menstruate, even within each treatment group, suggesting a potential therapeutic benefit of ovarian ablation. However, the contribution of treatment-induced amenorrhea to the beneficial effects of adjuvant chemotherapy remains uncertain and controversial. In counseling women with newly diagnosed breast cancer regarding the risk of chemotherapy-related amenorrhea or ovarian failure, age and risk of recurrence must be considered. Age at treatment is the primary factor in predicting chemotherapy-induced amenorrhea and is the most relevant consideration when counseling women with premenopausal breast cancer. Several studies have shown that younger women have a higher likelihood of resuming their menses and maintaining future fertility. For example, CMF has been associated with persistent amenorrhea in 21–71% of women less than 40 years old, compared to 49–100% in those over age 40 [91].

199

Other groups have found low rates of persistent amenorrhea (0–4%) in women under the age of 30 who received CMF or doxorubicin-based therapy, rates of 50% in women between 30 and 40 years old, and rates of 86% and higher in women over 40 years old [113, 114]. Although the choice of adjuvant therapy is primarily dependent on disease characteristics, in the situation where subsequent fertility is of great importance to the patient, considering the likelihood of amenorrhea with different adjuvant regimens may be helpful. In general, studies suggest that the combination of cyclophosphamide, methotrexate and 5-fluorouracil (CMF) is the regimen with the highest likelihood of causing premature ovarian failure as up to 2/3 of premenopausal women who receive CMF will experience persistent amenorrhea [91]. An early study of doxorubicin-based adjuvant therapy reported persistent amenorrhea in 59% of women [113], but more recent studies have found lower rates of persistent amenorrhea, ranging from 34 to 51% of premenopausal women treated with doxorubicin or epirubicin-based regimens [91, 115]. Although rarely used today, low rates of persistent amenorrhea have been reported with melphalan-based regimens (9%) [91]. These rates ignore the wide variability likely secondary to age at the onset of treatment, so the probability based on the age of the patient must also be considered (Table 10.4).

10.3.6.2 Lymphoma The risk of ovarian failure after other combination chemotherapy for hematologic malignancies is also

Table 10.4 Rates of amenorrhea after adjuvant regimens for breast cancer <40 yo >= 40 yo References CMF <=30 yo Doxorubin- None based regimens

CAF/CEF AC Melphalan/5FU

40–61%

76–95%

[103], [91]

31–39 yo

>= 40 yo

References

33%

96%

[113]

All ages

References

32.8–51% 34% 9%

[91, 115] [91] [91]

200

clearly related to the age of the patient at the time of treatment. Overall, at least 50% of women treated with MOPP or related regimens become amenorrheic [116–123]. The cessation of menses is accompanied by elevations of serum FSH and LH consistent with primary ovarian failure. Apart from age, no clear differences have been noted between those women who become amenorrheic during therapy and those who do not. Moreover, the time of onset of amenorrhea seemed to be age-related; ovarian failure occurred within 1 year of discontinuing therapy in all patients 39 years of age or older, whereas in younger patients there was a gradual decrease in frequency of menses occurring more than several years after therapy. Another group found similar results, as 76% of women who received MOPP or a related hybrid combination of chlorambucil, vinblastine, prednisolone, procarbazine, doxorubicin, vincristine and etoposide developed amenorrhea during or immediately after treatment. Despite this, ten women later regained normal menstrual periods while 16 had permanent amenorrhea. The mean age at treatment among the ten with recovery was 25 years, while the mean age in the latter group was 36 years old, illustrating the importance of age at the time of therapy [123]. At present, it seems unlikely that those patients treated when younger than age 25 will experience any significant therapy-related ovarian dysfunction during the initial 5–10 years after the completion of therapy [124]. As in men, ABVD chemotherapy may be less likely to produce premature ovarian failure, although longer follow-up is required to be certain. In a study comparing MOPP to ABVD, 50% of the patients who received MOPP and were older than 30 years old developed prolonged amenorrhea. All the women who received MOPP under the age of thirty and all the women who received ABVD, regardless of age, had resumption of normal menstrual cycles [60]. Combination chemotherapy regimens for aggressive non-Hodgkin’s lymphoma do not consistently cause premature ovarian failure, perhaps because procarbazine is rarely included in such regimens [25]. Of ten women who received various combined modality regimens for non-Hodgkin’s lymphoma, only one developed gonadal dysfunction. Similarly, among seven women aged 35–43 treated with MACOP-B or VACOP-B for aggressive non-Hodgkin’s lymphoma, only one developed amenorrhea [63].

A.R. Bradbury and R.L. Schilsky

10.3.6.3 Ovarian Germ Cell Tumors Although malignant germ cell tumors of the ovary are rare, they principally occur during adolescence and early adulthood. Many patients receive combination chemotherapy, and the regimens used appear to cause relatively little ovarian toxicity. In one study, 70% of women maintained regular menses after treatment with a variety of regimens containing drugs such as actinomycin D, vincristine, and cyclophosphamide [125]. Low et al. evaluated 44 women, between the ages of 10 and 35 years old, who received conservative surgery followed by cisplatin based regimens. Although two-thirds experienced amenorrhea during therapy, 43 of 47 (91%) resumed normal menstrual periods after completion of therapy [108]. Other groups have reported similar results, and it appears that the majority of women who receive chemotherapy for germ cell tumors of the ovary will resume menstrual function [126–128]. 10.3.6.4 High-Dose Chemotherapy and Bone Marrow Transplantation The risk of treatment related ovarian failure after high-dose chemotherapy and bone marrow transplant appears to be largely related to age at the time of treatment. From the Seattle experience, cyclophosphamidecontaining preparative regimens for allogeneic bone marrow transplantation induced reversible amenorrhea in women younger than 26 years of age, but permanent amenorrhea in 67% of women older than age 26 [129]. Likewise, Schimmer et al. evaluated 17 premenopausal patients treated with a variety of conditioning regimens followed by autologous bone marrow transplant for predictors of ovarian failure. Of the 17, only 5 (29%) had a return of normal menstrual cycles. The mean age of those with recovery of ovarian function was 19 years, while mean age of those with persistent amenorrhea was 30 years. In their analysis, younger age at treatment was a statistically significant predictor of future ovarian function. The number of prior chemotherapy salvage regimens or number of regimens containing alkylating agents did not predict for permanent amenorrhea [130]. The majority of studies suggest that younger women, who receive chemotherapy-containing conditioning regimens will regain menstrual function, while the majority over age

10 Effects of Cancer Chemotherapy on Gonadal Function

26 will have treatment related infertility [63, 109, 131, 132]. On the other hand, studies have suggested that regimens using total-body irradiation (TBI) cause premature menopause in nearly all patients [129, 130, 133]. Although most studies have found that the specific chemotherapy conditioning regimen did not appear to affect future fertility, Singhal et al. reported a higher pregnancy rate among women who were conditioned with melphalan alone when compared to those who received other conditioning regimens. These authors suggested that this regimen is adequate for engraftment and may be less likely to cause treatment related ovarian failure [134]. Further studies are needed to confirm these results, as variations in permanent ovarian failure among chemotherapy conditioning regimens could be important to young women undergoing high-dose chemotherapy and bone marrow transplantation.

10.4 Counseling Patients 10.4.1 Assisted Reproductive Techniques (ART) for Men 10.4.1.1 Semen Cryopreservation Pretreatment sperm banking is presently the only proven means of preserving fertility for men who are to receive combination chemotherapy for cancer. While pretreatment sperm banking does not guarantee a successful pregnancy in future years, advances in management of male factor infertility have made pregnancy possible for many men who are not azoospermic [135]. One of the significant challenges for preserving fertility in male patients with cancer has been poor quality semen, even prior to treatment, as close to 50% of male cancer patients have reduced sperm quality prior to chemotherapy [52, 57, 136–140]. Men with testicular cancer and Hodgkin’s disease have significantly lower sperm motility and a higher incidence of azoospermia than men with other malignancies [140, 141]. A review of patients from a single cryopreservation center found that 9.6% of men with testicular cancer and 18% of men with Hodgkin’s disease were azoospermic prior

201

to chemotherapy [140]. The cause of impaired spermatogenesis in male cancer patients prior to therapy is unknown. Despite a high rate of abnormal sperm quality, the majority of male cancer patients have adequate parameters for sperm storage [142]. Recent studies have found that only 12–17% of referred male cancer patients are unable to donate sperm for cryopreservation due to severe azoospermia prior to therapy [140, 143]. In the past, minimal standards of sperm quality for crypreservation were used to maximize the chances of successful insemination, denying cryopreservation to many male cancer patients. More recent data suggest that despite poor semen quality at the time of cryopreservation, many cancer patients are able to have successful pregnancies using advanced reproductive techniques [144–148]. Therefore, many groups suggest that cryopreservation be offered to all male cancer patients as long as the sperm sample contains some motile spermatozoa, even if the quality is below the required minimum standard for IVF (2 × 106 ml) [142, 144, 149, 150]. Although the technology of freezing, preserving, and thawing human semen has advanced considerably, ultimate conception rates using preserved semen have been limited by artificial insemination techniques. In the past, classic artificial insemination by husband (AIH) of the female partner using thawed spermatozoa was the only insemination technique available. AIH requires high numbers of spermatozoa and high quality semen. Most early studies suggest that it is not very effective in subfertility secondary to sperm abnormalities [151, 152]. More recent studies have reported better cumulative pregnancy rates with this technique in male cancer patients, ranging from 20 to 45% [144]. Despite success for some patients, the majority of male cancer patients have inadequate sperm quantity or quality for this procedure. With advances in technology, in vitro fertilization became the standard procedure for men with male factor infertility. In vitro fertilization (IVF) can be used with low spermatozoa quantity or when female factors prevent successful AIH. The fertilization rate with IVF for male factor infertility, and specifically male cancer patients, has been reported at 57–60% [146, 153–155]. The newest advance is intracytoplasmic sperm injection (ICSI), a type of gamete micromanipulation. This procedure has revolutionized the treatment of male factor infertility and holds particular promise for azoospermic and

202

oligospermic cancer survivors. ICSI involves the direct injection of a single spermatozoa into the cytoplasm of an oocyte in the context of in vitro fertilization. In the setting of male factor infertility, pregnancy rates of 52% have been reported with ICSI. The take-homebaby rate has been estimated at 22–37% per cycle, comparable to the 30% rate of successful pregnancy per cycle with natural conception [156–158]. Lass et al. described their experience at a tertiary assisted conception center and reported successful pregnancies in all six cancer patients that returned for use of their cryopreserved sperm. Two were accomplished with AIH cycles, two with in vitro fertilization cycles and two with ICSI [140]. Despite the increased success of semen cryopreservation with ICSI, the utility of sperm banking has been questioned by several authors due to the low percentage of later use to achieve pregnancy [142, 159, 160]. A survey of male cancer survivors found that only 24% of men completed sperm banking prior to cancer treatment [161]. In addition, of those who complete sperm collection <10% returned to use their collected sperm for fertilization [142, 143, 162]. Regardless, many feel that sperm collection prior to therapy should still be pursued as the number of patients referred for cryopreservation has been increasing over the last several years, and the studies to date may be biased by a short period of follow-up [143]. In addition, a recent survey suggests that the low rate of referral may be related to a lack of discussion on the part of treating physicians, as fewer than 50% of practitioners were consistently discussing sperm banking with their male cancer patients [161]. If lack of information is the primary reason for not pursuing sperm banking, increased attention to, and education regarding sperm cryopreservation may increase the number of referrals and later use of cryopreserved sperm.

10.4.1.2 Tese Although the majority of patients are able to have sperm collected prior to therapy, there are a proportion of male cancer patients who are azoospermic prior to therapy and therefore unable to undergo standard semen collection. In addition, many men fail to have sperm collected prior to therapy and find themselves azoospermic after treatment. For these patients, sperm may be obtained through newer technologies

A.R. Bradbury and R.L. Schilsky

such as epididymal aspiration, testicular sperm extraction (TESE) or transrectal electroejaculation (TE). With TESE, testicular biopsy tissue is macerated, centrifuged, and examined for the presence of sperm. Recovery rates with TESE in patients with either complete germinal aplasia or maturation arrest on biopsy have ranged from 45 to 76%, presumably because of adjacent areas of intact spermatogenesis [163, 164]. The reported pregnancy rates with TESE and ICSI range from 30 to 40%, do not appear to be significantly altered by the source of sperm or the testicular history [163, 164], and are comparable to rates in men with non-obstructive azoospermia due to non-neoplastic disorders [164]. As this technology becomes more available, even men with long-standing azoospermia and absent sperm production may be able to father children. Some authors have advocated pretreatment TESE in azoospermic men as it is difficult to predict who will regain fertility after therapy, there is a theoretical teratogenic risk to offspring, and pretreatment banking can reduce fertility-related concerns for the future [164–166].

10.4.1.3 Testicular Germ Cell Transplantation Testicular germ cell transplantation is an additional experimental technique that may be available to male cancer patients in the future. This procedure was first developed in male mice, where spermatogonial stem cells were transferred into the seminiferous tubules of busulfan sterilized recipient animals [167]. Several animal studies have shown that spermatogonial stem cells can repopulate the seminiferous tubules with resumption of spermatogenesis and production of functional spermatozoa leading to natural live births in the recipient animals [167–169]. Human application has just begun and remains experimental. One group has cryopreserved testicular cells in 12 patients with lymphoma prior to therapy. To date, seven of these patients have completed therapy and have undergone transplantation of their cryopreserved stem cells into the intratesticular rete testes. The outcomes of these transplants have not yet been published, but there is great hope that this approach will be feasible in humans [167, 170]. Despite the great interest in testicular germ cell transplantation, there is a theoretical risk of disease transmission, especially in the setting of hematologic malignancies [171]. Tumor cell depletion techniques

10 Effects of Cancer Chemotherapy on Gonadal Function

are currently being developed to address this limitation. If successful, sperm cell transplantation may be a viable option for male cancer patients hoping to preserve their reproductive potential.

10.4.2 Assisted Reproductive Techniques (ART) for Women 10.4.2.1 Embryo Cryopreservation Prior to the development of embryo cryopreservation, no reliable techniques existed for women who wished to retain the ability to bear children following ovarian ablative chemotherapy. Embryo cryopreservation with later intrafallopian or intrauterine embryo transfer [172] is the only successful clinical approach to post-chemotherapy ovarian failure. Before initiation of chemotherapy, women may have oocytes harvested and fertilized in vitro with husband or donor sperm. The embryos can be stored in liquid nitrogen and thawed for implantation at a later date when the patient’s endometrium has been hormonally prepared. This option has been associated with pregnancy and take-home baby rates of 30–35% and 29%, respectively [173]. In women who did not have frozen zygotes or embryos stored before chemotherapy, donor ova are available for fertilization and implantation at specialized fertility centers. Unfortunately, while successful, there are several reasons that this procedure is not available for many women. Firstly, embryo cryopreservation requires a partner at the time of harvest. While an anonymous sperm donor is an alternative, for many women this is an unacceptable option. In addition, embryo cryopreservation is not an option for prepubertal or pubertal girls. Secondly, the time involved in ovarian stimulation, monitoring and oocyte retrieval requires a delay in beginning cancer treatment that many oncologists discourage. For this reason, some centers offer IVF only during breaks in treatment or after remission is achieved [174, 175]. Lastly, ovarian stimulation increases levels of estradiol [176, 177], and studies have suggested that breast cancer cell proliferation and dissemination can be induced by estrogen [178, 179]. For this reason, many oncologists feel that conventional stimulation programs are contraindicated in women with hormone responsive malignancies such as breast cancer.

203

For women with breast cancer, an alternative to standard IVF is natural IVF or oocyte retrieval without hyperstimulation. Unfortunately, unstimulated cycles generally only yield one or two metaphase II eggs. Hyperstimuation significantly increases the chance of a successful pregnancy and allows storage of multiple embryos for future transfer attempts. Alternative stimulation programs using tamoxifen and aromatase inhibitors to block the rise in estradiol have recently been evaluated and may be available in the future [177]. 10.4.2.2 Cryopreservation of Oocytes While embryo cryopreservation is the standard option, oocyte cryopreservation would benefit prepubertal girls and women without a partner at the time of oocyte retrieval. Embryo cryopreservation became the procedure of choice because embryos survive cryopreservation better than oocytes. Animal studies have shown that freezing and thawing of unfertilized oocytes results in changes in the zona pellucida, leading to decreased rates of fertilization [180]. With advances in cryopreservation media and conditions, oocyte freezing and storage have been partially successful in animals [180–182]. There are 26 pregnancies derived from cryopreserved oocytes reported in the literature [183]. Despite these successes, the overall pregnancy and delivery rates (4.7 and 3.1%) are too low for widespread clinical application. With continued advances, oocyte cryopreservation may become a valid reproductive option in the future. 10.4.2.3 Ovarian Tissue Cryopreservation and Transplantation As in men, germ cell transplantation is a technique that holds great promise for women anticipating treatment with potentially sterilizing chemotherapy. Ovarian autografting relies on the removal of oocyterich ovarian cortical tissue that is then slowly cooled and stored in a cryopreservative. At a later date, the tissue may be thawed and reimplanted near the fallopian tubes for potentially natural ovulation and fertilization. Ovarian tissue cryopreservation and transplantation offers several advantages over oocyte and embryo cryopreservation including a greater number of immature oocytes, elimination of the need for hormonal

204

stimulation and delays in therapy, and easier cryopreservation as follicles are small, lack a zona pellucida and are metabolically inactive and undifferentiated. In addition, ovarian cryopreservation can be offered to prepubertal and pubertal girls who are too young for stimulation [184], and could provide an alternative to hormone replacement therapy for patients who develop premature ovarian failure. Gosden’s group, which pioneered this technique, reported successful pregnancies in sheep, and other groups have had similar success in various animals [185, 186]. Although still investigational, applications with cryopreserved ovarian implants have begun in humans [187–189]. Cortical ovarian biopsies have been easily obtained in women via laparascopy without significant complications [109]. In addition, case reports and small series of successful ovarian autotransplants have been described [190–192]. Despite these successes, this procedure is still in its infancy and pregnancies have not yet been reported. There are concerns with poor tissue survival due to ischemicreperfusion injury, the longevity of ovarian tissue grafts, the ability to achieve follicular development within the graft and malignant disease transmission via the autologous tissue graft. While ovarian tissue transplantation remains investigational, it may eventually become a management option for women with premature ovarian failure secondary to cytotoxic therapy.

10.4.3 Hormonal Manipulation to Prevent Infertility The recognition that some chemotherapy regimens produce irreversible gonadal injury has prompted a search for means to protect the germ cells from the toxic effects of these drugs. In men, reducing the rate of spermatogenesis by interrupting the pituitarygonadal axis has been proposed as a means of rendering the germinal epithelium relatively resistant to cytotoxic agents. Gonadotropin-releasing hormone (GnRH) analogs, both agonists and antagonists, have been shown to inhibit spermatogenesis in the rat [193], dog [194], monkey [195] and man [196]. In 1981, Glode et al. reported that treatment of mice with a GnRH analog resulted in protection of the testis from the damaging effects of cyclophosphamide [197], although recent studies have failed to confirm these

A.R. Bradbury and R.L. Schilsky

observations [198]. These experimental findings stimulated the initiation of clinical trials to evaluate this approach in patients receiving cancer chemotherapy, but human trials to date have been largely unsuccessful [199–202]. These failures in human studies have prompted new hypotheses and recent studies suggest that the mechanism of hormonal therapy is stimulation of the surviving type A spermatogonia to differentiate, rather than protection of the germ cells through inhibition of spermatogenesis. While some cases of infertility after cytotoxic chemotherapy result from complete depletion of germinal stem cells, some cytotoxic agents cause arrest of differentiation at different stages in sperm development. Results of animal studies have led to the recent hypothesis that testosterone and FSH may inhibit spermatogonial differentiation in surviving germ cells. Studies in animals have shown that GnRH agonists, and antagonists can prevent this block in differentiation through suppression of testosterone and FSH [203–208]. While these animal studies are very encouraging and much has been learned about the hormonal mechanisms controlling spermatogenesis, the relevance to humans remains unclear. As discussed earlier, human studies employing GnRH agonists and antagonists to stimulate recovery of spermatogenesis were largely unsuccessful. It now appears that administration of GnRH agents prior to cytotoxic therapy is not protective, but rather enhances differentiation of surviving spermatogonia after treatment. Animal studies suggest that the use of GnRH agents to stimulate surviving spermatogonial germ cells may be successful and this approach will need to be further investigated in humans. It appears that hormonal manipulation is likely to be most successful in a setting where there is some survival of type A spermatogonia [209]. Therefore, human studies will need to start with cytotoxic agents and doses that do not completely deplete the germinal stem cell population. Efforts to protect the ovary from the toxic effects of chemotherapy have focused on the use of oral contraceptives and GnRH-agonists to induce ovarian suppression. Preliminary data reported by Chapman and Sutcliffe [210] suggested that ovarian follicles could be protected and normal menses could be preserved by the administration of oral contraceptives during chemotherapy. Only a small number of young women were studied, and follow-up was brief. More recent

10 Effects of Cancer Chemotherapy on Gonadal Function

studies with longer follow-up failed to demonstrate a protective effect of oral contraceptives [121, 122, 211]. Thus, the incomplete gonadal suppression induced by oral contraceptives may not be sufficient to protect ovarian follicles during cytotoxic therapy [212]. Although GnRH analogs have not been proven to protect male germ cells, the studies in women have been much more encouraging. The goal of this approach is to induce a dormant state in germ cells, suppressing cellular replication and rendering the cells resistant to the cytotoxic effects of chemotherapy. GnRH analogs appear to partially protect ovarian follicles and fertility in rats and Rhesus monkeys from the damaging effects of cyclophosphamide, [213– 216] with variable protective effects from x-irradiation [217, 218]. However, preliminary clinical observations have failed to demonstrate a protective effect of the LHRH analog buserelin on ovarian function in women undergoing chemotherapy for Hodgkin’s disease [201]. In contrast, GnRH agonists may have a protective effect in young women receiving chemotherapy for lymphoma and breast cancer [212, 219, 220]. Continued long-term, prospective follow-up of women maintaining normal menses during chemotherapy is necessary to determine the degree of risk of premature ovarian failure and early menopause in these individuals.

10.4.4 Hormone Replacement Therapy 10.4.4.1 Estrogen Deficiency Although infertility is a primary concern of many young women who receive cytotoxic therapy, women who develop premature ovarian failure may also be subject to the physical and emotional disorders that accompany estrogen deficiency. Depressed libido, irritability, sleep disturbances, and poor self-image all occur commonly in women with treatment-related amenorrhea [117, 221]. Hormone replacement therapy may be of considerable benefit to patients with chemotherapy-induced amenorrhea, frequently producing dramatic relief of hot flashes, dyspareunia, and irritability. Another potential benefit of estrogen replacement therapy may be prevention of postmenopausal osteoporosis and decreased risk of premature atherosclerosis.

205

10.4.4.2 Leydig Cell Dysfunction While the effect on spermatogenesis appears to be the most clinically relevant effect of cytotoxic chemotherapy in men, Leydig cell dysfunction may occur as well. Leydig cells remain morphologically intact after chemotherapy and basal serum LH levels generally remain normal, yet many patients have been found to have hypersecretion of LH in response to LH releasing hormone, an indication of Leydig cell dysfunction [10, 53, 55, 222, 223]. In addition, the incidence of Leydig cell dysfunction appears to be associated with increasing age and more severe germinal damage [223, 224]. Like germinal epithelial damage, there is evidence of partial recovery of Leydig cell function following treatment, although a recent study suggests that recovery beyond 5 years is unlikely [224]. Despite recognition of these biochemical abnormalities, the clinical significance of these changes is unclear. Complete androgen deficiency has been associated with altered body composition, decreased sexual function, hot flushes, excessive sweating, fatigue, anxiety, depression and reduced bone mineral density (BMD) [225–229]. Mild to moderate testosterone deficiency has been less well studied, but may be associated with sexual dysfunction [230, 231], increased serum cholesterol [232] and decreased BMD [233]. Howell et al. compared 36 men with mild Leydig cell dysfunction to similarly treated men without evidence of Leydig cell dysfunction. They found a significantly lower BMD, increased incidence of truncal fat distribution, but no change in lipid profiles in the group with mild androgen deficiency [234]. These recent studies suggest that testosterone replacement may also be beneficial to the subset of men with moderate Leydig cell dysfunction. Further investigation is warranted to determine the incidence and clinical significance of mild androgen deficiency, as well as the role of replacement therapy.

10.4.5 Mutagenic Potential of Cancer Chemotherapy In addition to effects on fertility and Leydig cell function, cytotoxic treatment may be associated with chromosomal abnormalities in germ cells. These alterations may contribute to post-treatment infertility and may

206

place subsequent generations at risk for carcinogenesis or developmental disorders. Studies have found 9.4–19% of sperm from healthy men have chromosomal alterations [235–237]. The frequency of structural abnormalities of sperm in cancer patients receiving chemotherapy or radiation has been estimated at 9–40%, with more damage seen in patients who received multiple chemotherapeutic agents [236]. In addition, the quantity of DNA-damaged sperm appears to be related to time on treatment [238]. While many feel the rate of structural abnormalities is increased after exposure to chemotherapy, others have suggested that patients with cancer have a higher rate of sperm DNA abnormalities at baseline [239–241]. Until this controversy is resolved, there remains a concern that even men who have minimal germinal damage or recover germinal function may have underlying chromosomal changes that can be passed on to their progeny, resulting in genetic diseases including developmental abnormalities, metabolic abnormalities, or cancer [242]. These concerns originate from animal studies which have established the trans-generational effects of cytotoxic therapies. For example, dominant lethal mutations were detected in zygotes after mice were treated with doxorubicin. The mutation frequency was related to the dose with a rate of 7.4% after 6 mg/kg and 40% after 8 mg/kg [243]. Heritable translocations were identified in 17–21% of the offspring of mice treated with melphalan or chlorambucil [244]. The effects on the progeny of animals treated with cyclophosphamide, chlorambucil, doxorubicin, cisplatin and procarbazine have included intrauterine death, developmental and morphological abnormalities [245–247]. Despite the concerns generated from these studies, human studies to date have been inconclusive, and the risk to future generations remains unclear. Human epidemiological studies have failed to show increased developmental abnormalities or carcinogenesis in the offspring of men who received chemotherapy [248–253]. The reasons for the disparity between the findings in animals and humans is unknown. One possible explanation is the difference in timing of exposure to cytotoxic drugs and conception [246]. For this reason, many clinicians interpret the transgenerational human studies cautiously and feel it is reasonable to counsel men about the potential hazards to their offspring. In addition, it is reasonable to recommend contraception for 6 months to 1 year after completion of treatment to allow

A.R. Bradbury and R.L. Schilsky

for clearance of potentially affected germ cells from the reproductive tract [242, 247, 254]. In addition, the absence of trans-generational effects may not apply to offspring conceived by specialized infertility techniques that utilize sperm collected during or soon after chemotherapy and some discourage the use of sperm collection and cyropreservation during cancer treatment [242, 245, 247, 254]. Likewise, the mutagenic potential of cancer chemotherapy in women remains largely undefined. Some anecdotal reports suggest that there is no increased incidence of spontaneous abortion or fetal abnormalities in those women treated with chemotherapy in comparison with the general population [107, 255–258]. Several larger series and reviews have generally confirmed this observation [259–262] although others have reported congenital defects, fetal abnormalites and an increased rate of abortion in women previously treated with radiation or chemotherapy [259, 263]. At present, it is impossible to define the risk of fetal wastage or abnormality in patients previously treated with cytotoxic drugs. Whether a specific fetal abnormality may occur more commonly than others or whether a specific drug class, dose, or combination is more mutagenic than others remains unknown. Additional studies carried out over many years are required before the true risks to subsequent generations are known. The studies to date have evaluated outcomes in women who have conceived long after the administration of chemotherapy. The mutagenic effects of chemotherapy on the offspring from oocytes obtained by advanced reproductive techniques soon after chemotherapy administration are unknown. Women considering ooctye retrieval soon after the completion of chemotherapy should be counseled regarding the theoretical risk of congenital malformation and early pregnancy loss. Based on the timing of cyclophosphamide induced follicular injury in rats, Meirow suggests that oocytes obtained in the 6–12 months following therapy may be compromised and recommends that further studies are needed to better define the time period of greatest susceptibility [109].

References 1. Walsh PC, Amelar RD (1977) Embryology, anatomy and physiology of the male reproductive system. In: Amelar RD, Dublin L, Walsch PC (eds) Male infertility. Philadelphia, W.B. Saunders, pp 3–32

10 Effects of Cancer Chemotherapy on Gonadal Function 2. Clermont Y (1972) Kinetics of spermatogenesis in mammals: seminiferous epithelium cycle and spermatogonial renewal. Physiol Rev 52:198–236 3. Lu CC, Meistrich ML (1979) Cytotoxic effects of chemotherapeutic drugs on mouse testis cells. Cancer Res 39:3575–3582 4. Meistrich ML, Finch M, da Cunha MF et al (1982) Damaging effects of fourteen chemotherapeutic drugs on mouse testis cells. Cancer Res 42:122–131 5. Russell LD, Russell JA (1991) Short-term morphologic response of the rat testis to administration of five chemotherapeutic agents. Am J Anat 192:142 6. Jackson H (1964) The effects of alkylating agents on fertility. Br Med Bull 20:107 7. Jackson H, Fox BW, Craig AW (1961) Antifertility substances and their assessment in the male rodent. J Reprod Fertil 2:447 8. Schilsky RL, Sherins RJ (1982) Gonadal dysfunction. In: DeVita VT, Hellman S, Rosenberg SA (eds) Cancer: principles and practice of oncology. Philadelphia, J.B. Lippincott, pp 1713–1717 9. Van Thiel DH, Sherins RJ, Myers GH et al (1972) Evidence for a specific seminiferous tubular factor affecting follicle-stimulating hormone secretion in men. J Clin Invest 51:1009 10. Chapman RM, Sutcliffe SB, Rees LH et al (1979) Cyclical combination chemotherapy and gonadal function. Retrospective study in males. Lancet 1:285–289 11. Mecklenburg RS, Sherins RJ (1974) Gonadotropin response to luteinizing hormone-releasing hormone in men with germinal aplasia. J Clin Endocrinol Metabol 38:1005–1008 12. Waxman JH, Terry YA, Wrigley PF et al (1982) Gonadal function in Hodgkin’s disease: long-term follow-up of chemotherapy. Br Med J Clin Res Ed. 285:1612–1613 13. Whitehead E, Shalet S, Blackledge G et al (1982) The effects of Hodgkin’s disease and combination chemotherapy on gonadal function in the adult male. Cancer 49:418 14. Fairley KF, Barrie JU, Johnson W (1972) Sterility and testicular atrophy related to cyclophosphamide therapy. Lancet 1:568–569 15. Kumar R, Biggart JD, McEvoy J et al (1972) Cyclophosphamide and reproductive function. Lancet 1:1212–1214 16. Miller DG (1971) Alkylating agents and human spermatogenesis. JAMA 217:1662–1665 17. Qureshi MS, Pennington JH, Goldsmith HJ et al (1972) Cyclophosphamide therapy and sterility. Lancet 2: 1290–1291 18. Richter P, Calamera JC, Morganfeld MC et al (1970) Effect of chlorambucil on spermatogenesis in the human with malignant lymphoma. Cancer 25:1026 19. Maquire LC, Dick FR, Sherman BM (1981) The effects of antileukemia therapy on gonadal histology in adult males. Cancer 48:1967 20. Rivkees SA, Crawford JD (1988) The relationship of gonadal activity and chemotherapy-induced gonadal damage. JAMA 259:2123–2125 21. Cheviakoff S, Calamera JC, Morgenfeld M et al (1973) Recovery of spermatogenesis in patients with lymphoma after treatment with chlorambucil. J Reproduction Fertility 33:155–157

207 22. Buchanan JD, Fairley KF, Barrie JU (1975) Return of spermatogenesis after stopping cyclophosphamide therapy. Lancet 2:156–157 23. Meistrich ML, Wilson G, Brown BW et al (1992) Impact of cyclophosphamide on long-term reduction in sperm count in men treated with combination chemotherapy for Ewing and soft tissue sarcomas. Cancer 70: 2703–2712 24. Roeser HP, Stocks AE, Smith AJ (1978) Testicular damage due to cytotoxic drugs and recovery after cessation of therapy. Aust N Z J Med 8:250–4 25. Bokemeyer C, Schmoll HJ, van Rhee J et al (1994) Longterm gonadal toxicity after therapy for Hodgkin’s and nonHodgkin’s lymphoma. Ann Hematol 68:105–110 26. Sieber SM, Correa P, Dalgard DW et al (1978) Carcinogenic and other adverse effects of procarbazine in nonhuman primates. Cancer Res 38:2125–2134 27. Johnson FE, Doubek WG, Tolman KC et al (1993) Testicular cytotoxicity of intravenous procarbazine in rats. Surg Oncol 2:77–81 28. DeSantis M, Albrecht W, Holtl W et al (1999) Impact of cytotoxic treatment on long-term fertility in patients with germ-cell cancer. Int J Cancer 83:864–865 29. Longhi A, Macchiagodena M, Vitali G et al (2003) Fertility in male patients treated with neoadjuvant chemotherapy for osteosarcoma. J Pediatric Hematol/Oncol 25:292–296 30. Drasga RE, Einhorn LH, Williams SD et al (1983) Fertility after chemotherapy for testicular cancer. J Clin Oncol 1:179–183 31. Nijman JM, Schraffordt Koops H, Kremer J et al (1987) Gonadal function after surgery and chemotherapy in men with stage II and III nonseminomatous testicular tumors. J Clin Oncol 5:651–656 32. Leitner SP, Bosl GJ, Bajorunas D (1986) Gonadal dysfunction in patients treated for metastatic germcell tumors [erratum appears in J Clin Oncol 1987 Jan;5(1):162]. J Clin Oncol 4:1500–1505 33. Hansen SW, Berthelsen JG, von der Maase H (1990) Long-term fertility and Leydig cell function in patients treated for germ cell cancer with cisplatin, vinblastine, and bleomycin versus surveillance. J Clin Oncol 8: 1695–1698 34. Stephenson WT, Poirier SM, Rubin L et al (1995) Evaluation of reproductive capacity in germ cell tumor patients following treatment with cisplatin, etoposide, and bleomycin. J Clin Oncol 13:2278–2280 35. Grossfeld GD, Small EJ (1998) Long-term side effects of treatment for testis cancer. Urologic Clin N Am 25: 503–515 36. Stuart NS, Woodroffe CM, Grundy R et al (1990) Longterm toxicity of chemotherapy for testicular cancer–the cost of cure. Br J Cancer 61:479–484 37. Pont J, Albrecht W (1997) Fertility after chemotherapy for testicular germ cell cancer. Fertility Sterility 68:1–5 38. Kopf-Maier P (1992) Effects of carboplatin on the testis. A histological study. Cancer Chemother Pharmacol 29: 227–235 39. Reiter WJ, Kratzik C, Brodowicz T et al (1998) Sperm analysis and serum follicle-stimulating hormone levels before and after adjuvant single-agent carboplatin therapy for clinical stage I seminoma. Urology 52:117–119

208 40. Lampe H, Horwich A, Norman A et al (1997) Fertility after chemotherapy for testicular germ cell cancers. J Clin Oncol 15:239–45 41. Rautonen J, Koskimies AI, Siimes MA (1992) Vincristine is associated with the risk of azoospermia in adult male survivors of childhood malignancies. Eur J Cancer 28A:1837–1841 42. Shamberger RC, Rosenberg SA, Seipp CA et al (1981) Effects of high-dose methotrexate and vincristine on ovarian and testicular functions in patients undergoing postoperative adjuvant treatment of osteosarcoma. Cancer Treat Rep 65:739–746 43. Riccardi R VR, Bleyer WA et al (1981) Studies of the blood-testis barrier to methotrexate in rats. Proc Am Soc Clin Oncol 22:365 44. Russell LDRJ (1991) Short-term morphologic response of the rat testis to administration of five chemotherapeutic agents. Am J Anat 192:142 45. Lui R, LaRegina M, Johnson R (1985) Testicular cytotoxicity of doxorubicin in rats. Proc Am Assoc Cancer Res 26:371 46. Shamberger RC, Sherins RJ, Rosenberg SA (1981) The effects of postoperative adjuvant chemotherapy and radiotherapy on testicular function in men undergoing treatment for soft tissue sarcoma. Cancer 47:2368–2374 47. Meistrich ML, da Cunha MF, Chawla SP et al (1985) Sperm production following chemotherapy for sarcomas. Proc Am Assoc Cancer Res 26:170 48. Meistrich ML, Chawla SP, Da Cunha MF et al (1989) Recovery of sperm production after chemotherapy for osteosarcoma. Cancer 63:2115–2123 49. Bonadonna G, Santoro A (1982) Chemotherapy in the treatment of Hodgkin’s disease. Cancer Treat Rep 9:21 50. Sherins RJ, DeVita VT (1973) Effects of drug treatment for lymphoma on male reproductive capacity. Ann Intern Med 79:216 51. Asbjornsen G, Molne K, Klepp O et al (1976) Testicular function after combination chemotherapy for Hodgkin’s disease. Scand J Haematol 16:66–69 52. Chapman RM, Sutcliffe SB, Malpas JS (1981) Male gonadal dysfunction in Hodgkin’s disease. A prospective study. JAMA 245:1323–1328 53. Whitehead ESS, Blackledge G et al (1982) The effects of Hodgkin’s disease and combination chemotherapy on gonadal function in the adult male. Cancer 49:418 54. Wang C, Ng RP, Chan TK et al (1980) Effect of combination chemotherapy on pituitary gonadal function in patients with lymphoma and leukemia. Cancer 45:2030 55. Charak BS, Gupta R, Mandrekar P et al (1990) Testicular dysfunction after cyclophosphamide-vincristineprocarbazine-prednisolone chemotherapy for advanced Hodgkin’s disease. A long-term follow-up study. Cancer 65:1903–1906 56. Shafford EA, Kingston JE, Malpas JS et al (1993) Testicular function following the treatment of Hodgkin’s disease in childhood. Br J Cancer 68:1199–1204 57. Viviani S, Ragni G, Santoro A et al (1991) Testicular dysfunction in Hodgkin’s disease before and after treatment. Eur J Cancer 27:1389–1392 58. Dhabhar BN, Malhotra H, Joseph R et al (1993) Gonadal function in prepubertal boys following treatment for

A.R. Bradbury and R.L. Schilsky

59.

60.

61.

62.

63.

64.

65.

66.

67. 68.

69.

70.

71.

72.

73.

74.

Hodgkin’s disease. Am J Pediatr Hematol Oncol 15: 306–310 Ben Arush MW, Solt I, Lightman A et al (2000) Male gonadal function in survivors of childhood Hodgkin and non-Hodgkin lymphoma. Pediatr Hematol Oncol 17: 239–245 Santoro A, Bonadonna G, Valagussa P et al (1987) Longterm results of combined chemotherapy-radiotherapy approach in Hodgkin’s disease: superiority of ABVD plus radiotherapy versus MOPP plus radiotherapy. J Clin Oncol 5:27–37 Kulkarni SS, Sastry PS, Saikia TK et al (1997) Gonadal function following ABVD therapy for Hodgkin’s disease. Am J Clin Oncol 20:354–357 Tal R, Botchan A, Hauser R et al (2000) Follow-up of sperm concentration and motility in patients with lymphoma. Hum Reprod 15:1985–1988 Muller U, Stahel RA (1993) Gonadal function after MACOP-B or VACOP-B with or without dose intensification and ABMT in young patients with aggressive non-Hodgkin’s lymphoma. Ann Oncol 4:399–402 Pryzant RM, Meistrich ML, Wilson G et al (1993) Longterm reduction in sperm count after chemotherapy with and without radiation therapy for non-Hodgkin’s lymphomas. J Clin Oncol 11:239–247 Radford JA, Clark S, Crowther D et al (1994) Male fertility after VAPEC-B chemotherapy for Hodgkin’s disease and non-Hodgkin’s lymphoma. Br J Cancer 69: 379–381 Hendry WF, Stedronska J, Jones CR et al (1983) Semen analysis in testicular cancer and Hodgkin’s disease: preand post-treatment findings and implications for cryopreservation. Br J Urol 55:769–773 Meirow D, Schenker JG (1995) Cancer and male infertility. Hum Reprod 10:2017–2022 Tseng A, Kessler R, Freiha F (1984) Male fertility before and after treatment of testicular cancer. Proc Am Soc Clin Oncol 3:161 Fossa SD, Aabyholm T, Vespestad S et al (1993) Semen quality after treatment for testicular cancer. Eur Urol 23:172–176 Kader HA, Rostom AY (1991) Follicle stimulating hormone levels as a predictor of recovery of spermatogenesis following cancer therapy. Clin Oncol (Royal College of Radiologists) 3:37–40 Chakraborty PR, Neave F (1993) Recovery of fertility 14 years following radiotherapy and chemotherapy for testicular tumor. Clin Oncol (Royal College of Radiologists) 5:253 Petersen PM, Hansen SW (1999) The course of longterm toxicity in patients treated with cisplatin-based chemotherapy for non-seminomatous germ-cell cancer. Ann Oncol 10:1475–1483 Sanders J, Sullivan K, Witherspoon R et al (1989) Long term effects and quality of life in children and adults after marrow transplantation. Bone Marrow Transplant 4(Suppl 4):27–29 Sanders JE, Hawley J, Levy W et al (1996) Pregnancies following high-dose cyclophosphamide with or without high-dose busulfan or total-body irradiation and bone marrow transplantation. Blood 87:3045–3052

10 Effects of Cancer Chemotherapy on Gonadal Function 75. Anserini P, Chiodi S, Spinelli S et al (2002) Semen analysis following allogeneic bone marrow transplantation. Additional data for evidence-based counselling. Bone Marrow Transplant 30:447–451 76. Grigg AP, McLachlan R, Zaja J et al (2000) Reproductive status in long-term bone marrow transplant survivors receiving busulfan-cyclophosphamide (120 mg/kg). Bone Marrow Transplant 26:1089–1095 77. Lendon M, Hann IM, Palmer MK et al (1978) Testicular histology after combination chemotherapy in childhood for acute lymphoblastic leukaemia. Lancet 2:439–441 78. Quigley C, Cowell C, Jimenez M et al (1989) Normal or early development of puberty despite gonadal damage in children treated for acute lymphoblastic leukemia.[comment]. N E J Med 321:143–151 79. Evenson DP, Arlin Z, Welt S et al (1984) Male reproductive capacity may recover following drug treatment with the L-10 protocol for acute lymphocytic leukemia. Cancer 53:30–36 80. Wallace WH, Shalet SM, Lendon M et al (1991) Male fertility in long-term survivors of childhood acute lymphoblastic leukaemia. Int J Androl 14:312–319 81. Mayer DL, Odell WD (1971) Physiology of reproduction. St. Louis, C.V. Mosby, pp 20–27 82. Peters H, Byskov AG, Himelstein-Braw R et al (1975) Follicular growth: the basic event in the mouse and human ovary. J Reproduction Fertility 45:559–566 83. Chapman RM (1982) Effect of cytotoxic therapy on sexuality and gonadal function. Seminars Oncol 9:84–94 84. Sobrinho LG, Levine RA, DeConti RC (1971) Amenorrhea in patients with Hodgkin’s disease treated with antineoplastic agents. Am J Obstetrics Gynecol 109:135–139 85. Miller JJ 3rd, Williams GF, Leissring JC (1971) Multiple late complications of therapy with cyclophosphamide, including ovarian destruction. Am J Med 50:530–535 86. Jarrell J, Lai EV, Barr R et al (1987) Ovarian toxicity of cyclophosphamide alone and in combination with ovarian irradiation in the rat. Cancer Res 47:2340–2343 87. Tilly JL (1998) Molecular and genetic basis of normal and toxicant-induced apoptosis in female germ cells. Toxicol Lett 102–103:497–501 88. Meirow D, Nugent K, Epstein M et al (1998) An in vitro study of the effects of chemotherapy on human primordial follicles. Eur Soc Hum Reprod (ESHRE meeting). Gotenberg, Sweden 89. Gradishar WJ, Schilsky RL (1989) Ovarian function following radiation and chemotherapy for cancer. Seminars Oncol 16:425–436 90. Blumenfeld Z (2002) Preservation of fertility and ovarian function and minimalization of chemotherapy associated gonadotoxicity and premature ovarian failure: the role of inhibin-A and -B as markers. Mol Cell Endocrinol 187:93–105 91. Bines J, Oleske DM, Cobleigh MA (1996) Ovarian function in premenopausal women treated with adjuvant chemotherapy for breast cancer [comment]. J Clin Oncol 14:1718–1729 92. Ataya KM, Valeriote FA, Ramahi-Ataya AJ (1989) Effect of cyclophosphamide on the immature rat ovary. Cancer Res 49:1660–1664

209 93. Louis J, Limarzi LR, Best WR (1957) Treatment of chronic granulocytic leukemia and Myleran. Arch Intern Med 97:299 94. Galton DAG, Till M, Wiltshaw E (1958) Busulfan: summary of clinical results. Ann N Y Acad Sci 68:967 95. Fosdick WM, Parsons JL, Hill DF (1968) Longterm cyclophosphamide therapy in rheumatoid arthritis. Arthritis Rheumatism 11:151–161 96. Warne GL, Fairley KF, Hobbs JB et al (1973) Cyclophosphamide-induced ovarian failure. N E J Med 289:1159–1162 97. Uldall PR, Kerr DN, Tacchi D (1972) Sterility and cyclophosphamide. Lancet 1:693–694 98. Dnistrian AM, Schwartz MK, Fracchia AA et al (1983) Endocrine consequences of CMF adjuvant therapy in premenopausal and postmenopausal breast cancer patients. Cancer 51:803–807 99. Samaan NA, deAsis DN Jr, Buzdar AU et al (1978) Pituitary-ovarian function in breast cancer patients on adjuvant chemoimmunotherapy. Cancer 41:2084–2087 100. Ravdin PM, Fritz NF, Tormey DC et al (1988) Endocrine status of premenopausal node-positive breast cancer patients following adjuvant chemotherapy and long-term tamoxifen. Cancer Res 48:1026–1029 101. Koyama H, Wada T, Nishizawa Y et al (1977) Cyclophosphamide-induced ovarian failure and its therapeutic significance in patients with breast cancer. Cancer 39:1403–1409 102. Mehta RR, Beattie CW, Das Gupta TK (1992) Endocrine profile in breast cancer patients receiving chemotherapy. Breast Cancer Res Treat 20:125–132 103. Goldhirsch A, Gelber RD, Castiglione M (1990) The magnitude of endocrine effects of adjuvant chemotherapy for premenopausal breast cancer patients. The international breast cancer study group. Ann Oncol 1:183–188 104. Reichman BS, Green KB (1994) Breast cancer in young women: effect of chemotherapy on ovarian function, fertility, and birth defects. J Natl Cancer Inst Monogr 125–129 105. Hensley ML, Reichman BS (1998) Fertility and pregnancy after adjuvant chemotherapy for breast cancer. Crit Rev Oncol-Hematol 28:121–128 106. Choo YC, Chan SY, Wong LC et al (1985) Ovarian dysfunction in patients with gestational trophoblastic neoplasia treated with short intensive courses of etoposide (VP-16–213). Cancer 55:2348–2352 107. Sutton R, Buzdar AU, Hortobagyi GN (1990) Pregnancy and offspring after adjuvant chemotherapy in breast cancer patients. Cancer 65:847–850 108. Low JJ, Perrin LC, Crandon AJ et al (2000) Conservative surgery to preserve ovarian function in patients with malignant ovarian germ cell tumors. A review of 74 cases. Cancer 89:391–398 109. Meirow D (2000) Reproduction post-chemotherapy in young cancer patients. Mol Cell Endocrinol 169: 123–131 110. Wallace WH, Shalet SM, Crowne EC et al (1989) Gonadal dysfunction due to cis-platinum. Med Pediatric Oncol 17:409–413 111. Maneschi F, Benedetti-Panici P, Scambia G et al (1994) Menstrual and hormone patterns in women treated with

210

112.

113.

114.

115.

116.

117.

118.

119.

120.

121.

122.

123.

124.

125.

126.

A.R. Bradbury and R.L. Schilsky high-dose cisplatin and bleomycin. Gynecologic Oncol 54:345–348 Reyno LM, Levine MN, Skingley P et al (1992) Chemotherapy induced amenorrhoea in a randomised trial of adjuvant chemotherapy duration in breast cancer. Eur J Cancer 29A:21–23 Hortobagyi GN, Buzdar AU, Marcus CE et al (1986) Immediate and long-term toxicity of adjuvant chemotherapy regimens containing doxorubicin in trials at M.D. Anderson Hospital and Tumor Institute. NCI Monographs 105–109 Valagussa P, Moliterni A, Zambetti M et al (1993) Long-term sequelae from adjuvant chemotherapy. Recent Results Cancer Res 127:247–255 Levine MN, Bramwell VH, Pritchard KI et al (1998) Randomized trial of intensive cyclophosphamide, epirubicin, and fluorouracil chemotherapy compared with cyclophosphamide, methotrexate, and fluorouracil in premenopausal women with node-positive breast cancer. National cancer institute of canada clinical trials group [comment]. J Clin Oncol 16:2651–2658 Morgenfeld MC, Goldberg V, Parisier H et al (1972) Ovarian lesions due to cytostatic agents during the treatment of Hodgkin’s disease. Surg Gynecol Obstetrics 134:826–828 Chapman RM, Sutcliffe SB, Malpas JS (1979) Cytotoxicinduced ovarian failure in women with Hodgkin’s disease. I. Hormone function. JAMA 242:1877–1881 Schilsky RL, Sherins RJ, Hubbard SM et al (1981) Longterm follow up of ovarian function in women treated with MOPP chemotherapy for Hodgkin’s disease. Am J Med 71:552–556 Horning SJ, Hoppe RT, Kaplan HS et al (1981) Female reproductive potential after treatment for Hodgkin’s disease. N E J Med 304:1377–1382 Andrieu JM, Ochoa-Molina ME (1983) Menstrual cycle, pregnancies and offspring before and after MOPP therapy for Hodgkin’s disease. Cancer 52:435–438 Whitehead E, Shalet SM, Blackledge G et al (1983) The effect of combination chemotherapy on ovarian function in women treated for Hodgkin’s disease. Cancer 52: 988–993 Specht L, Hansen MM, Geisler C (1984) Ovarian function in young women in long-term remission after treatment for Hodgkin’s disease stage I or II. Scand J Haematol 32:265–270 Clark ST, Radford JA, Crowther D et al (1995) Gonadal function following chemotherapy for Hodgkin’s disease: a comparative study of MVPP and a seven-drug hybrid regimen. J Clin Oncol 13:134–139 Kreuser ED, Xiros N, Hetzel WD et al (1987) Reproductive and endocrine gonadal capacity in patients treated with COPP chemotherapy for Hodgkin’s disease. J Cancer Res Clin Oncol 113:260–266 Gershenson DM (1988) Menstrual and reproductive function after treatment with combination chemotherapy for malignant ovarian germ cell tumors. J Clin Oncol 6: 270–275 Zanetta G, Bonazzi C, Cantu M et al (2001) Survival and reproductive function after treatment of malignant germ cell ovarian tumors. J Clin Oncol 19:1015–1020

127. Brewer M, Gershenson DM, Herzog CE et al (1999) Outcome and reproductive function after chemotherapy for ovarian dysgerminoma [comment]. J Clin Oncol 17:2670–2675 128. Tangir J, Zelterman D, Ma W et al (2003) Reproductive function after conservative surgery and chemotherapy for malignant germ cell tumors of the ovary. Obstetrics Gynecol 101:251–257 129. Sanders JE, Buckner CD, Leonard JM et al (1983) Late effects on gonadal function of cyclophosphamide, total-body irradiation, and marrow transplantation. Transplantation 36:252–255 130. Schimmer AD, Quatermain M, Imrie K et al (1998) Ovarian function after autologous bone marrow transplantation. J Clin Oncol 16:2359–2363 131. Hinterberger-Fischer M, Kier P, Kalhs P et al (1991) Fertility, pregnancies and offspring complications after bone marrow transplantation. Bone Marrow Transplant 7:5–9 132. Salooja N, Chatterjee R, McMillan AK et al (1994) Successful pregnancies in women following single autotransplant for acute myeloid leukemia with a chemotherapy ablation protocol. Bone Marrow Transplant 13: 431–435 133. Chatterjee R, Goldstone AH (1996) Gonadal damage and effects on fertility in adult patients with haematological malignancy undergoing stem cell transplantation. Bone Marrow Transplant 17:5–11 134. Singhal S, Powles R, Treleaven J et al (1996) Melphalan alone prior to allogeneic bone marrow transplantation from HLA-identical sibling donors for hematologic malignancies: alloengraftment with potential preservation of fertility in women. Bone Marrow Transplant 18: 1049–1055 135. Palermo GD, Cohen J, Alikani M et al (1995) Intracytoplasmic sperm injection: a novel treatment for all forms of male factor infertility. Fertility Sterility 63: 1231–1240 136. Chlebowski RT, Heber D (1982) Hypogonadism in male patients with metastatic cancer prior to chemotherapy. Cancer Res 42:2495–2498 137. Sanger WG, Armitage JO, Schmidt MA (1980) Feasibility of semen cryopreservation in patients with malignant disease. JAMA 244:789–790 138. Thachil JV, Jewett MA, Rider WD (1981) The effects of cancer and cancer therapy on male fertility. J Urol 126:141–145 139. Berthelsen JG, Skakkebaek NE (1983) Gonadal function in men with testis cancer. Fertility Sterility 39:68–75 140. Lass A, Akagbosu F, Abusheikha N et al (1998) A programme of semen cryopreservation for patients with malignant disease in a tertiary infertility centre: lessons from 8 years’ experience. Human Reproduction 13: 3256–3261 141. Rueffer U, Breuer K, Josting A et al (2001) Male gonadal dysfunction in patients with Hodgkin’s disease prior to treatment [comment]. Ann Oncol 12:1307–1311 142. Lass A, Akagbosu F, Brinsden P (2001) Sperm banking and assisted reproduction treatment for couples following cancer treatment of the male partner. Human Reproduction Update 7:370–377

10 Effects of Cancer Chemotherapy on Gonadal Function 143. Ragni G, Somigliana E, Restelli L et al (2003) Sperm banking and rate of assisted reproduction treatment: insights from a 15-year cryopreservation program for male cancer patients. Cancer 97:1624–1629 144. Sanger WG, Olson JH, Sherman JK (1992) Semen cryobanking for men with cancer – criteria change [comment]. Fertility Sterility 58:1024–1027 145. Rowland GF, Cohen J, Steptoe PC et al (1985) Pregnancy following in vitro fertilization using cryopreserved semen from a man with testicular teratoma. Urology 26:33–36 146. Cohen J, Edwards R, Fehilly C et al (1985) In vitro fertilization: a treatment for male infertility. Fertility Sterility 43:422–432 147. Mahadevan MM, Trounson AO, Leeton JF (1983) Successful use of human semen cryobanking for in vitro fertilization. Fertility Sterility 40:340–343 148. Tournaye H, Camus M, Bollen N et al (1991) In vitro fertilization techniques with frozen-thawed sperm: a method for preserving the progenitive potential of Hodgkin patients. Fertility Sterility 55:443–445 149. Padron OF, Sharma RK, Thomas AJ Jr et al (1997) Effects of cancer on spermatozoa quality after cryopreservation: a 12-year experience. Fertility Sterility 67:326–331 150. Agarwal A, Shekarriz M, Sidhu RK et al (1996) Value of clinical diagnosis in predicting the quality of cryopreserved sperm from cancer patients. J Urol 155: 934–938 151. Hughes EG, Collins JP, Garner PR (1987) Homologous artificial insemination for oligoasthenospermia: a randomized controlled study comparing intracervical and intrauterine techniques. Fertility Sterility 48:278–281 152. Ho PC, Poon IM, Chan SY et al (1989) Intrauterine insemination is not useful in oligoasthenospermia. Fertility Sterility 51:682–684 153. Khalifa E, Oehninger S, Acosta AA et al (1992) Successful fertilization and pregnancy outcome in invitro fertilization using cryopreserved/thawed spermatozoa from patients with malignant diseases. Human Reproduction 7:105–108 154. Audrins P, Holden CA, McLachlan RI et al (1999) Semen storage for special purposes at Monash IVF from 1977 to 1997 [comment]. Fertility Sterility 72:179–181 155. Rosenlund B, Sjoblom P, Tornblom M et al (1998) Invitro fertilization and intracytoplasmic sperm injection in the treatment of infertility after testicular cancer. Human Reproduction 13:414–418 156. Schlegel PN, Girardi SK (1997) Clinical review 87: in vitro fertilization for male factor infertility. J Clin Endocrinol Metabol 82:709–716 157. Van Steirteghem AC, Liu J, Joris H et al (1993) Higher success rate by intracytoplasmic sperm injection than by subzonal insemination. Report of a second series of 300 consecutive treatment cycles. Human Reproduction 8:1055–1060 158. Van Steirteghem AC, Nagy Z, Joris H et al (1993) High fertilization and implantation rates after intracytoplasmic sperm injection [comment]. Human Reproduction 8:1061–10661993 159. Milligan DW, Hughes R, Lindsay KS (1989) Semen cryopreservation in men undergoing cancer chemotherapy–a UK survey. Br J Cancer 60:966–967

211 160. Radford J, Shalet S, Lieberman B (1999) Fertility after treatment for cancer. Questions remain over ways of preserving ovarian and testicular tissue [comment]. BMJ 319:935–936 161. Schover LR, Brey K, Lichtin A et al (2002) Knowledge and experience regarding cancer, infertility, and sperm banking in younger male survivors. J Clin Oncol 20: 1880–1889 162. Kelleher S, Wishart SM, Liu PY et al (2001) Long-term outcomes of elective human sperm cryostorage. Human Reproduction 16:2632–2639 163. Tournaye H, Liu J, Nagy PZ et al (1996) Correlation between testicular histology and outcome after intracytoplasmic sperm injection using testicular spermatozoa [comment]. Human Reproduction 11: 127–132 164. Chan PT, Palermo GD, Veeck LL et al (2001) Testicular sperm extraction combined with intracytoplasmic sperm injection in the treatment of men with persistent azoospermia postchemotherapy. Cancer 92: 1632–1637 165. Schrader M, Mller M, Sofikitis N et al (2003) “Oncotese”: testicular sperm extraction in azoospermic cancer patients before chemotherapy-new guidelines? Urology 61:421–425 166. Schrader M, Muller M, Straub B et al (2002) Testicular sperm extraction in azoospermic patients with gonadal germ cell tumors prior to chemotherapy – a new therapy option. Asian J Androl 4:9–15 167. Brinster RL, Zimmermann JW (1994) Spermatogenesis following male germ-cell transplantation [comment]. Proc Natl Acad Sci USA 91:11298–11302 168. Avarbock MR, Brinster CJ, Brinster RL (1996) Reconstitution of spermatogenesis from frozen spermatogonial stem cells [comment]. Nat Med 2:693–696 169. Ogawa T, Dobrinski I, Avarbock MR et al (1999) Xenogeneic spermatogenesis following transplantation of hamster germ cells to mouse testes. Biol Reproduction 60:515–521 170. Brook PF, Radford JA, Shalet SM et al (2001) Isolation of germ cells from human testicular tissue for low temperature storage and autotransplantation. Fertility Sterility 75:269–274 171. Jahnukainen K, Hou M, Petersen C et al (2001) Intratesticular transplantation of testicular cells from eukemic rats causes transmission of leukemia. Cancer Res 61:706–710 172. Abdalla HI, Baber RJ, Kirkland A et al (1989) Pregnancy in women with premature ovarian failure using tubal and intrauterine transfer of cryopreserved zygotes. Br J Obstetrics Gynaecol 96:1071–1075 173. Pados G, Camus M, Van Waesberghe L et al (1992) Oocyte and embryo donation: evaluation of 412 consecutive trials. Human Reproduction 7:1111–1117 174. Brown JR, Modell E, Obasaju M et al (1996) Natural cycle in-vitro fertilization with embryo cryopreservation prior to chemotherapy for carcinoma of the breast. Human Reproduction 11:197–199 175. Lipton JH, Virro M, Solow H (1997) Successful pregnancy after allogeneic bone marrow transplant with

212

176.

177.

178.

179.

180.

181.

182. 183.

184.

185.

186.

187.

188.

189.

190.

191.

192.

A.R. Bradbury and R.L. Schilsky embryos isolated before transplant. J Clin Oncol 15: 3347–3349 Blumenfeld Z, Avivi I, Ritter M et al (1999) Preservation of fertility and ovarian function and minimizing chemotherapy-induced gonadotoxicity in young women. J Soc Gynecol Invest 6:229–239 Oktay K, Buyuk E, Davis O et al (2003) Fertility preservation in breast cancer patients: IVF and embryo cryopreservation after ovarian stimulation with tamoxifen. Human Reproduction 18:90–95 Allred CD, Allred KF, Ju YH et al (2001) Soy diets containing varying amounts of genistein stimulate growth of estrogen-dependent (MCF-7) tumors in a dose-dependent manner. Cancer Res 61:5045–5050 Prest SJ, May FE, Westley BR (2002) The estrogenregulated protein, TFF1, stimulates migration of human breast cancer cells. FASEB J 16:592–594 Carroll J, Wood MJ, Whittingham DG (1993) Normal fertilization and development of frozen-thawed mouse oocytes: protective action of certain macromolecules. Biol Reproduction 48:606–612 Bos-Mikich A, Wood MJ, Candy CJ et al (1995) Cytogenetical analysis and developmental potential of vitrified mouse oocytes. Biol Reproduction 53:780–785 Trounson A, Bongso A (1996) Fertilization and development in humans. Curr Top Develop Biol 32:59–101 Oktay K, Kan MT, Rosenwaks Z (2001) Recent progress in oocyte and ovarian tissue cryopreservation and transplantation. Curr Opin Obstetrics Gynecol 13:263–268 Fabbri R, Venturoli S, D’Errico A et al (2003) Ovarian tissue banking and fertility preservation in cancer patients: histological and immunohistochemical evaluation. Gynecol Oncol 89:259–266 Gosden RG, Baird DT, Wade JC et al (1994) Restoration of fertility to oophorectomized sheep by ovarian autografts stored at -196 degrees C. Human Reproduction 9:597–603 Kim SS, Battaglia DE, Soules MR (2001) The future of human ovarian cryopreservation and transplantation: fertility and beyond. Fertility Sterility 75: 1049–1056 Newton H, Aubard Y, Rutherford A et al (1996) Low temperature storage and grafting of human ovarian tissue. Human Reproduction 11:1487–1491 Newton H (1998) The cryopreservation of ovarian tissue as a strategy for preserving the fertility of cancer patients. Human Reproduction Update 4:237–247 Law C (1996) Freezing ovary tissue may help cancer patients preserve fertility. J Natl Cancer Inst 88: 1184–1185 Radford JA, Lieberman BA, Brison DR et al (2001) Orthotopic reimplantation of cryopreserved ovarian cortical strips after high-dose chemotherapy for Hodgkin’s lymphoma. Lancet 357:1172–1175 Oktay K, Karlikaya G (2000) Ovarian function after transplantation of frozen, banked autologous ovarian tissue. N E J Med 342:1919 Oktay K, Aydin BA, Economos K et al (2000) Restoration of ovarian function after autologous transplantation of ovarian tissue into the forearm [Abstract]. Fertility Sterility 74:79

193. Heber D, Dodson R, Peterson M et al (1984) Counteractive effects of agonistic and antagonistic gonadotropin-releasing hormone analogs on spermatogenesis: sites of action. Fertility Sterility 41:309–313 194. Vickery BH, McRae GI, Briones W et al (1984) Effects of an LHRH agonist analog upon sexual function in male dogs. Suppression, reversibility, and effect of testosterone replacement. J Androl 5:28–42 195. Akhtar FB, Marshall GR, Wickings EJ et al (1983) Reversible induction of azoospermia in rhesus monkeys by constant infusion of a gonadotropin-releasing hormone agonist using osmotic minipumps. J Clin Endocrinol Metabol 56:534–540 196. Linde R, Doelle GC, Alexander N et al (1981) Reversible inhibition of testicular steroidogenesis and spermatogenesis by a potent gonadotropin-releasing hormone agonist in normal men: an approach toward the development of a male contraceptive. N E J Med 305:663–667 197. Glode LM, Robinson J, Gould SF (1981) Protection from cyclophosphamide-induced testicular damage with an analogue of gonadotropin-releasing hormone. Lancet 1:1132–1134 198. da Cunha MF, Meistrich ML, Nader S (1987) Absence of testicular protection by a gonadotropin-releasing hormone analog against cyclophosphamide-induced testicular cytotoxicity. Cancer Res 47:1093 199. Johnson DH, Linde R, Hainsworth JD et al (1985) Effect of a luteinizing hormone releasing hormone agonist given during combination chemotherapy on posttherapy fertility in male patients with lymphoma: preliminary observations. Blood 65:832–836 200. Kreuser ED, Hetzel WD, Hautmann R et al (1990) Reproductive toxicity with and without LHRHA administration during adjuvant chemotherapy in patients with germ cell tumors. Hormone Metabol Res 22:494–498 201. Waxman JH, Ahmed R, Smith D et al (1987) Failure to preserve fertility in patients with Hodgkin’s disease. Cancer Chemother Pharmacol 19:159–162 202. Krause W, Pfluger KH (1989) Treatment with the gonadotropin-releasinghormone agonist buserelin to protect spermatogenesis against cytotoxic treatment in young men. Andrologia 21:265–270 203. Meistrich ML, Kangasniemi M (1997) Hormone treatment after irradiation stimulates recovery of rat spermatogenesis from surviving spermatogonia. J Androl 18:80–87 204. Shetty G, Wilson G, Huhtaniemi I et al (2000) Gonadotropin-releasing hormone analogs stimulate and testosterone inhibits the recovery of spermatogenesis in irradiated rats. Endocrinology 141:1735–1745 205. Shuttlesworth GA, de Rooij DG, Huhtaniemi I et al (2000) Enhancement of A spermatogonial proliferation and differentiation in irradiated rats by gonadotropin-releasing hormone antagonist administration. Endocrinology 141:37–49 206. Meistrich MG, Shuttlesworth G, Huhtaniemi I et al (2001) GnRH agonists and antagonists stimulate recovery of fertility in irradiated LBNF1 rats. J Androl 22:809–817 207. Shetty G, Wilson G, Huhtaniemi I et al (2001) Testosterone inhibits spermatogonial differentiation in juvenile spermatogonial depletion mice. Endocrinology 142:2789–2795

10 Effects of Cancer Chemotherapy on Gonadal Function 208. Shetty G, Wilson G, Hardy MP et al (2002) Inhibition of recovery of spermatogenesis in irradiated rats by different androgens. Endocrinology 143:3385–3396 209. Howell SJ, Shalet SM (1999) Pharmacological protection of the gonads. Med Pediatric Oncol 33:41–45 210. Chapman RM, Sutcliffe SB (1981) Protection of ovarian function by oral contraceptives in women receiving chemotherapy for Hodgkin’s disease. Blood 58:849–851 211. Longhi A, Pignotti E, Versari M et al (2003) Effect of oral contraceptive on ovarian function in young females undergoing neoadjuvant chemotherapy treatment for osteosarcoma. Oncol Rep 10:151–155 212. Blumenfeld Z, Haim N (1997) Prevention of gonadal damage during cytotoxic therapy. Ann Med 29:199–206 213. Montz FJ, Wolff AJ, Gambone JC (1991) Gonadal protection and fecundity rates in cyclophosphamide-treated rats. Cancer Res 51:2124–2126 214. Ataya KM, McKanna JA, Weintraub AM et al (1985) A luteinizing hormone-releasing hormone agonist for the prevention of chemotherapy-induced ovarian follicular loss in rats. Cancer Res 45:3651–3656 215. Ataya K, Ramahi-Ataya A (1993) Reproductive performance of female rats treated with cyclophosphamide and/or LHRH agonist [comment]. Reproductive Toxicol 7:229–235 216. Ataya K, Rao LV, Lawrence E et al (1995) Luteinizing hormone-releasing hormone agonist inhibits cyclophosphamide-induced ovarian follicular depletion in rhesus monkeys. Biol Reproduction 52:365–372 217. Jarrell J, YoungLai EV, McMahon A et al (1987) Effects of ionizing radiation and pretreatment with [D-Leu6, des-Gly10] luteinizing hormone-releasing hormone ethylamide on developing rat ovarian follicles. Cancer Res 47:5005–5008 218. Jarrell JF, McMahon A, Barr RD et al (1991) The agonist (d-leu-6, des-gly-10)-LHRH-ethylamide does not protect the fecundity of rats exposed to high dose unilateral ovarian irradiation. Reproductive Toxicol 5: 385–388 219. Falkson G, Falkson HC (1989) CAF and nasal buserelin in the treatment of premenopausal women with metastatic breast cancer. Eur J Cancer Clin Oncol 25:737–741 220. Blumenfeld Z, Dann E, Avivi I et al (2002) Fertility after treatment for Hodgkin’s disease. Ann Oncol 13(Suppl 1): 138–147 221. Mortimer JE, Boucher L, Baty J et al (1999) Effect of tamoxifen on sexual functioning in patients with breast cancer [comment]. J Clin Oncol 17:1488–1492 222. Chatterjee R, Mills W, Katz M et al (1994) Germ cell failure and Leydig cell insufficiency in post-pubertal males after autologous bone marrow transplantation with BEAM for lymphoma. Bone Marrow Transplant 13:519–522 223. Howell SJ, Radford JA, Ryder WD et al (1999) Testicular function after cytotoxic chemotherapy: evidence of Leydig cell insufficiency. J Clin Oncol 17:1493–1498 224. Gerl A, Muhlbayer D, Hansmann G et al (2001) The impact of chemotherapy on Leydig cell function in long term survivors of germ cell tumors. Cancer 91:1297–1303 225. Greenspan SL, Neer RM, Ridgway EC et al (1986) Osteoporosis in men with hyperprolactinemic hypogonadism. Ann Intern Med 104:777–782

213 226. Finkelstein JS, Klibanski A, Neer RM et al (1987) Osteoporosis in men with idiopathic hypogonadotropic hypogonadism. Ann Intern Med 106:354–361 227. Katznelson L, Rosenthal DI, Rosol MS et al (1998) Using quantitative CT to assess adipose distribution in adult men with acquired hypogonadism. AJR. Am J Roentgenol 170:423–427 228. Bagatell CJ, Bremner WJ (1996) Androgens in men – uses and abuses. N E J Med 334:707–714 229. Fossa SD, Opjordsmoen S, Haug E (1999) Androgen replacement and quality of life in patients treated for bilateral testicular cancer. Eur J Cancer 35:1220–1225 230. Jonker-Pool G, van Basten JP, Hoekstra HJ et al (1997) Sexual functioning after treatment for testicular cancer: comparison of treatment modalities. Cancer 80:454–464 231. Howell SJ, Radford JA, Smets EM et al (2000) Fatigue, sexual function and mood following treatment for haematological malignancy: the impact of mild Leydig cell dysfunction. Br J Cancer 82:789–793 232. Goldberg RB, Rabin D, Alexander AN et al (1985) Suppression of plasma testosterone leads to an increase in serum total and high density lipoprotein cholesterol and apoproteins A-I and B. J Clin Endocrinol Metab 60:203–207 233. Holmes SJ, Whitehouse RW, Clark ST et al (1994) Reduced bone mineral density in men following chemotherapy for Hodgkin’s disease. Br J Cancer 70: 371–375 234. Howell SJ, Radford JA, Adams JE et al (2000) The impact of mild Leydig cell dysfunction following cytotoxic chemotherapy on bone mineral density (BMD) and body composition. Clin Endocrinol (Oxf) 52:609–616 235. Martin RH (1993) Detection of genetic damage in human sperm. Reproductive Toxicol 7(Suppl 1):47–52 236. Genesca A, Miro R, Caballin MR et al (1990) Sperm chromosome studies in individuals treated for testicular cancer. Human Reproduction 5:286–290 237. Bischoff FZ, Nguyen DD, Burt KJ et al (1994) Estimates of aneuploidy using multicolor fluorescence in situ hybridization on human sperm [erratum appears in Cytogenet Cell Genet 1995;69(3–4):189]. Cytogenetics Cell Genetics 66:237–243 238. Chatterjee R, Haines GA, Perera DM et al (2000) Testicular and sperm DNA damage after treatment with fludarabine for chronic lymphocytic leukaemia. Human Reproduction 15:762–766 239. Jenderny J, Jacobi ML, Ruger A et al (1992) Chromosome aberrations in 450 sperm complements from eight controls and lack of increase after chemotherapy in two patients. Human Genetics 90:151–154 240. Martin RH, Rademaker AW, Leonard NJ (1995) Analysis of chromosomal abnormalities in human sperm after chemotherapy by karyotyping and fluorescence in situ hybridization (FISH). Cancer Genetics Cytogenetics 80:29–32 241. Kobayashi H, Larson K, Sharma RK et al (2001) DNA damage in patients with untreated cancer as measured by the sperm chromatin structure assay. Fertility Sterility 75:469–475 242. Morris ID (2002) Sperm DNA damage and cancer treatment. Int J Androl 25:255–261

214 243. Meistrich ML, Goldstein LS, Wyrobek AJ (1985) Longterm infertility and dominant lethal mutations in male mice treated with adriamycin. Mutat Res 152:53 244. Generoso WM, Witt KL, Cain KT et al (1995) Dominant lethal and heritable translocation tests with chlorambucil and melphalan in male mice. Mutat Res 345:167–180 245. Brinkworth MH (2000) Paternal transmission of genetic damage: findings in animals and humans. Int J Androl 23:123–135 246. Hales BF, Robaire B (2001) Paternal exposure to drugs and environmental chemicals: effects on progeny outcome. J Androl 22:927–36 247. Meistrich ML (1993) Potential genetic risks of using semen collected during chemotherapy [comment]. Human Reproduction 8:8–10 248. Hawkins MM, Draper GJ, Winter DL (1995) Cancer in the offspring of survivors of childhood leukaemia and non-Hodgkin lymphomas [comment]. Br J Cancer 71: 1335–1339 249. Byrne J, Rasmussen SA, Steinhorn SC et al (1998) Genetic disease in offspring of long-term survivors of childhood and adolescent cancer [comment]. Am J Human Genetics 62:45–52 250. Meistrich ML, Byrne J (2002) Genetic disease in offspring of long-term survivors of childhood and adolescent cancer treated with potentially mutagenic therapies. Am J Human Genetics 70:1069–1071 251. Sankila R, Olsen JH, Anderson H et al (1998) Risk of cancer among offspring of childhood-cancer survivors. Association of the Nordic cancer registries and the Nordic society of paediatric haematology and oncology [comment]. N E J Med 338:1339–44 252. Hansen PV, Glavind K, Panduro J et al (1991) Paternity in patients with testicular germ cell cancer: pretreatment and post-treatment findings. Eur J Cancer 27:1385–1389 253. Babosa M, Baki M, Bodrogi I et al (1994) A study of children, fathered by men treated for testicular cancer, conceived before, during, and after chemotherapy. Med Pediatric Oncol 22:33–38 254. Carson SA, Gentry WL, Smith AL et al (1991) Feasibility of semen collection and cryopreservation during chemotherapy. Human Reproduction 6:992–994 255. Johnson SA, Goldman JM, Hawkins DF (1979) Pregnancy after chemotherapy for Hodgkin’s disease. Lancet 2:93

A.R. Bradbury and R.L. Schilsky 256. Li FP, Fine W, Jaffe N et al (1979) Offspring of patients treated for cancer in childhood. J Natl Cancer Inst 62:1193–1197 257. Van Thiel DH, Ross GT, Lipsett MB (1970) Pregnancies after chemotherapy of trophoblastic neoplasms. Science 169:1326–1327 258. Kung FT, Chang SY, Tsai YC et al (1997) Subsequent reproduction and obstetric outcome after methotrexate treatment of cervical pregnancy: a review of original literature and international collaborative follow-up. Human Reproduction 12:591–595 259. Green DM, Zevon MA, Lowrie G et al (1991) Congenital anomalies in children of patients who received chemotherapy for cancer in childhood and adolescence [comment]. N E J Med 325:141–146 260. Aisner J, Wiernik PH, Pearl P (1993) Pregnancy outcome in patients treated for Hodgkin’s disease. J Clin Oncol 11:507–512 261. Dodds L, Marrett LD, Tomkins DJ et al (1993) Casecontrol study of congenital anomalies in children of cancer patients. BMJ 307:164–168 262. Garber JE (1989) Long-term follow-up of children exposed in utero to antineoplastic agents. Seminars Oncol 16:437–444 263. Holmes GE, Holmes FF (1978) Pregnancy outcome of patients treated for Hodgkin’s disease: a controlled study. Cancer 41:1317–1322 264. Petersen PM, Hansen SW, Giwercman A et al (1994) Dose-dependent impairment of testicular function in patients treated with cisplatin-based chemotherapy for germ cell cancer. Ann Oncol 5:355–358 265. Howell S, Shalet S (1998) Gonadal damage from chemotherapy and radiotherapy. Endocrinol Metabol Clin N Am 27:927–943 266. Schilsky RL, Davidson HS, Magid D (1987) Gonadal and sexual function in male patients with hairy cell leukemia: lack of adverse effects of recombinant alpha-2 interferon treatment. Cancer Treat Repo 179:71 267. Fisher B, Sherman B, Rockette H et al (1979) 1-phenylalanine mustard (L-PAM) in the management of premenopausal patients with primary breast cancer: lack of association of disease-free survival with depression of ovarian function. National surgical adjuvant project for breast and bowel cancers. Cancer 44:847–857

Chapter 11

Targeting the Tumor Microenvironment for Enhancing Chemotherapy in Hematologic Malignancies Luis A. Crespo, Xinwei Zhang, and Jianguo Tao

Abbreviations ALL AML APRIL BAFF bFGF BMSC CAM-DR CLL CML ECM EM-DR FADD FLIP FN HDACi HSC HSP IL-6 MAPK MRD MM NF-κB NHL STAT TGF-β TNF VEGF

Acute lymphoblastic leukemia Acute myelocytic leukemia A proliferation-inducing ligand B cell-activating factor of the tumor necrosis factor family Basic fibroblast growth factor Bone marrow stromal cell Cell adhesion mediated drug resistance Chronic lymphocytic leukemia Chronic myelocytic leukemia Extracellular matrix Environment mediated drug resistance Fas-associated via death domain FADD-like interleukin-1beta-converting enzyme (FLICE)-like inhibitory protein Fibronectin Histone deacetylase inhibitor Hematopoietic stem cell Heat shock protein Interleukin-6 Mitogen-activated protein kinase Minimal residual disease Multiple myeloma Nuclear factor-kappaB Non-Hodgkin’s lymphoma Signal transducers and activators of transcription Transforming growth factor-beta Tumor necrosis factor Vascular endothelial growth factor

J. Tao () Hematopathology and Laboratory Medicine, University of South Florida College of Medicine, H. Lee Moffitt Cancer Center and Research Institute, 12901 Magnolia Drive, Tampa, FL 33612, USA e-mail: [email protected] B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_11, © Springer Science+Business Media B.V. 2011

215

216

11.1 Introduction Although profound advances have been made in the treatment of hematologic malignancies, many of these cancers remain incurable due to the effects of minimal residual disease (MRD) and the emergence of drug resistance. The emergence of clinical drug resistance continues to be an obstacle for the successful treatment of hematologic malignancies l. It is generally believed that many cancers develop resistance to drugs as a result of the selection of rare mutant cells which are resistant to the cytotoxic action of certain drugs. Most research on drug resistance so far has focused on identifying genetics, epigenetic and phenotypic properties of tumor cells based unicellular drug selection. The unicellular drug-resistant model has been critical in elucidating drug-resistant mechanism and in some cases have aided in the identification of drug targets. However, these models do not address resistance mechanisms that contribute to de novo drug resistance. The cancer cell is only part of the story in tumorgenesis. As a cancer cell grows within the elaborate architecture of the body’s tissues and organs, it interacts with its surrounding environment. Mounting evidence now suggests that a dynamic interaction occurs between the tumor cell and its local and systemic microenvironment, with each profoundly influencing the behavior of the other. This “tumor microenvironment,” is a critical determinant for tumor initiation, progression and response to therapy. We propose that specific niches within the tumor microenvironment may provide a sanctuary for subpopulations of tumors cells that affords a survival advantage (due to stromal-tumor cell-cell interaction) following initial drug exposure and may facilitate the acquisition of acquired drug. Certain cancer cells can elicit mechanisms, such as the evasion of apoptosis, to avoid cell death and persist in the patient even after many rounds of chemotherapy. Unfortunately, many of these patients relapse and eventually succumb to disease due to these remaining, often initially undetectable, tumor cells. Some of these cancer cells are intrinsically resistant to chemotherapeutic agents, while others become resistant to drugs throughout the course of treatment. The evasion of apoptosis in hematologic cancer cells is influenced, if not enhanced, by factors, both soluble

L.A. Crespo et al.

and physical, of the tumor microenvironment. The tumor microenvironment of a hematologic malignancy is a source of nutrition and survival factors for the tumor cell, and provides a sanctuary for the tumor cells to prosper, even following chemotherapeutic insult. This microenvironment is comprised of physical determinants, such as bone marrow stromal cells (BMSCs), blood vessels, and extracellular matrix (ECM) components, including fibronectin; and soluble factors, such as growth factors and cytokines [81] (see Fig. 11.1). Microenvironment-mediated drug resistance is a form of de novo drug resistance that protects tumour cells from the initial effects of diverse therapies. Surviving foci of residual disease can then develop complex and permanent acquired resistance in response to the selective pressure of therapy. Recent evidence demonstrated that microenvironment-mediated drug resistance arises from an adaptive, reciprocal signalling dialogue between tumour cells and the surrounding microenvironment [89]. We propose that new therapeutic strategies targeting this interaction should be applied during initial treatment to prevent the emergence of acquired. This chapter is divided into three sections and each we will discuss the intermingled roles of the tumor microenvironment and apoptosis in hematologic malignancies. First, we discuss the role of the tumor microenvironment in hematologic tumorigenesis and cancer cell survival, highlighting one of the main mechanisms by which certain cells become malignant: via evasion of apoptosis. Second, we discuss the drug resistance due to microenvironmental influences in hematologic malignancies are discussed. The emergence of drug resistance and the role that the tumor microenvironment and cell cycle proteins play in evasion of apoptosis are described. Finally, we will summarize current treatment strategies of hematologic malignancies aimed at overcoming drug resistance and completely eradicating the cancer, by targeting the tumor cell, the tumor microenvironment, and/or the interactions between the tumor cell and the tumor microenvironment. Each section focuses on a different regulatory aspect of the tumor microenvironment, with an emphasis on microenvironmental regulations which aid the tumor cell in evading apoptosis.

11 Tumor Microenvironment for Enhancing Chemotherapy

217

Fig. 11.1 Illustration of tumor microenvironment in hematologic tumors and drug resistance model

11.2 Tumor Microenvironment Influences Hematologic Tumorigenesis and Tumor Cell Survival Early work by Hanahan and Weinberg identified six hallmarks of cancer, and suggested that these six alterations within the cell dictate the origination of a malignancy [46]. These six characteristics are: “self-sufficiency in growth signals, insensitivity to growth-inhibitory signals, evasion of apoptosis, limitless replicative potential, sustained angiogenesis, and tissue invasion and metastasis” [46]. Hematologic malignancies exhibit many, if not all, of these traits, and understanding the mechanisms of tumorigenesis is

crucial to both diagnosing and finding a cure for these diseases. To this end, much effort has been focused on determining how hematopoietic cells evade apoptosis, a key component of cellular homeostasis, and eventually become malignant. Factors that are present in tumour microenvironments induce tumor cell drug resistance by two primary mechanisms: soluble factormediated drug resistance and cell adhesion-mediated drug resistance (CAM-DR). Most tumour cells succumb to therapy, but the interaction of a subset of tumour cells with microenvironmental factors allows them to survive the insult of therapy in a quiescent, protected state, resulting in minimal residual disease (MRD). Over time, genetic instability inherent in cancer cells combined with the strong selective pressure of therapy leads to successive, random genetic

218

changes that cause the gradual development of more complex, diverse and permanent acquired-resistance phenotypes. These persistent tumour cells eventually cause disease recurrence and are much less likely to respond to subsequent therapy after acquired resistance develops. Therapeutic strategies that disrupt stromatumor cell interaction pathways would reduce the level of residual tumor cells and therefore reduce the emergence of acquired resistance. The following section focuses on the role of dysregulated apoptosis in the formation of hematologic malignancies by highlighting the involvement of the tumor microenvironment in this process. Numerous growth factors and cytokines has been demonstrated to play a role in hematologic tumorigenesis, and the survival factors described below provide examples of how environmental cues can support the growth of the tumor cell.

11.2.1 Transforming Growth Factor-β ß1-integrin is a major cell surface adhesion receptor that transmits signals from the ECM and that plays critical roles in growth, differentiation and carcinogenesis. ß1-integrin can block the apoptosis that is induced by several reagents and can therefore function as a survival factor [114]. TGF-ß is highly expressed in many malignant tumors with varying sensitivity of the tumor cells to TGF-ß. The loss of the growth inhibitory effects of TGF-ß is regarded as an important pathway to carcinogenesis and have been shown to contribute to hematopoietic tumorigenesis. The transforming growth factor-β (TGF-β) family of growth factors is known to play a vital, negative-regulatory role in hematopoiesis. The TGF-β signaling pathway has been shown to regulate the cellular processes of differentiation, motility and adhesion, proliferation and apoptosis [39]. Specifically, TGF-β, an inhibitor of the growth of hematopoietic cells, causes arrest at the G1 phase of the cell cycle [2], which can in turn induce apoptosis [27, 86]. Aberrant expression of TGF-β can, therefore, have detrimental outcomes due to uninhibited cell growth, and this growth factor has indeed been linked to hematologic tumorigenesis. For example, a study of using murine plasmacytomas found that these plasmacytomq cells exhibited inactivated TGFβ receptors, and became refractory to the treatment effects of TGF-β when compared to non-transformed

L.A. Crespo et al.

plasma cells [3]. Similar results on TGF-β , where loss of TGF-β receptors or receptor mutations, and thus resistance to the growth inhibitory effects of TGF-β, has also been found in chronic lymphocytic leukemia (CLL) [22, 80], non-Hodgkin lymphoma (NHL) [10], and multiple myeloma [30]. Altered TGF-β signaling due to defects downstream of the TGF-β receptor have also been discovered in a number of hematologic malignancies [27], including acute myeloid leukemia (AML) [62], acute lymphocytic leukemia (ALL) [125], and essential thromobcythemia [78]. Three mammalian isoforms of TGF-β (TGF-β1, 2, and 3) has been described [110]. Bone marrow stromal cells (BMSCs), a component of the tumor microenvironment, as well as multiple myeloma (MM) cells, have been shown to produce TGF-β1 [121]. This study also reported that BMSCs from MM patients secrete significantly more TGF-β1 than do BMSCs from disease-free subjects [121], and BMSCs derived from ALL patients also show enhanced TGF-β1 expression when compared to their normal counterparts [15]. These results suggest that these tumor cells may be resistant to the inhibitory effects of TGF–β. Finally, it has been reported that TGF-β1 and –β2 can stimulate the production of such growth factors as IL-6 and VEGF [49, 65], leading to enhanced tumor cell survival in a microenvironment where TGF-β is overexpressed.

11.2.2 Vascular Endothelial Growth Factor and Fibroblast Growth Factor Other elements in the microenvironment that may influence tumor sensitivity to therapy are the response of stromal cells to therapy and the expression of factors such as basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF). Although the importance of angiogenesis in the progression of hematopoietic malignancies is not fully understood, these growth factors have been shown to play a crucial role. Patients with CLL, as characterized by accumulation of B-lymphocytes, typically display elevated levels of bFGF, and these levels correlate with the disease stage and are associated with resistance to the apoptosis-inducing drug fludarabine [90]. NonHodgkin’s lymphoma (NHL) survival has also been

11 Tumor Microenvironment for Enhancing Chemotherapy

shown to be decreased in patients with elevated VEGF and bFGF levels [112], and increased plasma levels of VEGF and bFGF when compared to normal controls have been found in myelodysplastic syndrome and certain leukemias [128]. Also, in multiple myeloma (MM) increased angiogenesis patients correlates with prognosis [8], and FGF and VEGF receptors are found to be expressed on MM patient cells, which implies an autocrine loop that may be important for MM cell survival [107, 128]. Additionally, a frequent translocation seen in MM patients is the t(4:14), which involves the FGF receptor (FGFR) 3 locus. This activating translocation has been shown to regulate tumor progression, and to promote transformation by activating the MAP kinase pathway [13]. Finally, MM cell survival is further aided by enhanced secretion of IL-6 by the BMSCs, which has been shown to be regulated in part by VEGF [20]. Fragoso et al. analyzed the effects of activation of a VEGF receptor, VEGFR-1/FLT-1, on ALL survival [33] and revealed that activation of this receptor on ALL cells in vitro resulted in cell proliferation as well as tumor cell migration. Moreover, in vivo neutralization of FLT-1 led to increased leukemic apoptosis [33], indicating that VEGF plays an important role in tumor cell survival. Both VEGF and bFGF have been shown to influence apoptotic pathways, leading to enhanced tumor cell survival. The Bcl-2/Bax ratio has been found to be increased following activation of VEGF and leads to a decrease in apoptosis [24]. Overexpression of VEGF increases the expression of heat shock protein (Hsp) 90, resulting in activation of the mitogen-acitvated protein kinase (MAPK) cascade, and increased expression of Bcl-2 [25]. Furthermore, infection of VEGF receptor positive normal endothelial cells with VEGF enhanced Hsp90 and Bcl-2 expression, which resulted in downregulation of apoptosis following both serum starvation and treatment with the Hsp90 inhibitor geldanamycin [25]. The anti-apoptotic effects of these growth factors have also been reported in CLL cells. Bcl-2 mRNA and protein expression in B-CLL cell lines and patient specimens were analyzed following treatment with bFGF [77] and bFGF did indeed upregulate bcl-2 expression, and that this upregulation likely contribute to delayed fludarabine-induced apoptosis. Overall, VEGF and FGF, play a important role in hematopoietic tumor cell survival and evasion of

219

apoptosis. It is becoming increasingly evident that these factors are vital and may be relevant targets for the treatment of such diseases.

11.2.3 Interleukin-6 Interleukin 6 (IL-6) is known to mediate resistance to various chemotoxics in in vitro stroma-mediated drug resistance models of haematological cancer and are produced at higher levels in tumour-associated stroma than in normal bone marrow stroma. IL-6 is a pleiotropic cytokine that has been shown to have roles in gene activation, differentiation and proliferation [14]. Increased levels of IL-6 have been found in the supernatants of pediatric ALL patient marrow samples when compared to control samples, and these levels decreased back to normal levels once these patients were in remission [29]. This cytokine has also been shown to have growth inhibitory effects on B cells while promoting growth and survival of MM cells [14]. Moreover, one study found that autocrine production of IL-6 by MM patient mononuclear cells produced a “highly malignant phenotype”, and these IL-6- producing clones were also shown to be more resistant to spontaneous and dexamethasone-induced apoptosis [34], indicating that IL-6 promotes tumor cell survival via protection from apoptosis. Given the importance of this cytokine in MM cell survival, treatment of MM cells with anti-IL-6 monoclonal antibodies inhibited MM cell proliferation [5]. The most widely studied survival effects on IL-6 have been from in MM. In the normal B-cell development, B lymphocytic maturation into antibody producing plasma cells is known to be induced by IL-6 [12], and these short-lived cells die via apoptosis within a matter of weeks [14]. However, IL-6 acts as a growth factor in MM cell lines and patient specimens [67, 74], often through inhibition of apoptosis. IL-6 has been found to be produced by both the MM cell itself as well as by the BMSCs [47, 67, 73], indicating a positive regulation of MM cell growth and survival by tumor microenvironmental influences. IL-6 secretion by BMSCs induces a number of survival pathways, including the nuclear factor (NF-κB), signal transducers and activators of transcription (STAT) and MAPK pathways. The STAT family of transcription factors, which contains seven members [31], have been shown

220

to regulate the processes of cellular differentiation, proliferation and apoptosis [9]. Catlett-Falcone et al. reported constitutive activation of Stat3 in the IL-6 dependent U266 MM cell line, as well as in MM patient mononuclear cells [11]. Further, it was determined that the U266 cells, which exhibit resistance to Fas-induced apoptosis, overexpressed anti-apoptotic Bcl-xL , and blocking IL-6 receptor signaling led to attenuated Bcl-xL expression and induction of apoptosis [11]. This report indicates that IL-6 can prevent apoptosis of MM cells via activation of Stat3 and subsequent upregulation of Bcl-xL , which contributes to overall tumor cell survival. In a different report, using B16 melanoma cells, overexpression of a STAT3 dominant-negative variant was shown to induce both cell cycle arrest and apoptosis in the tumor cells [102]. These reports indicate targeting IL-6 secretion as well as by targeting the signaling pathways induced by this cytokine should be applied in MM therapy.

11.2.4 B Cell Activating-Factor of the Tumor Necrosis Factor Family B cell activating-factor of the tumor necrosis factor family (BAFF) protein has been shown to specifically target B lymphocytes, promote B cell proliferation, activation, and differentiation, enhance B lymphocyte survival, and thereby stimulate immunoglobulin production both in vitro and in vivo [26]. In normal mice receiving injections of BAFF, lymphoid compartments in the spleen undergo marked expansion, and plasma levels of immunoglobulins increase significantly [106] supporting the role of BAFF in B cell homeostasis [41, 113] and BAFF transgenic mice [42, 70, 87]. Mice lacking BAFF have extreme reductions of mature B cells in peripheral blood, whereas mice overexpressing BAFF have increased numbers of mature splenic and lymph node B cells, elevated immunoglobulin levels, and manifestations of autoimmune disease [42]. BAFF exerts these effects through improving survival of peripheral B cells [91, 100], and allow escape of B cells from cytotoxic apoptosis, leading to autoimmune diseases. Collectively, these findings suppoet that that BAFF plays a critical role in maintaining B cell homeostasis, with insufficient signaling by BAFF resulting in B cell deficiency and excessive signaling causing B cell disorders [82]. For example, He

L.A. Crespo et al.

et al. report that lymphoma B cells evade apoptosis through upregulation of BAFF [57]. The role of BAFF in B lymphoma cell survival and drug resistance has been further substantiated by recent emerging reports on CLL and MM. Kern et al. demonstrated that addition of soluble BAFF or APRIL protected B-CLL cells against spontaneous and drug-induced apoptosis and conversely, addition of anti-BAFF and anti-APRIL antibodies enhanced B-CLL cell apoptosis [68]. Most recently, Moreaux and colleagues provided evidence that BAFF was involved in the survival of primary MM cells and protected MM cells from dexamethasoneinduced apoptosis [95]. Taken together, these results indicate that B-CLL and MM cells can be rescued from apoptosis through a process involving BAFF and its receptors. Of note the origin of BAFF remains undefined, even though an autocrine interaction can account for a subset of CLL. Although the majority of lymphoma cells exhibit characteristics consistent with prolonged cell survival in vivo, when cultured in vitro lymphoma cells often undergo spontaneous apoptosis. This observation suggests that autocrine regulation of BAFF is not sufficient to maintain hematopoietic cell survival. However, BAFF has been detected on BMSCs derived from MM patients, and secretion of BAFF was enhanced by adhesion of the tumor cell to the BMSC [117]. This group also reported that addition of BAFF enhanced tumor-BMSC adhesion, further implicating the involvement of this factor in mediating interactions between the tumor and its microenvironment. Our recent work demonstrates that bone marrow derived BAFF protect lymphoma from therapy-induced apoptosis [85]. The molecular signaling of BAFF has been shown to activate the NF-kB signaling pathway and, consequently, NF-κB activation can lead to upregulation of BAFF [83, 117]. The transcription factor NF-κB is widely recognized as a critical mediator of immune and inflammatory responses. In most cell types, NF-κB is found in the cytoplasm where it is associated with an inhibitory protein known as IκB. After activation by a large number of inducers, the IκB proteins become phosphorylated, ubiquitylated and, subsequently, degraded by the proteasome. The degradation of IκB allows NF-κB proteins to translocate to the nucleus and bind their cognate DNA binding sites to regulate the transcription of a large number of genes, including antimicrobial peptides,

11 Tumor Microenvironment for Enhancing Chemotherapy

cytokines, chemokines, stress-response proteins and anti-apoptotic proteins. NF-κB has attracted attention because of both its unique activation pathways and its physiological importance as a key regulatory molecule in the immune response, cell proliferation and cell survival during stress. NF-κB protects cells from apoptosis by promoting expression of survival factors, such as members of the inhibitor of apoptosis (IAP) family (c-IAP-1, c-IAP-2, XIAP) and the Bcl-2 homologs (Bfl-1/A1 and Bcl-XL ). In a signaling cascade that involves activation of IKK, p100 and p105 can be phosphorylated and partially cleaved to yield the product proteins p52 and p50, respectively [58, 111, 126]. This allows nuclear translocation of p50 and p52 and binding to target DNA sequences. This pathway has been called the “alternative” or “non-canonical” NF-κB signaling pathway, with a bias towards differentiation, architecture and proliferation within the B cell compartment. BAFF are among few cytokines that are known induce non-canonical NF-κB activation [48, 113]. As a consequence of BAFF-mediated NF-κB activation, antiapoptotic genes encoding Bcl-2, Bcl-xL and Bfl-1/A1 are activated, leading to enhanced cell survival [26] and drug resistance.

11.3 Tumor Microenvironment Influences Drug Sensitivity and Resistance Dynamic signalling interactions between tumour cells and mesenchymal stroma in the microenvironment induce a transient, resistant state that protects tumour cells from therapy by inducing the stroma-mediated drug resistance phenotype. Integrins on tumour cells bind to fixed extracellular matrix components secreted by both tumour cells and stroma, and to receptors expressed on stroma, such as vascular cell adhesion protein 1 (VCAM1). This adhesion of haematopoietic and epithelial tumour cells induces quiescence and modulates the regulation of pro- and anti-apoptotic molecules, conferring cell adhesion-mediated drug resistance (CAM-DR) in microenvironments. The treatment of a hematologic malignancy often involves chemotherapy, radiation, or both. Also, many treatment regimens call for combination therapy, where more than one chemotherapeutic drugs are used as a means of trying to completely eradicate the cancer

221

by targeting multiple mechanisms that contribute to tumor cell survival. Although patients with hematologic malignancies typically respond to initial therapy, many relapse and often cannot be cured of their disease. This relapse is mainly due to minimal residual disease (MRD), where a small population of cancer cells is able to withstand the chemotherapeutic insult. Tumor cells can be resistant to drug by means of intrinsic resistance, de novo resistance due to extrinsic factors, or acquired resistance. Many molecular changes are seen when a hematopoietic cell turns malignant, and some of these modifications and the affected signaling pathways are known to contribute not only to carcinogenesis but also to intrinsic drug resistance. For example, FLIP (FADD-like interleukin-1beta-converting enzyme (FLICE)-like inhibitory protein) proteins prevent the effective activation of procaspase-8 and procaspase-10 by forming complexes with these proteins [108], and therefore inhibit apoptosis. FLIP overexpression has been shown to be imperative for tumor cell survival in a number of hematologic malignancies, including Burkitt’s lymphomas [122] and KSHV-associated lymphoma cells [43], and overexpression of FLIP has also been linked to intrinsic drug resistance to Fas and TRAIL [108]. Resistance to tumor therapy can be subdivided into two broad categories: de novo and acquired. Acquired resistance develops over time as a result of sequential genetic changes that ultimately culminate in complex therapy-resistant phenotypes. Conversely, one form of de novo drug resistance is stroma-mediated drug resistance (EMDR), in which tumor cells are transiently protected from apoptosis induced by either chemotherapy, radiotherapy or receptor-mediated cell death. Aside from being intrinsically resistant to chemotherapeutic drugs, tumor cells may also be able to survive initial cytotoxic insult by means of de novo resistance associated with a tumor cell’s interactions with its surrounding microenvironment. Once a cell survives initial chemotherapeutic treatment, it may then develop mutations that allow it to become resistant to the drug(s) being used, a phenomenon known as acquired drug resistance. For example, low-grade follicular lymphomas regress after treatment, but relapse due to MRD occurs with a drug resistant tumor at the same site [60], indicating that the microenvironment of the tumor acts as a sanctuary to promote tumor cell survival and drug resistance. The remainder of this section

222

of the chapter will focus on the contribution of the tumor microenvironment to both de novo and acquired drug resistance, which typically occur via deregulation of apoptotic pathways.

11.3.1 De novo Drug Resistance Durand and Sutherland first reported that single cells were less likely to survive damage due to radiation than were cells grown as a spheroid [28]. They reported that cells that were grown in contact with one another were better able to repair radiation damage than those that were not grown as a spheroid, and repair capacity was also increased when these cells were irradiated while maintaining cellular contact [28]. This work indicates that cells can impart essential signals to surrounding cells, signals that can enhance cell survival. In a later publication by Teicher et al. [118], EMT-6 murine mammary tumors were made resistant to drugs in vivo, by treating the tumor-bearing mice with drugs commonly used as therapies these tumors. Interestingly, it was discovered that following six months treatment, high levels of drug resistance were seen in vivo, but these tumor cells were not resistant to the drugs in vitro. These results indicate that the environment in which these cells live is a crucial determinant of cellular survival and drug resistance. To support the involvement of the tumor microenvironment in tumor cell survival and drug resistance, much research is now focused not only on analyzing the tumor cell by itself, but also analyzing the tumor cell in the context of different components of what would be its in vivo environment. Damiano et al. analyzed a multiple myeloma (MM) cell line, namely 8226, in the presence of the extracellular matrix component fibronectin (FN) [18] and demonstrated that MM cells adhered to FN via α4 β1 and α5 β1 integrins were more resistant to apoptosis following exposure to melphalan or doxorubicin than were cells grown in suspension. This group coined the term cell adhesion mediated drug resistance (CAM-DR), which emphasizes the fact that the cells must be physically adhered to the FN in order for the drug resistance phenotype to occur. Although it had previously been reported in that adhesion of B-CLL and Chinese hamster ovary cells to FN via α4 β1 or α5 β1 integrins, respectively, supported cell survival through up-regulation of the

L.A. Crespo et al.

anti-apoptotic bcl-2 protein [21, 88, 127], the mechanism of CAM-DR in the case of the 8226 cells was determined not to be due to altered expression of bcl2 family proteins. It was later found that CAM-DR in the 8226 cell line was associated with increased levels of p27kip1 protein [52]. This protein caused a G1 phase cell cycle arrest, and once cells were detached from FN, p27kip1 levels were rapidly reduced, cells entered S phase, and the CAM-DR phenotype was reversed. Furthermore, treatment of these cells with antisense p27kip1 attenuated drug resistance as measured by apoptosis, implicating this protein, a cell cycle regulatory protein, in the anti-apoptotic effects of CAM-DR [52]. Lwin and colleagues have also shown that adhesion of non-Hodgkin’s lymphoma cell lines to bone marrow stromal cells (BMSCs), another component of the tumor microenvironment, resulted in a G1 cell cycle arrest that was associated with elevated p27Kip1 and p21 protein levels [83]. And, as a final point, the clinical relevance of the CAM-DR phenotype has also been confirmed, in a report showing that adhesion of primary MM patient specimens to FN attenuated the percentage of apoptotic cells and thus conferred resistance to melphalan [53]. CAM-DR has also been found to be relevant in other hematopoietic tumors as well. Following adhesion of the histiocytic lymphoma U937 cell line to FN, enhanced resistance to the topoisomerase II inhibitor mitoxantrone was seen [56]. Adhesion to FN also enhanced U937 cell survival following exposure to Fas, and inhibition of apoptosis in this case was determined to be due to a redistribution of c-FLIPL to the cytosol [116]. Chronic myelogenous leukemia K562 cell line was also found to be resistant to melphalan and BCR-ABL inhibitors upon adhesion to FN [19]. A subsequent paper reported that adhesion of K562 cells to FN via β1 integrins enhanced proteasomal degradation of Bim, a pro-apoptotic bcl-2 family member, and reduction of Bim levels contributed to de novo drug resistance in these cells [50]. Taken together, these works indicate that components of the tumor microenvironment augment tumor cell survival and drug resistance by enhancing anti-apoptotic signaling, and thus should be taken into consideration when studying and attempting to overcome drug resistance. Tumor cells are co-cultured with BMSCs, and the effects that the combination of both soluble factors and cell-cell contact have on microenvironment-mediated drug resistance can be analyzed. As a means to

11 Tumor Microenvironment for Enhancing Chemotherapy

Fig. 11.2 Research models utilized to study tumor microenvironmental effects. (a) Fibronectin (FN) model. Tumor cells are adhered to plates coated with FN. (b) Co-culture model. Tumor cells are co-cultured with bone marrow stromal cells (BMSCs), and the concurrent effects of soluble factors and direct contact between the two cells are studied. (c) Transwell model. BMSCs and tumor cells are separated by a microporous membrance to study of the effect of soluble factor production on the tumor cells, without the component of direct adhesion

decipher mechanisms involved in EM-DR, the transwell system was created; this system allows for analysis of the role of soluble factors, adhesion, or both, in this de novo resistance. In this system, the BMSCs are plated and the tumor cells can be adhered to these cells as a means to study the tumor microenvironmental effects as a whole, taking into consideration influences due to both adhesion and soluble factors. Alternatively, the tumor cells can be separated from the BMSCs by a thin, microporous membrane that allows for the freeflow of soluble factors, produced by both the BMSCs and the tumor cells, throughout the well, as a means to study only the impact of soluble factors on tumor cell survival without the added component of cellular adhesion (see Fig. 11.2). The BMSC system has been utilized to study the impact that these cells have on the survival of a variety of hematological cancer types. For instance, chronic lymphocytic leukemia (CLL) cells were shown to be protected from spontaneous apoptosis via contact with normal BMSCs, a protection that was not extended to normal B cells under the same conditions [79]. The anti-apoptotic phenotype observed in the CLL cells was associated with bcl-2 expression. Additionally, using both the transwell system and stromal cell conditioned media, it was observed that direct contact

223

with the BMSCs was necessary to attenuate spontaneous apoptosis [79]. Survival following chemotherapy of acute lymphoblastic leukemia (ALL) cells in the presence of BMSCs has been analyzed in acute lymphoblastic leukemia cells [98]. ALL cells alone or cocultured with BMSCs were treated with cytarabine (Ara-C) or etoposide (VP-16). Following drug treatment, a reduction in apoptosis was observed in leukemic cells cocultured with BMSCs compared to cells exposed in the absence of BMSCs. Furthermore, it was reported that adhesion to the stroma was necessary for protection from apoptosis, as leukemic cells treated with conditioned media, which contains soluble factors provided by the BMSCs, did not exhibit attenuated apoptosis [98]. A subsequent study by this group revealed that the BMSCs protected the ALL cells from apoptosis induced by Ara-C and VP-16 by regulating the caspase-3 activity of the leukemia cells [32]. In another study, this time analyzing a panel of acute myeloid leukemia (AML) patient specimens, it was also observed that direct adhesion of the tumor cells to BMSCs inhibited chemotherapy-induced apoptosis of the AML cells. Interestingly, bcl-2 protein expression in the AML cells was not consistently linked to the anti-apoptotic effect observed [36], suggesting that the mechanisms of CAM-DR may vary from patient to patient. Finally, using the transwell system, this group also found that the mere presence of BMSCs could inhibit leukemic cell apoptosis as well, but to a much lesser degree than conferred by direct contact with the BMSCs [36]. Analysis of bone marrow-tumor cell interactions has also revealed that the tumor cells themselves can affect the microenvironment in which they reside, often leading to a microenvironment that is even more conducive to tumor cell survival. Viega et al. reported that ALL cells can stimulate bone marrow endothelium and promote angiogenesis in the bone marrow surrounding the leukemic cells [123]. In turn the bone marrow endothelium then supported tumor cell survival via regulation of anti-apoptotic bcl-2. In addition to bcl-2, Notch signaling has also been implicated in hematologic tumor cell survival and de novo resistance associated with BMSCs. Notch family members and their associated targets have been found to be overexpressed in various hematologic malignancies [61, 63, 119], including in T cell acute lymphoblastic leukemia, where NOTCH1 activating mutations were found in more than half

224

of the cells analyzed [124]. Notch1 is a transmembrane receptor expressed on hematopoietic cells. The intracellular domain of Notch1 is release upon ligand binding, and this intracellular region of Notch1 (IRN1) then translocates to the nucleus and regulates gene transcription [38]. Notch signaling in MM cells was analyzed by Nefedova et al. [101]. This group found that adhesion to BMSCs activated Notch signaling. Furthermore, activation of Notch-1 due to BMSC adhesion was found to be involved in protection of the MM cells from apoptosis induced by melphalan and mitoxantrone, a protection that was also associated with enhanced regulation of the cell cycle protein p21WAF/Cip [101]. As a final example of how the tumor microenvironment influences de novo drug resistance, it was recently reported that adhesion of the SUDH-4 and SUDH-10 cell lines, two B-cell lymphoma cell lines, to BMSCs protected the lymphoma cells from mitoxantrone-induced apoptosis, and this protection was associated with activation of the NF-κB (RelB/p52) pathway [84]. The anti-apoptotic molecules XIAP, cIAP1 and cIAP2, which are known to be regulated by NF-κB, were also found to be up-regulated following adhesion to BMSCs [84].

11.3.2 Acquired Drug Resistance When a tumor cell is able to survive the initial stress induced by chemotherapeutic drugs, by means of de novo drug resistance via tumor microenvironmental interactions, it may eventually develop acquired resistance to the drug. This acquired drug resistance is often the cause of treatment failure in hematologic malignancies, as these cancer cells can no longer be eliminated by way of standard therapy. To study acquired drug resistance mechanisms, unicellular models are commonly utilized, where a tumor cell line is treated with a particular drug over a period of time until the emergence of drug resistance. The cancer cell type and the selective pressure used both influence the mechanism of acquired drug resistance [17, 89]. Known mechanisms of acquired drug resistance include: modifying the target of the drug, through overexpression of the target or point mutations; reducing drug concentrations within the cell by decreasing drug uptake or increasing drug efflux; enhancing the efficiency of drug metabolism; enhancing DNA repair; and inhibiting apoptosis by activating anti-apoptotic pathways while

L.A. Crespo et al.

decreasing pro-apoptotic factors [55, 81]. Furthermore, acquisition of drug resistance by a tumor cell may involve more than one of these mechanisms to avoid being killed by a cytotoxic agent. The 8226/MR4 MM cell line, for instance, was selected for resistance to mitoxantrone, and acquired resistance in this cell line was associated with decreased intracellular drug levels via an efflux pump, as well as redistribution and reduction of enzymatic activity of topoisomerase II (the target of mitoxantrone) [17, 54]. In an effort to compare mechanisms associated with acquired drug resistance to those associated with de novo resistance, Hazlehurst et al. analyzed melphalan resistance in the 8226 MM cell line [53]. In this study, the characteristics of 8226 cells adhered to FN were compared to those of the 8226/LR5 cell line. The 8226/LR5 cell line was selected for resistance to melphalan by continued exposure of these cells to this drug for a period of 47 weeks, and thus represents a tumor cell line with acquired melphalan resistance [6]. Cells adhered to FN and 8226/LR5 cells both display reduced levels of apoptosis following exposure to melphalan when compared to the parental 8226 line in suspension. To compare de novo resistance to acquired resistance, oligonucleotide microarray analysis was performed, comparing the parental 8226 cell line to the 8226/LR5 cells or to 8226 cells adhered to FN. Changes in 1479 genes were observed in the 8226/LR5 cell line when compared to the parental 8226 line; 69 changes were found when comparing the parent to FN-adhered cells; and only 21 of the gene changes observed in both comparisons overlapped [53]. These results suggest that the mechanisms of de novo and acquired drug resistance are diverse, and therefore should both be taken into account when attempting to determine resistance mechanisms operative in vivo. Although the work described above defined mechanisms of both de novo and acquired drug resistance, the influence of the tumor microenvronment in the acquisition of drug resistance was not addressed in this study. However, in another study, the role that the tumor microenvironment plays in acquired drug resistance was analyzed [51]. In this study, U937 histiocytic lymphoma cell lines were selected for resistance to the topoisomerase II inhibitor mitoxantrone. These cells were selected for resistance both unicellularly (U937 cells in suspension) and while adhered to FN. Thus, the influence of CAM-DR on acquisition of drug resistance was studied. Interestingly, this group

11 Tumor Microenvironment for Enhancing Chemotherapy

found that following acquisition of drug resistance, the FN-adhered cells displayed greater than 2-fold mitoxantrone resistance levels when compared to their suspension counterpart. To measure levels of drug resistance, MTT assays were performed to determine the mean IC50 for each cell line. Importantly, the drug resistance levels were determined by analyzing cells in suspension, so the cells that were selected for resistance on FN were first detached then analyzed. Therefore, the 2- to 3- fold difference seen in resistance between the suspension-selected and FNselected cells was due to acquired drug resistance, without including the effects of de novo resistance; in other words, adhesion itself did not cause drug resistance, but FN-adhesion during selection of cells caused an increase in drug resistance. These results underscore the importance of considering the tumor microenvironment when studying drug resistance in hematologic malignancies. Hazlehurst et al. next wanted to determine the mechanism(s) by which these tumor cells, selected for resistance to mitoxantrone alone or in the presence of the extracellular matrix component FN, acquired drug resistance. It was reported that although drug resistance in both cases was associated with attenuated topoisomerase II activity and a decrease in DNA damage induced by drug, cells selected for resistance in suspension and cells selected while adhered to FN regulated this activity and damage utilizing different mechanisms [51]. Specificlly, it was determined that the mitoxantrone resistant U937 cells selected for resistance while in suspension exhibited decreased topoisomerase IIβ RNA and protein expression, which was linked with reduced expression of a transcription factor, NF-YA, known to regulate topoisomerase IIβ expression. On the other hand, when the CAM-DR model was used to select for selection, decreases in topoisomerase IIβ protein levels were associated with resistance, but no change in topoisomerase IIβ RNA expression or NF-YA levels was observed [51]. Taken together, this work and the work of others who have studied the role of the tumor microenvironment in drug resistance emphasizes the importance of considering tumor microenvironmental interactions. Genetic instability inherent in cancer cells combined with the strong selective pressure of therapy leads to successive, random genetic changes that cause the gradual development of more complex, diverse

225

and permanent acquired-resistance phenotypes. These persistent tumor cells eventually cause disease recurrence and are much less likely to respond to subsequent therapy after acquired resistance develops. Therapeutic strategies that disrupt EMDR pathways would reduce the level of MRD and therefore reduce the emergence of acquired resistance. Taking into account the influences of the tumor microenvironment when studying mechanisms of cell survival and resistance to chemotherapeutics will be of benefit by more realistically recapitulating the setting of the tumor cell in the cancer patient. Hopefully, better understanding of the mechanisms associated with drug resistance will ultimately lead to better treatment options through targeted therapy, and even cures of hematopoietic malignancies.

11.4 Targeting Tumor-Stroma Interaction and Pathways for Therapy of Hematologic Malignancies There are three categories of possible anti-EMDR therapeutic targets: extracellular ligand–receptor interactions, downstream pathways in tumour cells and downstream pathways in tumour stroma. In this next section we will focuses on chemotherapeutics aimed at eradicating hematopoietic malignancies by targeting stroma-tumor or its associated pathways. Certain drug in use today directly target the tumor cell by altering pathways activated in the tumor cell by the microenvironment, while others have been shown to induce cytotoxic effects by influencing interactions between the tumor and the microenvironment. Another example of chemotherapy being used today involves targeting the microenvironment itself as a means to decrease tumor cell survival. As an example of why targeting the microenvironment itself may be important, Moshaver and colleagues found that treatment of BMSCs with the chemotherapeutic agent cytarabine greatly reduced the ability of these cells to protect AML cells from spontaneous and cytarabine-induced cell death [98]. Importantly, many chemotherapeutic regimens in effect today for the treatment of hematopoietic malignancies often involve combinations of drugs, as a means to target various networks of pathways that are deregulated and lead to tumor

226

L.A. Crespo et al.

Fig. 11.3 Targets of overcoming microenvironment-mediated drug resistance: (1) cell-cell interaction (integrins), (2) soluble factors (BAFF and IL-6) and (3) stroma-tumor interaction induced signaling pathways

cell survival. For example, using a combination of two drugs, one of which induces apoptosis and the other which does not allow for cellular adhesion to tumor microenvironmental components, may ultimately be more efficacious in eliminating MRD and thus eradicating the cancer than treating a patient with only a single agent. The next few examples provide sound evidence for targeting deregulated pathways in the tumor cells as well as tumor microenvironmental influences as a means to overcome drug resistance and eliminate the tumor cells (see Fig. 11.3).

11.4.1 Chemotherapy Targeting bcl-2 It is well known that the bcl-2 family members are commonly aberrantly expressed in hematologic malignancies and involved in stroma-mediated tunor cell survival. For instance, Bcl-2 protein is commonly overexpressed in diffuse large B-cell lymphoma, CLL, MM and acute leukemias [75, 94]. Furthermore, the ratio of bax to bcl-2 has been shown to predict clinical outcome of AML patients [23], and bcl-2 expression is upregulated in MM cells following treatment with various cytotoxics [120]. Also, elevated expression of the proapoptotic bcl-2 family member bax in newly diagnosed AML patients has been found to be a good prognostic

indicator [104]. These studies, taken together with those above that implicate the apoptotic pathways in enhanced tumor cell survival, provide reason to target bcl-2 as a means to eliminate hematologic tumors. Antisense oligonucleotides targeting bcl-2 mRNA are currently undergoing laboratory as well as clinical studies. For example, oblimesen sodium (G3139, Genasense), which binds to the first six codons of Bcl2 mRNA [16], has been widely studied. Oblimesen has been shown to enhance the cytotoxic effects of a variety of chemotherapeutic agents [71], and this enhancement has been shown pre-clinically in hematologic tumor types such as NHL and EBV-associated lymphoproliferative disease [44, 72]. Also, Phase III clinical trials are currently underway using oblimersen for the treatment of CLL, which has shown promising results in combination with other chemotherapeutic agents [103]. In addition to bcl-2 antisense oligonucleotides, other agents have also been shown to target bcl-2 activity and therefore induce apoptosis. For example, histone deacetylases (HDACs) inhibitors have been reported to attenuate BCL2 expression in leukemia cell lines as well as in primary myeloma and leukemia specimens [69, 96, 108, 109]. Another inhibitor of bcl-2 and bcl-2 family proteins is the small molecule inhibitor ABT-737. This molecule binds to bcl-2 and bcl-xL, and has been shown to induce

11 Tumor Microenvironment for Enhancing Chemotherapy

apoptosis in MM cell lines [76]. Furthermore, this group also reported that addition of VEGF and IL-6 could not overcome the apoptotic effects of ABT737 [76], suggesting that this molecule may also be effective in overcoming tumor microenvironmental influences.

11.4.2 Targeting Soluble Factors and Adhesion Molecules As discussed above, soluble factors such as TGF-β, VEGF, bFGF, IL-6 and BAFF, are known to influence and enhance hematologic tumorigenesis and tumor cell survival. These factors, which can be produced by the tumor cell or other cellular components of the tumor cell’s microenvironment, are thus rational chemotherapeutic targets. VEGF monoclonal antibodies and VEGF receptor tyrosine kinase inhibitors are currently being studied in both the lab and the clinic. Bevacizumab, a recombinant humanized monoclonal anti-VEGF antibody, has shown favorable results in AML patients resistant to traditional chemotherapy [66]. Furthermore, Gabrilove postulates that since antiangiogenic therapies, such as inhibitors of VEGF and bFGF, do not directly target the tumor cell, drugresistant tumor cells will not emerge [35]. Aside from neutralization of VEGF and bFGF, targeting IL-6 secretion has also been shown to overcome tumor cell survival. For example, IL-6 secretion by BMSCs was abrogated by treatment with a receptor tyrosine kinase inhibitor, and this inhibitor also induced apoptosis in a subset of MM patient specimens. IL-6, as well as VEGF, production by stromal cells was also reported to be inhibited by treatment with an HDAC inhibitor [40]. Additionally, neutralization of BAFF led to increased apoptosis in B-cell lymphoma cell lines [75]. Antibody therapy may be effective not only in attenuating the effects of survival factors, but also in decreasing the positive influences that direct contact with the tumor microenvironment has on tumor cell survival. Monoclonal antibodies targeting tumor cell integrin α4 β1 or VCAM-1 on BMSCs, which are involved in tumor cell adhesion to the stromal cells, led to leukemic cell apoptosis. Also, treatment with an anti-α4 integrin antibody was found to suppress MM development in a mouse model [97].

227

11.4.3 Immunomodulatory Drugs Recent studies have shown that immunomodulatory drug (IMiD) thalidomide and its second-generation derivatives, including lenalidomide, are now widely used in the treatment of hematologic malignancies. These drugs have anti-angiogenic and antiinflammatory effects [105], and thalidomide has been reported to inhibit VEGF secretion by BMSCs [45]. Aside from inhibition of angiogenesis, these drugs have also been shown to induce apoptosis in MM cells [92]. IMiDs enhance apoptosis through inhibition of NF-kB activity and decreasing the expression of FLIP [45]. Furthermore, these drugs have been shown to affect tumor cell interactions with the surrounding environment. IMiDs have been shown to downregulate expression of cell adhesion molecules [37, 115], and also inhibit adhesion of MM cells to BMSCs [4]. Thus, treatment of hematologic malignancies with IMiDs will likely continue to prove beneficial, as these drugs target both the tumor and its microenvironment.

11.4.4 Bortezomib Bortezomib (PS-341, Velcade) is a reversible 26S proteasome inhibitor [1]. The proteasome function is to degrade most intracellular proteins, such as apoptotic, cell cycle regulatory, and cell growth proteins [128]. Bortezomib, which has been approved for the treatment of MM [63], has shown encouraging results for the treatment of MM in combination with melphalan [7], and is also being studied for the treatment of other hematopoietic tumors. This drug has been shown to enhance melphalan activity in MM cells by inhibiting NF-κB activity [93]. Furthermore, Hideshima et al. reported that bortezomib decreases IL-6 production in BMSCs, as well as decreases adhesion of MM cells to BMSCs [59]. Therefore, like the IMiDs, bortezomib’s mechanisms of action include targeting the tumor cell as well as the tumor cell’s microenvironment.

11.5 Conclusions Mounting evidence now suggests that dynamic interactions between the cancer cell and its local and systemic

228

microenvironment play a critical role in tumor development and that all of the clinical properties of a tumor, including response to therapy, depend heavily on the tumor stroma. We have much less understanding of the biology and genetics of stroma-tumor interactions than we do of tumor cells. Despite recent advances in the treatment of cancer, cancer still remains incurable, largely because of the emergence of drug-resistant tumor cells. Although today provides better treatment options for the treatment of many hematologic malignancies, the problem of minimal residual disease and drug resistance is still a major obstacle for overcoming these devastating diseases. The tumor microenvironment has been shown to be involved in hematologic tumorigenesis by providing growth and survival factors to the tumor, as well as enhancing anti-apoptotic pathways in the tumor. This microenvironment, whose composition is different depending on the type of malignancy, has also been shown to contribute to both de novo and acquired drug resistance. Targeting the apoptotic pathways is a promising approach for the treatment of many of these devastating diseases, especially combination therapy to enhance both the intrinsic and extrinsic apoptotic pathways. It is also critical to target soluble factors produced in the tumor microenvironment as well as to directly target interactions between the tumor and its microenvironment, as this type of treatment has shown promising results to date and will likely prove most effective in eliminating minimal residual disease and drug resistance, ultimately leading to cures for hematologic malignancies. Therefore, new therapeutic strategies targeting this interaction should be applied during initial treatment to prevent the emergence of acquired resistance.

References 1. Adams J, Kauffman M (2004) Development of the proteasome inhibitor Velcade (Bortezomib). Cancer Invest 22:304–311 2. Alexandrow MG, Moses HL (1995) Transforming growth factor beta and cell cycle regulation. Cancer Res 55:1452–1457 3. Amoroso SR, Huang N, Roberts AB, Potter M, Letterio JJ. (1998) Consistent loss of functional transforming growth factor beta receptor expression in murine plasmacytomas. Proc Natl Acad Sci USA 95:189–194 4. Anderson KC (2003) The role of immunomodulatory drugs in multiple myeloma. Semin Hematol 40:23–32

L.A. Crespo et al. 5. Bataille R, Barlogie B, Lu ZY, Rossi JF, Lavabre-Bertrand T, Beck T, Wijdenes J, Brochier J, Klein B (1995) Biologic effects of anti-interleukin-6 murine monoclonal antibody in advanced multiple myeloma. Blood 86:685–691 6. Bellamy WT, Dalton WS, Gleason MC, Grogan TM, Trent JM (1991) Development and characterization of a melphalan-resistant human multiple myeloma cell line. Cancer Res 51:995–1002 7. Berenson JR, Yang HH, Sadler K, Jarutirasarn SG, Vescio RA, Mapes R, Purner M, Lee SP, Wilson J, Morrison B, Adams J, Schenkein D, Swift R (2006) Phase I/II trial assessing bortezomib and melphalan combination therapy for the treatment of patients with relapsed or refractory multiple myeloma. J Clin Oncol 24: 937–944 8. Bisping G, Leo R, Wenning D, Dankbar B, Padró T, Kropff M, Scheffold C, Kröger M, Mesters RM, Berdel WE, Kienast J (2003) Paracrine interactions of basic fibroblast growth factor and interleukin-6 in multiple myeloma. Blood 101(7):2775–2783 9. Bromberg J, Darnell JE Jr (2000) The role of STATs in transcriptional control and their impact on cellular function. Oncogene 19:2468–2473 10. Capocasale RJ, Lamb RJ, Vonderheid EC, Fox FE, Rook AH, Nowell PC, Moore JS (1995) Reduced surface expression of transforming growth factor beta receptor type II in mitogen-activated T cells from Sezary patients. Proc Natl Acad Sci USA 92:5501–5505 11. Catlett-Falcone R, Landowski TH, Oshiro MM, Turkson J, Levitzki A, Savino R, Ciliberto G, Moscinski L, Fernandez-Luna JL, Nunez G, Dalton WS, Jove R (1999) Constitutive activation of Stat3 signaling confers resistance to apoptosis in human U266 myeloma cells. Immunity 10:105–115 12. Chen-Kiang S (1995) Regulation of terminal differentiation of human B-cells by IL-6. Curr Top Microbiol Immunol 194:189–198 13. Chesi M, Brents LA, Ely SA, Bais C, Robbiani DF, Mesri EA, Kuehl WM, Bergsagel PL (2001) Activated fibroblast growth factor receptor 3 is an oncogene that contributes to tumor progression in multiple myeloma. Blood 97:729–736 14. Cheung WC, Van Ness B (2002) Distinct IL-6 signal transduction leads to growth arrest and death in B cells or growth promotion and cell survival in myeloma cells. Leukemia 16:1182–1188 15. Corazza F, Hermans C, Ferster A, Fondu P, Demulder A, Sariban E (2004) Bone marrow stroma damage induced by chemotherapy for acute lymphoblastic leukemia in children. Pediatr Res 55:152–158 16. Cotter FE, Johnson P, Hall P, Pocock C, al Mahdi N, Cowell JK, Morgan G (1994) Antisense oligonucleotides suppress B-cell lymphoma growth in a SCID-hu mouse model. Oncogene 9:3049–3055 17. Dalton WS (2003) The tumor microenvironment: focus on myeloma. Cancer Treat Rev 29(Suppl 1):11–19 18. Damiano JS, Cress AE, Hazlehurst LA, Shtil AA, Dalton WS (1999) Cell adhesion mediated drug resistance (CAM-DR): role of integrins and resistance to apoptosis in human myeloma cell lines. Blood 93: 1658–1667

11 Tumor Microenvironment for Enhancing Chemotherapy 19. Damiano JS, Hazlehurst LA, Dalton WS (2001) Cell adhesion-mediated drug resistance (CAM-DR) protects the K562 chronic myelogenous leukemia cell line from apoptosis induced by BCR/ABL inhibition, cytotoxic drugs, and gamma-irradiation. Leukemia 15:1232–1239 20. Dankbar B, Padró T, Leo R, Feldmann B, Kropff M, Mesters RM, Serve H, Berdel WE, Kienast J (2000) Vascular endothelial growth factor and interleukin-6 in paracrine tumor-stromal cell interactions in multiple myeloma. Blood 95(8):2630–2636 21. de la Fuente MT, Casanova B, Garcia-Gila M, Silva A, Garcia-Pardo A (1999) Fibronectin interaction with alpha4beta1 integrin prevents apoptosis in B cell chronic lymphocytic leukemia: correlation with Bcl-2 and Bax. Leukemia 13:266–274 22. DeCoteau JF, Knaus PI, Yankelev H, Reis MD, Lowsky R, Lodish HF, Kadin ME (1997) Loss of functional cell surface transforming growth factor beta (TGF-beta) type 1 receptor correlates with insensitivity to TGF-beta in chronic lymphocytic leukemia. Proc Natl Acad Sci USA 94:5877–5881 23. Del Poeta G, Venditti A, Del Principe MI, Maurillo L, Buccisano F, Tamburini A, Cox MC, Franchi A, Bruno A, Mazzone C, Panetta P, Suppo G, Masi M, Amadori S (2003) Amount of spontaneous apoptosis detected by Bax/Bcl-2 ratio predicts outcome in acute myeloid leukemia (AML). Blood 101:2125–2131 24. Dias S, Choy M, Alitalo K, Rafii S (2002) Vascular endothelial growth factor (VEGF)-C signaling through FLT-4 (VEGFR-3) mediates leukemic cell proliferation, survival, and resistance to chemotherapy. Blood 99:2179–2184 25. Dias S, Shmelkov SV, Lam G, Rafii S (2002) VEGF(165) promotes survival of leukemic cells by Hsp90-mediated induction of Bcl-2 expression and apoptosis inhibition. Blood 99:2532–2540 26. Do RK, Hatada E, Lee H, Tourigny MR, Hilbert D, ChenKiang S (2000) Attenuation of apoptosis underlies B lymphocyte stimulator enhancement of humoral immune response. J Exp Med 192:953–964 27. Dong M, Blobe GC (2006) Role of transforming growth factor-beta in hematologic malignancies. Blood 107:4589–4596 28. Durand RE, Sutherland RM (1972) Effects of intercellular contact on repair of radiation damage. Exp Cell Res 71:75–80 29. Espinoza-Hernandez L, Cruz-Rico J, Benitez-Aranda H, Martinez-Jaramillo G, Rodriguez-Zepeda MC, VelezRuelas MA, Mayani H (2001) In vitro characterization of the hematopoietic system in pediatric patients with acute lymphoblastic leukemia. Leuk Res 25:295–303 30. Fernandez T, Amoroso S, Sharpe S, Jones GM, Bliskovski V, Kovalchuk A, Wakefield LM, Kim SJ, Potter M, Letterio JJ (2002) Disruption of transforming growth factor beta signaling by a novel ligand-dependent mechanism. J Exp Med 195:1247–1255 31. Ferrajoli A, Faderl S, Ravandi F, Estrov Z (2006) The JAK-STAT pathway: a therapeutic target in hematological malignancies. Curr Cancer Drug Targets 6:671–679 32. Fortney JE, Zhao W, Wenger SL, Gibson LF (2001) Bone marrow stromal cells regulate caspase 3 activity

229

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

in leukemic cells during chemotherapy. Leuk Res 25:901–907 Fragoso R, Pereira T, Wu Y, Zhu Z, Cabecadas J, Dias S (2006) VEGFR-1 (FLT-1) activation modulates acute lymphoblastic leukemia localization and survival within the bone marrow, determining the onset of extramedullary disease. Blood 107:1608–616 Frassanito MA, Cusmai A, Iodice G, Dammacco F (2001) Autocrine interleukin-6 production and highly malignant multiple myeloma: relation with resistance to drug-induced apoptosis. Blood 97:483–489 Gabrilove JL (2001) Angiogenic growth factors: autocrine and paracrine regulation of survival in hematologic malignancies. Oncologist 6(Suppl 5):4–7 Garrido SM, Appelbaum FR, Willman CL, Banker DE (2001) Acute myeloid leukemia cells are protected from spontaneous and drug-induced apoptosis by direct contact with a human bone marrow stromal cell line (HS-5). Exp Hematol 29:448–457 Geitz H, Handt S, Zwingenberger K (1996) Thalidomide selectively modulates the density of cell surface molecules involved in the adhesion cascade. Immunopharmacology 31:213–221 Gery S, Koeffler HP (2007) Transcription factors in hematopoietic malignancies. Curr Opin Genet Dev 17: 78–83 Glasgow E, Mishra L (2008) Transforming growth factor{beta} signaling and ubiquitinators in cancer. Endocr Relat Cancer 15:59–72 Golay J, Cuppini L, Leoni F, Mico C, Barbui V, Domenghini M, Lombardi L, Neri A, Barbui AM, Salvi A, Pozzi P, Porro G, Pagani P, Fossati G, Mascagni P, Introna M, Rambaldi A (2007) The histone deacetylase inhibitor ITF2357 has anti-leukemic activity in vitro and in vivo and inhibits IL-6 and VEGF production by stromal cells. Leukemia 21:1892–1900 Gross JA, Dillon SR, Mudri S, Johnston J, Littau A, Roque R, Rixon M, Schou O, Foley KP, Haugen H, McMillen S, Waggie K, Schreckhise RW, Shoemaker K, Vu T, Moore M, Grossman A, Clegg CH (2001) TACI-Ig neutralizes molecules critical for B cell development and autoimmune disease impaired B cell maturation in mice lacking BLyS. Immunity 15:289–302 Gross JA, Johnston J, Mudri S, Enselman R, Dillon SR, Madden K, Xu W, Parrish-Novak J, Foster D, LoftonDay C, Moore M, Littau A, Grossman A, Haugen H, Foley K, Blumberg H, Harrison K, Kindsvogel W, Clegg CH (2000) TACI, BCMA are receptors for a TNF homologue implicated in B-cell autoimmune disease. Nature 404:995–999 Guasparri I, Keller SA, Cesarman E (2004) KSHV vFLIP is essential for the survival of infected lymphoma cells. J Exp Med 199:993–1003 Guinness ME, Kenney JL, Reiss M, Lacy J (2000) Bcl-2 antisense oligodeoxynucleotide therapy of EpsteinBarr virus-associated lymphoproliferative disease in severe combined immunodeficient mice. Cancer Res 60:5354–5358 Gupta D, Treon SP, Shima Y, Hideshima T, Podar K, Tai YT, Lin B, Lentzsch S, Davies FE, Chauhan D, Schlossman RL, Richardson P, Ralph P, Wu L, Payvandi

230

46. 47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

L.A. Crespo et al. F, Muller G, Stirling DI, Anderson KC (2001) Adherence of multiple myeloma cells to bone marrow stromal cells upregulates vascular endothelial growth factor secretion: therapeutic applications. Leukemia 15:1950–1961 Hanahan D, Weinberg RA (2000) The hallmarks of cancer. Cell 100:57–70 Hata H, Xiao H, Petrucci MT, Woodliff J, Chang R, Epstein J (1993) Interleukin-6 gene expression in multiple myeloma: a characteristic of immature tumor cells. Blood 81:3357–3364 Hatada EN, Do RK, Orlofsky A, Liou HC, Prystowsky M, MacLennan IC, Caamano J, Chen-Kiang S (2003) NF-kappa B1 p50 is required for BLyS attenuation of apoptosis but dispensable for processing of NF-kappa B2 p100 to p52 in quiescent mature B cells. J Immunol 171:761–768 Hayashi T, Hideshima T, Nguyen AN, Munoz O, Podar K, Hamasaki M, Ishitsuka K, Yasui H, Richardson P, Chakravarty S, Murphy A, Chauhan D, Higgins LS, Anderson KC (2004) Transforming growth factor beta receptor I kinase inhibitor down-regulates cytokine secretion and multiple myeloma cell growth in the bone marrow microenvironment. Clin Cancer Res 10:7540–7546 Hazlehurst LA, Argilagos RF, Dalton WS (2007) Beta1 integrin mediated adhesion increases Bim protein degradation and contributes to drug resistance in leukaemia cells. Br J Haematol 136:269–275 Hazlehurst LA, Argilagos RF, Emmons M, Boulware D, Beam CA, Sullivan DM, Dalton WS (2006) Cell adhesion to fibronectin (CAM-DR) influences acquired mitoxantrone resistance in U937 cells. Cancer Res 66:2338–2345 Hazlehurst LA, Damiano JS, Buyuksal I, Pledger WJ, Dalton WS (2000) Adhesion to fibronectin via beta1 integrins regulates p27kip1 levels and contributes to cell adhesion mediated drug resistance (CAM-DR). Oncogene 19:4319–4327 Hazlehurst LA, Enkemann SA, Beam CA, Argilagos RF, Painter J, Shain KH, Saporta S, Boulware D, Moscinski L, Alsina M, Dalton WS (2003) Genotypic and phenotypic comparisons of de novo and acquired melphalan resistance in an isogenic multiple myeloma cell line model. Cancer Res 63:7900–7906 Hazlehurst LA, Foley NE, Gleason-Guzman MC, Hacker MP, Cress AE, Greenberger LW, De Jong MC, Dalton WS (1999) Multiple mechanisms confer drug resistance to mitoxantrone in the human 8226 myeloma cell line. Cancer Res 59:1021–1028 Hazlehurst LA, Landowski TH, Dalton WS (2003) Role of the tumor microenvironment in mediating de novo resistance to drugs and physiological mediators of cell death. Oncogene 22:7396–7402 Hazlehurst LA, Valkov N, Wisner L, Storey JA, Boulware D, Sullivan DM, Dalton WS (2001) Reduction in druginduced DNA double-strand breaks associated with beta1 integrin-mediated adhesion correlates with drug resistance in U937 cells. Blood 98:1897–1903 He B, Chadburn A, Jou E, Schattner EJ, Knowles DM, Cerutti A (2004) Lymphoma B cells evade apoptosis through the TNF family members BAFF/BLyS, APRIL. J Immunol 172:3268–3279

58. Heissmeyer V, Krappmann D, Wulczyn FG, Scheidereit C (1999) NF-kappaB p105 is a target of IkappaB kinases and controls signal induction of Bcl-3-p50 complexes. Embo J 18:4766–4778 59. Hideshima T, Richardson P, Chauhan D, Palombella VJ, Elliott PJ, Adams J, Anderson KC (2001) The proteasome inhibitor PS-341 inhibits growth, induces apoptosis, and overcomes drug resistance in human multiple myeloma cells. Cancer Res 61:3071–3076 60. Horning SJ (1994) Treatment approaches to the low-grade lymphomas. Blood 83:881–884 61. Hubmann R, Schwarzmeier JD, Shehata M, Hilgarth M, Duechler M, Dettke M, Berger R (2002) Notch2 is involved in the overexpression of CD23 in B-cell chronic lymphocytic leukemia. Blood 99:3742–3747 62. Imai Y, Kurokawa M, Izutsu K, Hangaishi A, Maki K, Ogawa S, Chiba S, Mitani K, Hirai H (2001) Mutations of the Smad4 gene in acute myelogeneous leukemia and their functional implications in leukemogenesis. Oncogene 20:88–96 63. Jagannath S, Barlogie B, Berenson J, Siegel D, Irwin D, Richardson PG, Niesvizky R, Alexanian R, Limentani SA, Alsina M, Adams J, Kauffman M, Esseltine DL, Schenkein DP, Anderson KC (2004) A phase 2 study of two doses of bortezomib in relapsed or refractory myeloma. Br J Haematol 127:165–172 64. Jundt F, Anagnostopoulos I, Forster R, Mathas S, Stein H, Dorken B (2002) Activated Notch1 signaling promotes tumor cell proliferation and survival in Hodgkin and anaplastic large cell lymphoma. Blood 99:3398–3403 65. Kaminska B, Wesolowska A, Danilkiewicz M (2005) TGF beta signalling and its role in tumour pathogenesis. Acta Biochim Pol 52:329–337 66. Karp JE, Gojo I, Pili R, Gocke CD, Greer J, Guo C, Qian D, Morris L, Tidwell M, Chen H, Zwiebel J (2004) Targeting vascular endothelial growth factor for relapsed and refractory adult acute myelogenous leukemias: therapy with sequential 1-betad-arabinofuranosylcytosine, mitoxantrone, and bevacizumab. Clin Cancer Res 10:3577–3585 67. Kawano M, Hirano T, Matsuda T, Taga T, Horii Y, Iwato K, Asaoku H, Tang B, Tanabe O, Tanaka H, et al (1988) Autocrine generation and requirement of BSF-2/IL-6 for human multiple myelomas. Nature 332: 83–85 68. Kern C, Cornuel JF, Billard C, Tang R, Rouillard D, Stenou V, Defrance T, Ajchenbaum-Cymbalista F, Simonin PY, Feldblum S, Kolb JP (2004) Involvement of BAFF, APRIL in the resistance to apoptosis of B-CLL through an autocrine pathway. Blood 103: 679–688 69. Khan SB, Maududi T, Barton K, Ayers J, Alkan S (2004) Analysis of histone deacetylase inhibitor, depsipeptide (FR901228), effect on multiple myeloma. Br J Haematol 125:156–161 70. Khare SD, Sarosi I, Xia XZ, McCabe S, Miner K, Solovyev I, Hawkins N, Kelley M, Chang D, Van G, Ross L, Delaney J, Wang L, Lacey D, Boyle WJ, Hsu H (2000) Severe B cell hyperplasia and autoimmune disease in TALL-1 transgenic mice. Proc Natl Acad Sci USA 97:3370–3375

11 Tumor Microenvironment for Enhancing Chemotherapy 71. Kim R, Emi M, Tanabe K, Toge T (2004) Therapeutic potential of antisense Bcl-2 as a chemosensitizer for cancer therapy. Cancer 101:2491–2502 72. Klasa RJ, Bally MB, Ng R, Goldie JH, Gascoyne RD, Wong FM (2000) Eradication of human non-Hodgkin’s lymphoma in SCID mice by BCL-2 antisense oligonucleotides combined with low-dose cyclophosphamide. Clin Cancer Res 6:2492–2500 73. Klein B, Zhang XG, Jourdan M, Content J, Houssiau F, Aarden L, Piechaczyk M, Bataille R (1989) Paracrine rather than autocrine regulation of myeloma-cell growth and differentiation by interleukin-6. Blood 73:517–526 74. Klein B, Zhang XG, Lu ZY, Bataille R (1995) Interleukin6 in human multiple myeloma. Blood 85:863–872 75. Klener P Jr, Andera L, Klener P, Necas E, Zivny J (2006) Cell death signalling pathways in the pathogenesis and therapy of haematologic malignancies: overview of therapeutic approaches. Folia Biol (Praha) 52:119–136 76. Kline MP, Rajkumar SV, Timm MM, Kimlinger TK, Haug JL, Lust JA, Greipp PR, Kumar S (2007) ABT737, an inhibitor of Bcl-2 family proteins, is a potent inducer of apoptosis in multiple myeloma cells. Leukemia 21:1549–1560 77. Konig A, Menzel T, Lynen S, Wrazel L, Rosen A, AlKatib A, Raveche E, Gabrilove JL (1997) Basic fibroblast growth factor (bFGF) upregulates the expression of bcl-2 in B cell chronic lymphocytic leukemia cell lines resulting in delaying apoptosis. Leukemia 11:258–265 78. Kuroda H, Matsunaga T, Terui T, Tanaka I, Takimoto R, Fujikawa K, Takayama T, Kato J, Hirayama Y, Sakamaki S, Kohda K, Niitsu Y (2004) Decrease of Smad4 gene expression in patients with essential thrombocythaemia may cause an escape from suppression of megakaryopoiesis by transforming growth factor-beta1. Br J Haematol 124:211–220 79. Lagneaux L, Delforge A, Bron D, De Bruyn C, Stryckmans P (1998) Chronic lymphocytic leukemic B cells but not normal B cells are rescued from apoptosis by contact with normal bone marrow stromal cells. Blood 91:2387–2396 80. Lagneaux L, Delforge A, Bron D, Massy M, Bernier M, Stryckmans P (1997) Heterogenous response of B lymphocytes to transforming growth factor-beta in Bcell chronic lymphocytic leukaemia: correlation with the expression of TGF-beta receptors. Br J Haematol 97:612–620 81. Li ZW, Dalton WS (2006) Tumor microenvironment and drug resistance in hematologic malignancies. Blood Rev 20:333–342 82. Liou HC, Nolan GP, Ghosh S, Fujita T, Baltimore D (1992) The NF-kappa B p50 precursor, p105, contains an internal I kappa B-like inhibitor that preferentially inhibits p50. Embo J 11:3003–3009 83. Lwin T, Hazlehurst LA, Dessureault S, Lai R, Bai W, Sotomayor E, Moscinski LC, Dalton WS, Tao J (2007) Cell adhesion induces p27Kip1-associated cellcycle arrest through down-regulation of the SCFSkp2 ubiquitin ligase pathway in mantle-cell and other nonHodgkin B-cell lymphomas. Blood 110:1631–1638 84. Lwin T, Hazlehurst LA, Li Z, Dessureault S, Sotomayor E, Moscinski LC, Dalton WS, Tao J (2007) Bone marrow

231

85.

86.

87.

88.

89.

90.

91.

92.

93.

94.

95.

96.

stromal cells prevent apoptosis of lymphoma cells by upregulation of anti-apoptotic proteins associated with activation of NF-kappaB (RelB/p52) in non-Hodgkin’s lymphoma cells. Leukemia 21:1521–1531 Lwin T, Crespo L, Wu A, Dessureault S, Shu H, Sotomayor E, Moscinski LC, Dalton WS, Tao J (2009) Lymphoma cell adhesion-induced expression of B cell-activating factor of the TNF family (BAFF) in bone marrow stromal cells protects non-Hodgkin’s B lymphoma cells from apoptosis. Leukemia 23(1):170–177 MacDonald I, Wang H, Grand R, Armitage RJ, Fanslow WC, Gregory CD, Gordon J (1996) Transforming growth factor-beta 1 cooperates with anti-immunoglobulin for the induction of apoptosis in group I (biopsy-like) Burkitt lymphoma cell lines. Blood 87:1147–1154 Mackay F, Woodcock SA, Lawton P, Ambrose C, Baetscher M, Schneider P, Tschopp J, Browning JL (1999) Mice transgenic for BAFF develop lymphocytic disorders along with autoimmune manifestations. J Exp Med 190:1697–1710 Matter ML, Ruoslahti E (2001) A signaling pathway from the alpha5beta1 and alpha(v)beta3 integrins that elevates bcl-2 transcription. J Biol Chem 276:27757–27763 Meads MB, Gatenby RA, Dalton WS (2009). Environment-mediated drug resistance: a major contributor to minimal residual disease. Nat Rev Cancer 9(9):665–674. Epub 2009 Menzel T, Rahman Z, Calleja E, White K, Wilson EL, Wieder R, Gabrilove J (1996) Elevated intracellular level of basic fibroblast growth factor correlates with stage of chronic lymphocytic leukemia and is associated with resistance to fludarabine. Blood 87:1056–1063 Mercurio F, DiDonato JA, Rosette C, Karin M (1993) p105 and p98 precursor proteins play an active role in NF-kappa B-mediated signal transduction. Genes Dev 7:705–718 Mitsiades N, Mitsiades CS, Poulaki V, Chauhan D, Richardson PG, Hideshima T, Munshi NC, Treon SP, Anderson KC (2002) Apoptotic signaling induced by immunomodulatory thalidomide analogs in human multiple myeloma cells: therapeutic implications. Blood 99:4525–4530 Mitsiades N, Mitsiades CS, Richardson PG, Poulaki V, Tai YT, Chauhan D, Fanourakis G, Gu X, Bailey C, Joseph M, Libermann TA, Schlossman R, Munshi NC, Hideshima T, Anderson KC (2003) The proteasome inhibitor PS341 potentiates sensitivity of multiple myeloma cells to conventional chemotherapeutic agents: therapeutic applications. Blood 101:2377–2380 Monni O, Joensuu H, Franssila K, Klefstrom J, Alitalo K, Knuutila S (1997) BCL2 overexpression associated with chromosomal amplification in diffuse large B-cell lymphoma. Blood 90:1168–1174 Moreaux J, Legouffe E, Jourdan E, Quittet P, Reme T, Lugagne C, Moine P, Rossi JF, Klein B, Tarte K (2004) BAFF, APRIL protect myeloma cells from apoptosis induced by interleukin 6 deprivation and dexamethasone. Blood 103:3148–3157 Mori N, Matsuda T, Tadano M, Kinjo T, Yamada Y, Tsukasaki K, Ikeda S, Yamasaki Y, Tanaka Y, Ohta T, Iwamasa T, Tomonaga M, Yamamoto N (2004) Apoptosis

232

97.

98.

99.

100.

101.

102.

103.

104.

105.

106.

107.

L.A. Crespo et al. induced by the histone deacetylase inhibitor FR901228 in human T-cell leukemia virus type 1-infected T-cell lines and primary adult T-cell leukemia cells. J Virol 78:4582–4590 Mori Y, Shimizu N, Dallas M, Niewolna M, Story B, Williams PJ, Mundy GR, Yoneda T (2004) Anti-alpha4 integrin antibody suppresses the development of multiple myeloma and associated osteoclastic osteolysis. Blood 104:2149–2154 Moshaver B, van der Pol MA, Westra AH, Ossenkoppele GJ, Zweegman S, Schuurhuis GJ (2008) Chemotherapeutic treatment of bone marrow stromal cells strongly affects their protective effect on acute myeloid leukemia cell survival. Leuk Lymphoma 49:134–148 Mudry RE, Fortney JE, York T, Hall BM, Gibson LF (2000) Stromal cells regulate survival of Blineage leukemic cells during chemotherapy. Blood 96:1926–1932 Naumann M, Wulczyn FG, Scheidereit C (1993) The NF-kappa B precursor p105 and the proto-oncogene product Bcl-3 are I kappa B molecules and control nuclear translocation of NF-kappa B. Embo J 12:213–222 Nefedova Y, Cheng P, Alsina M, Dalton WS, Gabrilovich DI (2004) Involvement of Notch-1 signaling in bone marrow stroma-mediated de novo drug resistance of myeloma and other malignant lymphoid cell lines. Blood 103: 3503–3510 Niu G, Shain KH, Huang M, Ravi R, Bedi A, Dalton WS, Jove R, Yu H (2001) Overexpression of a dominantnegative signal transducer and activator of transcription 3 variant in tumor cells leads to production of soluble factors that induce apoptosis and cell cycle arrest. Cancer Res 61:3276–3280 O’Brien S, Moore JO, Boyd TE, Larratt LM, Skotnicki A, Koziner B, Chanan-Khan AA, Seymour JF, Bociek RG, Pavletic S, Rai KR (2007) Randomized phase III trial of fludarabine plus cyclophosphamide with or without oblimersen sodium (Bcl-2 antisense) in patients with relapsed or refractory chronic lymphocytic leukemia. J Clin Oncol 25:1114–1120 Ong YL, McMullin MF, Bailie KE, Lappin TR, Jones FG, Irvine AE (2000) High bax expression is a good prognostic indicator in acute myeloid leukaemia. Br J Haematol 111:182–189 Pangalis GA, Kyrtsonis MC, Vassilakopoulos TP, Dimopoulou MN, Siakantaris MP, Emmanouilides C, Doufexis D, Sahanas S, Kontopidou FN, Kalpadakis C, Angelopoulou MK, Dimitriadou EM, Kokoris SI, Panayiotidis P (2006) Immunotherapeutic and immunoregulatory drugs in haematologic malignancies. Curr Top Med Chem 6:1657–1686 Parry TJ, Riccobene TA, Strawn SJ, Williams R, Daoud R, Carrell J, Sosnovtseva S, Miceli RC, Poortman CM, Sekut L, Li Y, Fikes J, Sung C (2001) Pharmacokinetics and immunological effects of exogenously administered recombinant human B lymphocyte stimulator (BLyS) in mice. J Pharmacol Exp Ther 296:396–404 Podar K, Tai YT, Davies FE, Lentzsch S, Sattler M, Hideshima T, Lin BK, Gupta D, Shima Y, Chauhan D, Mitsiades C, Raje N, Richardson P, Anderson KC (2001) Vascular endothelial growth factor

108. 109.

110.

111.

112.

113.

114.

115.

116.

117.

118.

119.

120.

triggers signaling cascades mediating multiple myeloma cell growth and migration. Blood 98:428–435 Reed JC, Pellecchia M (2005) Apoptosis-based therapies for hematologic malignancies. Blood 106:408–418 Rosato RR, Almenara JA, Grant S (2003) The histone deacetylase inhibitor MS-275 promotes differentiation or apoptosis in human leukemia cells through a process regulated by generation of reactive oxygen species and induction of p21CIP1/WAF1 1. Cancer Res 63:3637–3645 Ruscetti FW, Akel S, Bartelmez SH (2005) Autocrine transforming growth factor-beta regulation of hematopoiesis: many outcomes that depend on the context. Oncogene 24:5751–5763 Salmeron A, Janzen J, Soneji Y, Bump N, Kamens J, Allen H, Ley SC (2001) Direct phosphorylation of NF-kappaB1 p105 by the IkappaB kinase complex on serine 927 is essential for signal-induced p105 proteolysis. J Biol Chem 276:22215–22222 Salven P, Orpana A, Teerenhovi L, Joensuu H (2000) Simultaneous elevation in the serum concentrations of the angiogenic growth factors VEGF, bFGF is an independent predictor of poor prognosis in non-Hodgkin lymphoma: a single-institution study of 200 patients. Blood 96:3712–3718 Schiemann B, Gommerman JL, Vora K, Cachero TG, Shulga-Morskaya S, Dobles M, Frew E, Scott ML (2001) An essential role for BAFF in the normal development of B cells through a BCMA-independent pathway. Science 293:2111–2114 Sethi T, Rintoul RC, Moore SM, MacKinnon AC, Salter D, Choo C, Chilvers ER, Dransfield I, Donnely SC, Strieter R, Haslett C (1999) Extracellular matrix proteins protect small cell lung cancer cells against apoptosis: a mechanism for small cell lung cancer growth and drug resistance in vivo. Nat Med 5:662–668 Settles B, Stevenson A, Wilson K, Mack C, Ezell T, Davis MF, Taylor LD (2001) Down-regulation of cell adhesion molecules LFA-1 and ICAM-1 after in vitro treatment with the anti-TNF-alpha agent thalidomide. Cell Mol Biol (Noisy-le-grand) 47:1105–1114 Shain KH, Landowski TH, Dalton WS (2002) Adhesionmediated intracellular redistribution of c-Fas-associated death domain-like IL-1-converting enzyme-like inhibitory protein-long confers resistance to CD95-induced apoptosis in hematopoietic cancer cell lines. J Immunol 168:2544–2553 Tai YT, Li XF, Breitkreutz I, Song W, Neri P, Catley L, Podar K, Hideshima T, Chauhan D, Raje N, Schlossman R, Richardson P, Munshi NC, Anderson KC (2006) Role of B-cell-activating factor in adhesion and growth of human multiple myeloma cells in the bone marrow microenvironment. Cancer Res 66:6675–6682 Teicher BA, Herman TS, Holden SA, Wang YY, Pfeffer MR, Crawford JW, Frei E 3rd (1990) Tumor resistance to alkylating agents conferred by mechanisms operative only in vivo. Science 247:1457–1461 Tohda S, Nara N (2001) Expression of Notch1 and Jagged1 proteins in acute myeloid leukemia cells. Leuk Lymphoma 42:467–472 Tu Y, Xu FH, Liu J, Vescio R, Berenson J, Fady C, Lichtenstein A (1996) Upregulated expression of BCL-2

11 Tumor Microenvironment for Enhancing Chemotherapy

121.

122.

123.

124.

in multiple myeloma cells induced by exposure to doxorubicin, etoposide, and hydrogen peroxide. Blood 88: 1805–1812 Urashima M, Ogata A, Chauhan D, Hatziyanni M, Vidriales MB, Dedera DA, Schlossman RL, Anderson KC (1996) Transforming growth factor-beta1: differential effects on multiple myeloma versus normal B cells. Blood 87:1928–1938 Valnet-Rabier MB, Challier B, Thiebault S, Angonin R, Margueritte G, Mougin C, Kantelip B, Deconinck E, Cahn JY, Fest T (2005) c-Flip protein expression in Burkitt’s lymphomas is associated with a poor clinical outcome. Br J Haematol 128:767–773 Veiga JP, Costa LF, Sallan SE, Nadler LM, Cardoso AA (2006) Leukemia-stimulated bone marrow endothelium promotes leukemia cell survival. Exp Hematol 34:610–621 Weng AP, Ferrando AA, Lee W, Morris JPT, Silverman LB, Sanchez-Irizarry C, Blacklow SC, Look AT, Aster JC (2004) Activating mutations of NOTCH1 in human T cell acute lymphoblastic leukemia. Science 306:269–271

233 125. Wolfraim LA, Fernandez TM, Mamura M, Fuller WL, Kumar R, Cole DE, Byfield S, Felici A, Flanders KC, Walz TM, Roberts AB, Aplan PD, Balis FM, Letterio JJ (2004) Loss of Smad3 in acute T-cell lymphoblastic leukemia. N Engl J Med 351:552–559 126. Xiao G, Cvijic ME, Fong A, Harhaj EW, Uhlik MT, Waterfield M, Sun SC (2001) Retroviral oncoprotein Tax induces processing of NF-kappaB2/p100 in T cells: evidence for the involvement of IKKalpha. Embo J 20:6805–6815 127. Zhang Z, Vuori K, Reed JC, Ruoslahti E (1995) The alpha 5 beta 1 integrin supports survival of cells on fibronectin and up-regulates Bcl-2 expression. Proc Natl Acad Sci USA 92:6161–6165 128. Zhou J, Mauerer K, Farina L, Gribben JG (2005) The role of the tumor microenvironment in hematological malignancies and implication for therapy. Front Biosci 10:1581–1596

Part II

Biological Therapy

Chapter 12

Cytokines in the Treatment of Cancer Adrian Bot

12.1 Introduction Immune system has the exquisite potential to discriminate between various categories of antigens; however, the regulation of the onset, magnitude, decline and profile of immune response against self or non-self antigens is a complex process [1]. This is dependent on a variety of soluble and membranebound molecules controlling T cell immunity especially. Highly pathogenic processes such as acute viral infections or inflammation due to immunopathology lead to up-regulation of cytokines, chemokines and co-stimulatory molecules and down-regulation of inhibiting pathways that overall, amplify or maintain the response necessary for clearance of pathogens or result in autoimmune disorders. However, many chronic infections with viruses possessing a latent phase do not elicit a wide array of pro-inflammatory regulatory molecules; thus, the immune system, despite presence of low levels of recognizable antigens, does not usually mount a potent or effective response. To project the impact and applicability of immune modulating as opposed to bone-marrow stimulating cytokines (Fig. 12.1) one needs to consider the relationship between the tumoral process, standard therapy and immunity. Schematically, from the standpoint of the relationship between immunity and cancer process, we can divide the disease in four phases (there

A. Bot () Scientific Management, MannKind Corporation, Valencia, CA 91354, USA e-mail: [email protected]

are obviously particularities associated with the nature and stage of a particular tumor) (Fig. 12.2). First, during earliest stage (in situ) when in case of carcinoma for example, the basal membrane has not been penetrated and the invasion of surrounding tissue is minimal, the exposure of immune system to TAAs and its overall ‘awareness’ of a pathogenic process is negligible, unless the tumor has been initiated or is associated with a viral infection (e.g. HPV), or the process affects cells of bone-marrow lineage (e.g. lymphomas, leukemias). This phase of immune ignorance precludes early onset of immunity against eventual TAAs. If that occurs due to inherent monitoring by circulating DCs, the magnitude is minimal and/or the profile may encompass regulatory T cells not unlike normal homeostatic mechanisms; however, it is conceivable that in numerous cases, immune surveillance disposes of transformed cells or keeps in check in situ lesions (incomplete immune ignorance). The second phase is elicited by tumor invasion within the surrounding tissue, promoted by accumulating genome mutations due to the inherent genomic instability. This process results in various degrees of local inflammation, that may or may not lead to potent immunity against TAAs depending on the degree of tissue inflammation, a factor that is key in regulating the onset, magnitude and profile of the T cell response. A prompt and potent immune response fueled by trafficking of APCs, NK cells and T cells in and out the tumor, may result in regression of the localized tumor mass or its containment. Overall, the immune system has been primed to the tumor but the nature and magnitude of response differs and may be mostly suboptimal, depending on a variety of factors such as cytokine, chemokine production and/or expression of co-stimulatory molecules. As an analogy, a traumatic skin lesion does not usually

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_12, © Springer Science+Business Media B.V. 2011

237

238

A. Bot A. Immune modulating cytokines (IL-2, IFN-alpha, TNF-alpha)

Immunity Primary effect

Tumor

Cytokine

Suppression

Bone-marrow lineages B. Supportive care cytokines and growth factors (G-CSF, GM-CSF*, erythropoietin)

Immunity

Infection control

Cytokine

Tumor

Primary effect

Suppression

Bone-marrow lineages

Treatment

Fig. 12.1 General categories of cytokines in cancer therapy. ∗ GM-CSF may be regarded as a dual acting cytokine, fitting both scenarios B and A

Phase 1

Phase 2

Phase 3

Phase 4

In situ

Local invasion

Metastases

Post-standard therapy

None / Low

Yes

Yes

Yes

Co-stimulating environment

Low

Low / High

Low / High

Low / High

Immune competence

Yes

Yes

Yes / Low

Yes / Low

Susceptibility of tumor cells to immunity

Yes

Yes/ Low

Yes / Low

Yes / Low

Applicability of immune stimulating cytokines

None unless targeted

Yes / No

Yes / No

Yes / No

None*/ Low

None*/ Low

Low / Yes

Low / Yes

None*

None*

None / Yes

None / Yes

Tumor stage

Immune recognition of TAA

Bone marrow Suppression Applicability of cytokines as supportive therapies

Representation of interaction between immunity and tumor antigen

Ag

X

T cells

Ag

X

T cells

Ag

X

T cells

Ag

X

T cells

Reg T cells

Fig. 12.2 Applicability of cytokines to cancer therapy. ∗ This may not be applicable to tumors of bone marrow lineage. Boxes represent instances when cytokine therapy (immune modulating such as IL-2 or supportive such as G-CSF) are applicable

12 Cytokines in the Treatment of Cancer

result in a protracted autoimmune process even against tissue specific antigens (such as those expressed by melanocytes). Obviously, there are significant immune homeostatic mechanisms limiting this occurrence and in addition, the tumoral process deploys genetic instability associated with selection of clonotypes that evade ongoing immunity. Thus, in this stage, if immunity is not effective initially in curbing the process, metastasis usually occurs. In the third phase, M0 and M1 cells emigrate from the primary tumor site and colonize internal organs where metastases develop and impact more significantly the clinical status. From an immunological standpoint, the immune system has been exposed to a wide array of TAAs already – however, the magnitude, nature and the expression or relevance of TAAs to which there is immunity, are limiting factors. Immune ‘sculpting’ may results in a modification of TAA expression profile: loss of immunogenic/antigenic ones and gain of new antigens operating in a tolerogenic environment devoid of optimal co-stimulation despite systemic exposure to antigens. The latter may not occur at all if for example, immune escape occurred via down-regulation of MHC class I presentation altogether via loss of β2-microglobulin or TAP. Altogether, transition from phase two to three represent a leap or ‘catastrophic’ event from immunological standpoint, at the interface between genetic instability, tumor progression and immune monitoring versus evasion. It is conceivable that in this phase, there may be exploitable TAAs and thus, specific or non-specific immune modulation approaches may be applicable if and in those circumstances when immune escape involved mechanisms that left major immune recognition and effector mechanisms unaffected. In addition, the latter aspect intervenes post-standard, cytoreductive therapy (surgery, radiotherapy and/or chemotherapy) in partial or complete clinical remission state, when residual disease may encompass clonotypes highly resistant to endogenous immunity (phase 4). There is a special circumstance that is a phase 4 scenario but more reminiscent of phase 2 from immunological standpoint, represented by cancers diagnosed in early stage, prior to metastasis (locally invasive or not), followed by surgery and/or minimal radio and chemotherapy, with good immune competence and minimal systemic exposure to TAAs. This scenario is – similar to a subset within phase 2 (Fig. 12.2) – amenable to cytokine immune modulation.

239

Based on these considerations, it is clear that provision of co-stimulatory signals, for example in form of immune enhancing cytokines such as IL-2 (with impact on T cells mostly) or IFN-alpha (with effect on APCs but possibly pleiotropic) may have a beneficial impact on anti-tumoral immunity. If cytokines are delivered systemically, it is predicted that this impact occurs in a phase when TAAs are already being presented to the immune system and when there is still immune competence without irrevocable alteration of tumor cell sensitivity to immune mechanisms. Alternately, topical or targeted, intra-tumoral administration of cytokines may abrogate immune ignorance in early disease stages or during relapse – broadening up the range of indications and leveraging local and systemic effect of such biological response modifiers. In contrast, the effectiveness of immune modulating cytokines is expected to be limited or nil if cells or pathways that are key to the mechanism of action are affected or not involved (e.g. systemic cytokine therapy for in situ lesions, systemic or local cytokine therapy in heavily immune suppressed patients or when tumor encompasses MHC class I/TAP/β2-microglobulin mutants, or the T cell repertoire is tolerant against TAAs, etc). Herein, we focus on the most used immune modulating cytokines in clinical practice, IL-2 and IFNalpha – mechanism of action, proven efficacy in pivotal trials, therapeutic index, limitations from both efficacy and safety standpoint. We do not approach other strategies to enhance endogenous production of immune modulating cytokines currently in development and encompassing biological response modifiers such as CpG oligodeoxynucleotides, other adjuvants, or antibodies (e.g. anti-CTLA4 mAb). In addition, we will not discuss cytokines, growth factors or biological response modifiers aimed also to restore or amplify the function of bone marrow lineages, such as GS-CSF, GM-CSF, erythropoietin, FLT3-L. Finally, we outline potential avenues to improve on overall therapeutic index of cytokines by focusing their administration to patient subpopulations that have a higher likelihood of response.

12.2 Interleukin-2 (IL-2) Interleukin-2 is probably the most studied cytokine since its discovery in the 80s. It has been implicated

240

A. Bot

as a key regulator of T cell activation and proliferation, acting in autocrine and paracrine fashion subsequent to TCR engagement by MHC II-peptide complexes onto APCs. The impact of IL-2 on CD4+ and CD8+ T cell proliferation is profound and the signaling pathway involves itk and PLCγ1 activation, Ca2++ translocation from intra-cellular and extracellular depots via calcineurin followed by transition of T cells from G0 state to DNA replication and mitosis. In addition to stimulating T cell proliferation, IL-2 elicits cytokine production (IFN-γ, TNF-α, IL-1) by T cells, activation of NK and LAK cells, eosinophilia and thromocytosis. In addition, even more important than the role in the onset of immune responses, IL-2 has dual participation to immune regulation or homeostasis: first, it is a key pre-requisite for AICD (antigen induced cell death) mediated by Fas – FasL interaction and a consequence of prolonged, exaggerated antigen stimulation. Secondly, IL-2 has been involved (along with its low affinity CD25 receptor triggered pathway) in the positive regulation of CD4+ CD25+ FoxP3+ T reg cells, important for the maintenance of peripheral tolerance. In fact, mice that are defective in IL-2/IL-2R, while able to mount immune responses, show progressive, generalized and lethal immune pathology reminiscent of break of most basic immune homeostatic mechanisms in the periphery. Overall, the role of IL-2 in vivo – similar to other soluble or membrane bound endogenous immune regulating molecules – is dual, sharpening up the kinetics of onset and decline of immunity (more rapid onset, higher magnitude and more rapid decline to baseline).

It is thus somewhat ironic that IL-2 has been first tried and successfully tested as an immune stimulating cytokine in tumor types such as melanoma and renal clear cell carcinoma. This is likely to mirror the earlier interest in understanding the role of cytokines in induction and amplification of immune response as opposed to regulation or inhibition, an area benefiting from progress only relatively recently. There are several versions of recombinant IL-2 evaluated in a variety of indications and clinical settings. For R lacks the N-terminal Alanine, example, Proleukin has a Serine substituted for Cysteine at position 125 to optimize pharmacological properties and is devoid of glycosylation since it is manufactured in E. Coli. Recombinant IL-2 was tested in pivotal clinical trials, encompassing more than 200 subjects, in melanoma and renal clear cell carcinoma (RCC) and subsequently approved for commercial use in these indications [2, 3]. In RCC, the overall response rate was 15% (with 7% complete remission) (Table 12.1). In addition, the response rate in metastatic melanoma was quite similar, with 16% overall response rate and 6% complete response. The median duration of response in patients that underwent complete remission was notable: more than 80 and 59 months, respectively. Recombinant IL-2 is given i.v. in infusions (15 min) every 8 h for up to 14 doses per cycle. The treatment is re-instated after a period of 9 days, with 14 additional infusions given. During the following 4 weeks, there is an assessment of clinical response and toxicities. Since there are three different receptors for IL-2 and possibly, only the ones expressed by T cells are intimately

Table 12.1 Cytokine therapy to stimulate immunity or target malignant cells in cancer (IL-2 and IFN-α) Cytokine Variants Indications Rate of response IL-2

IFNα

R Recombinant IL-2 (Proleukin , R HLR ) Recombinant IL-2 – DT fusion protein R (Ontak ) R Recombinant IFNα-2a (Roferon-A , R R Intron-A , Pegasys )

R Interferon alfa-n3 (Alferon N )

R collected in pivotal trials with Proleukin dose (18 mg/kg/dose) c Cytogenetic response d CD4+ T cells: 0–200 cells/mm3 e CD4+ T cells: >400 cells/mm3 CR complete response; PR partial response

a Data

b Highest

Metastatic RCC, Metastatic melanoma Cutaneous T cell lymphoma (persistent or recurrent) Ph+ CML (previously treated) Hairy cell leukemia AIDS related Kaposi’s sarcoma Condyloma acuminata (refractory or recurrent)

CR 7%, PR 8%a CR 10%, PR 6%a CR 11%, PR 25%b CR 10%, PR 12%c PR+CR 61% CR 3%, PR 3%d CR 24%, PR 21%e CR 54%, PR 26%

12 Cytokines in the Treatment of Cancer

involved with the mechanism of action, on-target toxicity is not unexpected and in fact, numerous times treatment is withheld because of this reason. Compared to the native recombinant IL-2 product (Hoffman La R (Chiron) has a more attenuated Roche), Proleukin safety profile, with fewer events of fever, nausea, hepatic toxicity and vomiting [4]. In addition, irrespective of the version of rIL-2 used, there were instances of exacerbation of inflammatory or autoimmune diseases and/or very serious CNS toxicities [5]. Naturally, the unpredictability of clinical response combined with the toxicity of IL-2 caused by its intrinsic pleiotropism, hamper its clinical applicability. Based on its documented safety and efficacy profile, various investigators evaluated IL-2 as an adjuvant to antigen-based immunization in cancers, more notoriously malignant melanoma. With the progress in understanding the key role of IL-2 in expansion and maintenance of Treg cells, however, there are questions on whether clinical use of IL-2 as adjuvant for immunotherapy does have a dual, somewhat contradictory effect on immunity. An interesting ‘flavor’ of the IL-2 based approach is represented by the use of IL-2-toxin fusion molecules R , encompassing the diphtheria (exemplified by Ontak toxin ADP-ribosylation subunit) [6]. The mechanism of action is direct and consists in binding of the fusion molecule to cells that express IL-2R followed by the internalization of the fusion protein and cellular apoptosis. Certain T cell malignancies (such as cutaneous T cell lymphoma – CTL and acute T cell leukemia/lymphoma – ATL) encompass T cell clonotypes that express CD4 and CD25, the low affinity isoform of the IL-2 receptor. Efficacy clinical trials with the IL-2 – Dyphteria toxin fusion molecule in CTL showed a significant response rate: 11% of patients underwent complete remission and 25% partial remission. On this basis, the drug has been approved for the treatment of CTL (stage Ib to IV), in patients that show CD25 expression on their malignant cells (at least 20% of cancer cells must express the target molecule). This is definitely an example of a targeted approach fitting the “theranostic” concept (use of biomarkers to identify the patients to be treated). Nevertheless, one important limiting factor is the safety profile [7] especially due to instances of vascular leak syndrome (hypotension, hypoalbuminemia, edema) sometimes resulting in life-threatening conditions, acute hypersensitivity in roughly two thirds of the patients, hence the drug can be administered only in the hospitals in

241

units equipped with cardiovascular resuscitation capaR bilities. Since CD25, the desired target of Ontak is the lower affinity IL-2R, it is conceivable that the safety profile of this drug results from off-target toxicity (binding to and killing cells that express other isoforms of IL-2) combined with exaggerated in vivo cytokine production. In addition, Diphteria toxin component is a foreign antigen and since the treatment encompasses multiple intravenous infusions, an antibody response to the drug often develops. Finally, 48% of the patients develop infections, with a quarter of them advancing to serious illness, due to significant depletion of normal T cells. Overall, even if CD25 is used as a biomarker to identify the patient subpopulation to be treated, two thirds of the treated patients do not show a response and many of them, instead, develop toxicities. Conversely, toxicity may become dose limiting in numerous patients that respond to the drug.

12.3 Interferon-Alpha IFN-α is a key cytokine regulating the innate and adaptive immune response at multiple levels. In addition, it may have direct effect on tumor cells of select phenotype. Since its discovery as a crucial mediator and effector molecule in virus infections, it became apparent that IFN-α was a component of the first phase response responsible for both keeping in check replication of extraneous genetic material as well as transmitting “danger signals” to APCs and lymphoid cells. The pleiotropic nature of IFN-α is dramatically reflected by the widespread expression of its receptor on both bone marrow as well as somatic cells, the conserved nature of this defense pathway through evolution, including STAT-1-mediated signaling that in man, results in induction of T1 immunity. In fact, its viral inhibition, capability to restore ALT serum levels and hepatic histology were tested and led to approval of rIFN-α in chronic hepatitis with HCV, a milestone in the therapy of this disorder [8]. In patients that show persisting titers of HCV, rIFN-α is able to keep those in check or trigger their decline, possibly by acting directly on virus infected hepatocytes. Several versions of rIFN-α were tested in cancer indications (Table 12.1) and interestingly, showed beneficial clinical effect and resulted in approval for

242

treatment in CML, hairy cell leukemia, nonHodgkin lymphoma and Kaposi sarcoma [9–12]. In Philadelphia chromosome positive, chronic myelR ) showed ogenous leukemia (CML), rIFN-α (Roferon a 10% complete response and 12% partial response rate when cytogenetic response criteria were used. An exciting overall response rate of 61% was reported in case of hairy cell leukemia. There were responses seen in patients with non-Hodgkin lymphoma as well. Excitingly, AIDS or HIV infected patients with Kaposi sarcoma showed significant response to IFN-α: in patients that are relatively immune competent (CD4+ T cells in blood > 400 mm3 ), the complete response rate was 24% and the partial response rate was 21% (a staggering 45% overall response rate); whereas in immune compromised patients (CD4+ T cells in blood < 200 mm3 ), the response rate was dismal (3% complete and 3% partial response, respectively). This has dual implications: first, it sheds some light on the mechanism of action, likely to be dependent on T helper cells; secondly, it outlines a key biomarker for patient stratification, with clear predictive value, prior to initiating therapy – namely the frequency of CD4+ T cells. A different synthetic IFN-α (interferon-a R ) was tested and approved in a benign n3, Alferon tumor, relapsing or recurring condyloma acuminata resulting from chronic infection with select human paillomavirus (HPV) subtypes [13]. Interestingly and in line with the concept shown in Fig. 12.2, IFN-α was most effective and is being administered by direct tumor injection in this particular case, likely associated with minimal antigen exposure to the immune system. Toxicity, as expected, has been a problem with rIFN-α since its native counterpart mediates a significant portion of flu symptoms such as fever and chills [14]. In addition, there are significant central nervous reactions, psychiatric side-effects in a subset of patients culminating with clinical depression and suicide. Finally, other serious toxicities such as gastrointestinal hemorrhage and bone marrow suppression may occur. To ameliorate these side effects and optimize the administration regimen otherwise requiring frequent injections, second-generation rIFN-α with longer half-life were developed (such as R ) and were initially approved for the most Pegasys common application, HCV positive hepatic disease. Another aspect hampering the chronic use of rIFN-α is represented by induction of antibodies that may

A. Bot

become neutralizing. It has been shown that a potential solution to this problem is the alternate use of natR , the ural IFN-α, hence the approval of Multiferon native human molecules (multiple IFN-α isoforms) purified from stimulated cell cultures and administered to patients with malignant melanoma.

12.4 Challenges Associated with Cytokine Therapy in Cancer Cytokine treatment in cancer represented a significant advent in cancer therapy, with IL-2 and IFN-α leading the path. We are however at a cross road that may result in a significant modification of the therapeutic landscape in oncology practice, fueled by new generations of molecular targeted therapies, both biomolecules and small molecules. This revolution witnessing the coming to age of monoclonal antibodies and emergence of multi-tyrosine kinase inhibitors, may phase out the use of cytokines per se, in the therapy of cancers. This is due to the overall reduced efficacy of cytokines and the associated toxicities. A closer look however offers some hope: a subset of patients treated with IL-2 or IFN-α does respond by complete or partial regression that lasts for a few weeks, months or sometime even years depending on the tumor type. In light of this and the grave side effects experienced by many patients, it is clear that the limitations associated with cytokine therapy (more specifically IL-2 and IFN-α) in cancer are two fold: unpredictability of clinical response and the modest therapeutic index. A stratified medicine concept is in principle able to address both these problems. It is already evident that a biomarker-guided treatment makes a positive albeit relatively modest difference in context of cytokine R (recombitherapy in cancer. For example, Ontak nant IL-2 – Dyphteria toxin fusion protein) is administered to cutaneous T cell lymphoma patients that express CD25 on their malignant cells. Despite the fact that there are little data in patients with CD25 negative malignant cells, a thorough understanding of the mechanism of action including the pharmacelogically relevant target, enables development of ‘upstream’ biomarkers that can be used to stratify the patient population. In this particular case, the stratification leads to two groups: patients that may respond

12 Cytokines in the Treatment of Cancer

243

and patients that do not respond. Thus, since a clinical response requires a number of parameters to be simultaneously met, while clinical failure is easier to achieve (a single pre-requisite not met would suffice), it is thus more straightforward to develop biomarkers predicting lack of response just based on thorough understanding of the mechanism of action and pharmacology. Mathematically, this still makes a significant difference resulting in focusing the therapy to a subset of patients with a higher likelihood of success. Unfortunately, use of IL-2 and IFN-α as immune modulating agents in cancer therapy, is faced with an inherent difficulty to develop predictive biomarkers due to the complexity of the mechanism of action and their pleiotropic activity. Interestingly, in case of Kaposi sarcoma the frequency of CD4+ T cells and thus the degree of immune suppression is a good biomarker: immune suppressed patients have a likelihood of complete response of <3% while immune competent ones have a rate of response that is approximately an order of magnitude higher (Fig. 12.3). The partial success of individual biomarkers in conjunction with the complexity of mechanism of action suggests that a better predictive value can be obtained by integrating several biomarkers, associated with the pharmacological response and susceptibility of the pathogenic process to effector mechanisms. This may require measurement of such biomarkers from both lymphoid cells and tumor tissue. More specifically, a prospective study encompassing expression analysis in

cancer patients treated with IL-2 or IFN-α followed by comparison between responders and non-responders (correlation analysis), would yield a set of biomarkers to better distinguish between patients that have an increased likelihood of response relative to refractory patients (Fig. 12.3). Overall, this approach would result in significant improvement of the therapeutic index since first, patients that are not likely to respond are not exposed; instead, the treatment is focused at patients that have a predictable response rate. Thus, at a population level, the ratio between efficacy and safety is improved, although the safety profile is not significantly modified, by just implementing a “theranostic” approach. Very promising progress has been made in understanding why certain melanoma and kidney cancer patients respond to rIL-2 [15]: by comprehensive analysis of serum samples from patients dosed with IL2, the authors defined fibronectin and VEGF as two key predictors of response to this cytokine. In brief, higher serum levels of fibronectin and VEGF prior to therapy, are negative predictors of clinical response. This paves the way to an exciting and practical strategy to direct IL-2 to patients who are most likely to benefit from the treatment, complementing previous findings attempting to correlate a specific gene signature in tumors or circulating T cells with treatment outcome [16]. In the same lines, there has been recent progress in defining defects in signal transduction pathways downstream of IFN-α, which may correlate with response of melanoma patients to this cytokine [17]. Thus, the premises are created for a coherent effort to develop

Example Clinical Study

CD4+T cells and response of Kaposi Sarcoma to IFNα % Objective Response Rate

100 90 80 70 60 50 40 30 20 10 0

Complete response Partial response Progression

IL-2 IFN-alpha

Responders 0 −200

201−400

NonResponders

>400

CD4+ T cells (cells/mm^3)

Differential expression profile (tissue harvested prior to treatment)

Fig. 12.3 Predictive biomarkers in support of cytokine therapies

Develop and refine predictive markers

Biomarkers (focus the treatment to responders and limit exposure of non-responders)

244

predictive tests for cytokine treatment, truly enabling an effective application of such therapies in clinic.

12.5 Conclusions Implementation of cytokines in therapy of oncologic disorders represented a milestone; nevertheless, there are significant challenges associated with use of such biological response modifiers: a modest response rate and significant side effects. Nevertheless, the quite durable objective response displayed by a subset of patients, such as RCC or melanoma patients treated with rIL-2, provides a strong rationale for the intrinsic capability of immune system to affect cancer progression if harnessed appropriately. However, to continue to compete in a rapidly changing therapeutic landscape, cytokines must raise to the challenge of stratified medicine or biomarker-guided therapy. This will allow improvement of their therapeutic index by focusing the treatment to patient subpopulations that have the highest likelihood of response. In addition, the advent of second generation cytokines – such as IL-15, devoid of some undesirable bystander effects of IL-2 – along with pleiotropic biological response modifiers that elicit a ‘storm’ of synergistic cytokines (such as Toll-like receptor agonists), or block negative regulatory mechanisms (such as α-CTLA4 mAb), carry the promise of furthering this therapeutic area.

References 1. Matzinger P (1994) Tolerance, danger, and the extended family. Annu Rev Immunol 12:991–1045 2. Riker AI, Radfar S, Liu S, Wang Y, Khong HT (2007) Immunotherapy of melanoma: a critical review of current concepts and future strategies. Expert Opin Biol Ther 7(3):345–358 3. Hutson TE, Quinn DI (2005) Cytokine therapy: a standard of care for metastatic renal cell carcinoma? Clin Genitourin Cancer 4(3):181–186

A. Bot 4. Hank JA, Surfus J., Gan J., Albertini M, Lindstrom M, Schiller JH, Hotton KM, Khorsand M, Sondel PM (1999) Distinct clinical and laboratory activity of two recombinant interleukin-2 preparations. Clin Cancer Res 5(2): 281–289 5. Lentsch AB, Miller FN, Edwards MJ (1999) Mechanisms of leukocyte-mediated tissue injury induced by interleukin-2. Cancer Immunol Immunother 47(5): 243–248 6. Turturro F (2007) Denileukin diftitox: a biotherapeutic paradigm shift in the treatment of lymphoid-derived disorders. Expert Rev Anticancer Ther 7(1):11–17. Review 7. Kuzel TM (2000) DAB(389)IL-2 (denileukin diftitox, ONTAK): review of clinical trials to date. Clin Lymphoma 1(Suppl 1):S33–S36. Review 8. Boyer N, Marcellin P (2003) Pathogenesis, diagnosis and management of hepatitis C. J Hepatol 32(1 Suppl):98–112 9. Gidron A, Tallman MS (2006) Hairy cell leukemia: towards a curative strategy. Hematol Oncol Clin North Am 20(5):1153–1162 10. Armitage AE, Armitage JD, Armitage JO (2006) Alphainterferon for relapsed non-Hodgkin’s lymphoma. Bone Marrow Transplant 38(10):701–702 11. Quintas-Cardama A, Cortes JE (2006) Chronic myeloid leukemia: diagnosis and treatment. Mayo Clin Proc 81(7):973–988 12. Vanni T, Sprinz E, Machado MW, Santana Rde C, Fonseca BA, Schwartsmann G (2006) Systemic treatment of AIDSrelated Kaposi sarcoma: current status and perspectives. Cancer Treat Rev 32(6):445–455 13. Kodner CM, Nasraty S (2004) Management of genital warts. Am Fam Physician 70(12):2335–2342 14. Sleijfer S, Bannink M, Van Gool AR, Kruit WH, Stoter G (2005) Side effects of interferon-alpha therapy. Pharm World Sci 27(6):423–431 15. Sabatino M, Kim-Schulze S, Panelli MC, Stroncek D, Wang E, Taback B, Kim DW, Deraffele G, Pos Z, Marincola FM, Kaufman HL (2009) Serum vascular endothelial growth factor and fibronectin predict clinical response to high-dose interleukin-2 therapy. J Clin Oncol 27(16): 2645–2652 16. Panelli MC, Wang E, Phan G, Puhlmann M, Miller L, Ohnmacht GA, Klein HG, Marincola FM (2002) Geneexpression profiling of the response of peripheral blood mononuclear cells and melanoma metastases to systemic IL-2 administration. Genome Biol 3(7):RESEARCH0035. Epub 2002 Jun 25 17. Critchley-Thorne RJ, Yan N, Nacu S, Weber J, Holmes SP, Lee PP (2007) Down-regulation of the interferon signaling pathway in T lymphocytes from patients with metastatic melanoma. PLoS Med 4(5):e176

Chapter 13

Antibody-Based Therapies for Solid Tumors Satish Shanbhag and Barbara Burtness

13.1 Introduction The introduction of monoclonal antibodies into clinical oncology began a new era in cancer therapy. These therapies add new mechanisms of action and possess relatively favorable toxicity profiles compared to standard chemotherapy drugs. Monoclonal antibodies are used widely in clinical medicine. Rituximab, a chimeric antibody directed against the CD20 antigen on B lymphocytes, was the first monoclonal antibody to gain regulatory approval for the treatment of lymphomas, which was granted in 1997 [1]. The current decade has seen the introduction of four therapeutic antibodies for treatment of solid tumors, and these are in wide clinical use. Trastuzumab for breast cancer, bevacizumab for breast, lung and colorectal cancer, cetuximab for colorectal and squamous cell cancers of the head and neck and panitumumab for colorectal cancer are currently approved in the United States; many other novel agents are under investigation. Reference [2], doi:10.1038/35101072

13.2 History Initial monoclonal antibodies in experimental trials were of murine origin. The development of neutralizing human anti-mouse antibodies (HAMA) with

S. Shanbhag () Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111-2497, USA e-mail: [email protected]

repeated use was a significant barrier to the activity and development of these as drugs. To enhance efficacy and minimize immunogenicity, chimeric and humanized antibodies were studied. Chimeric antibodies are obtained by joining the antigen-binding variable domains of a mouse monoclonal antibody to human constant domains and are about 65% human [2]. Humanized antibodies are created by grafting the antigen-binding loops, known as complementarity-determining regions (CDRs), from a mouse antibody into a human IgG. Human

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_13, © Springer Science+Business Media B.V. 2011

245

246

S. Shanbhag and B. Burtness

Table 13.1 Antibodies in solid malignancies Antibody

Target

Indications

Significant side effects

Bevacizumab

VEGF

Trastuzumab Cetuximab

HER2 EGFR

Colorectal carcinoma, Breast cancer NSCLC HER2 overexpressing breast cancer Colorectal carcinoma

Panitumumab

EGFR

Colorectal carcinoma

Hypertension, Proteinuria, Thrombosis, Bleeding Cardiac dysfunction Skin rash, Hypomagnesemia, Infusion reactions Skin rash, Hypomagnesemia

antibodies are produced from very large, single-chain variable fragments or Fab phage display libraries (Table 13.1) [2].

13.3 Antibodies Targeting VEGF The formation of vascular networks in the developing embryo by endothelial cells is termed vasculogenesis. Angiogenesis is completed when vascular smooth muscle elements associate with the endothelial cell network. VEGF, which is expressed in the tumor microenvironment, mediates angiogenesis which plays a critical role in tumor growth and metastasis [3]. Vascular Endothelial Growth Factor (VEGF) belongs to a sub-family of platelet-derived growth factors (PDGF). The entire VEGF family, consisting of isoforms VEGF-A, VEGF-B, VEGF-C, VEGF-D and VEGF-E (orf virus VEGF), act as important regulators of endothelial cell function controlling vasculogenesis, vascular permeability and endothelial cell survival. VEGF-A is important in pathologic angiogenesis while VEGF-C plays a crucial role in lymphangiogenesis. The exact role of the other VEGF forms in angiogenesis is a subject of investigation. VEGF signal transduction occurs through endothelial cell receptors VEGFR-1, VEGFR-2 and VEGFR-3. Their structures include an extracellular immunoglobulin-like domain and an intracellular tyrosine kinase-like domain. Approaches to angiogenesis inhibition have involved either targeting the extracellular domain with antibodies or the intracellular domain with small molecule tyrosine kinase inhibitors. VEGF stimulates endothelial cells lining nearby microvessels to proliferate and migrate. Proteolysis of extracellular matrix is carried out by the prourokinaseurokinase-plasmin system [4]. This permits leakage of plasma proteins into the extravascular space; the

Antibody type Humanized Humanized Chimeric Fully Human

resultant fibrin gel acts as a matrix for ingrowth of new vasculature and tumor cells [5]. VEGF expression is regulated by the amount of oxygen available in the developing tumor stroma; hypoxia-induced transcription factors play a primary role in up-regulating VEGF in response to hypoxia. VEGF expression is increased in a large variety of cancer types. In normal tissues VEGF is produced by endothelial cells alone, but tumor cells can produce VEGF and may bear VEGFR. VEGF expression is predictive of poor disease-free survival, specifically linked to distant metastasis in patients with locally advanced rectal cancer [6]. A Japanese study found vascular endothelial growth factor-C expression was an independent risk factor for the local recurrence of rectal carcinoma [7]. Similar results have been found in colon cancer, correlating VEGF expression with development of liver metastasis and poor prognosis [8]. Expression of VEGF inversely correlated with overall survival in gastric cancer patients [9]. VEGF upregulation by intra-tumoral hypoxia and aberrant signaling promotes new blood vessel growth connected to the neighbouring vasculature. This “angiogenic switch” provides a novel target for anticancer therapy [10]. Angiogenesis may be inhibited through targeting of the angiogenic growth factors (such as VEGF and HIF1-alpha) or their receptors. The VEGF-directed antibody bevacizumab is the first such agent to impact survival in human cancer.

13.4 Bevacizumab Bevacizumab is a humanized monoclonal antibody that blocks binding of VEGF to the ligand-binding domain in the extracellular portion of VEGF-receptor on vascular endothelium, and likely also when it is expressed by malignant cells.

13 Antibody-Based Therapies for Solid Tumors

13.4.1 Colorectal Carcinoma Bevacizumab was first approved for the treatment of colorectal carcinoma. In a randomised placebocontrolled trial studying addition of bevacizumab to the IFL regimen (irinotecan, 5-fluorouracil and leucovorin), the addition of bevacizumab improved outcome significantly. Median overall survival improved from 15.6 to 20.3 months, and median progression-free survival from 6.2 to 10.6 months [11]. This benefit was maintained when FOLFIRI was used as the chemotherapeutic backbone [12]. The ECOG 3200 trial addressed the question of utility of bevacizumab in second-line therapy of metastatic colon cancer. Eight hundred twenty-nine patients previously treated with a fluoropyrimidine and irinotecan were randomised to three groups: oxaliplatin, fluorouracil, and leucovorin (FOLFOX4) with bevacizumab; FOLFOX4 without bevacizumab; or bevacizumab alone. The median overall survival for the group treated with FOLFOX4 and bevacizumab was 12.9 months compared with 10.8 months for the group treated with FOLFOX4 alone (p = 0.0011) [13]. This study also demonstrated that bevacizumab has relatively little activity in colon cancer when given without chemotherapy. The addition of bevacizumab to modified FOLFOX6 as a part of adjuvant therapy for resected stage II or III carcinoma of the colon did not result in an overall statistically significant prolongation in disease free survival (DFS) [14]. Although there was a transient benefit in DFS during the one-year interval that bevacizumab was utilized, this benefit diminished over time.

13.4.2 Breast Cancer The addition of bevacizumab to cytotoxic chemotherapy in patients with metastatic breast cancer was the subject of ECOG 2100; this randomised 722 patients to paclitaxel with or without bevacizumab. Bevacizumab significantly prolonged progression-free survival when added to paclitaxel (median, 11.8 vs. 5.9 months; P<0.001) and increased the objective response rate (36.9% vs. 21.2%, P<0.001) without a significant difference in the overall survival (median, 26.7 vs. 25.2 months; hazard ratio, 0.88; P = 0.16) [15]. The difference in progression-free survival was the basis

247

of the approval granted by the FDA for use of bevacizumab in metastatic breast cancer [14]. It also raised important questions of cost and benefit which will be outlined further below, especially when these data are considered in the context of a previous trial in which bevacizumab did not improve survival when added to capecitabine in previously treated metastatic breast cancer [16].

13.4.3 Non-small-cell Lung Cancer The ECOG also examined the use of bevacizumab in non-small-cell lung cancer (NSCLC). Eight hundred and seventy eight patients with recurrent or advanced NSCLC (stage IIIB or IV) were randomly assigned to paclitaxel and carboplatin chemotherapy with or without the addition of bevacizumab. Patients with predominantly squamous-cell cancers, with brain metastases or with clinically significant hemoptysis were excluded because of safety considerations. Significant improvements in median survival (12.3 months vs. 10.3 months HR 0.79; P = 0.003), progression-free survival (6.2 vs 4.5 months) and response rate (35% vs 15%) were described in the group receiving bevacizumab. However this survival benefit came at a cost of increased treatment-related deaths (15 in the experimental compared to 2 in the control arm) [17]. The European AVAiL (Avastin in Lung Cancer) trial examined cisplatin/gemcitabine with or without bevacizumab at 15 or 7.5 mg/kg IV every three weeks. Preliminary reports showed a modest improvement in progression-free survival in both arms containing bevacizumab without a significant survival benefit for either over control (6.7 and 6.5 vs. 6.1 months) [18]. The failure to confirm the earlier impressive data with regard to survival may reflect regression to the mean, differences in the patient populations, as reflected in the different median survivals for the control arms in the 2 studies, differences in the backbone chemotherapy regimens used, inadequate statistical power in AVAiL, or post-study access to differing therapies.

13.4.4 Renal Cell Carcinoma Angiogenesis blockade has proven to have significant clinical activity in renal cell carcinoma; the

248

tyrosine kinase inhibitors sorafenib and sunitinib which target the intracellular domain of VEGF are standard treatments for advanced disease [19, 20]. The AVOREN trial randomised 649 previously untreated with metastatic renal cell carcinoma to interferon alfa (IFNa, 9 million units three times/week for one year) plus either bevacizumab (10 mg/kg every two weeks) or placebo. The median progression-free survival was significantly longer in the bevacizumab plus interferon alfa group than in the control group (10.2 months vs 5.4 months; HR 0.63, 95% CI 0.52–0.75; P = 0. 0001). The overall response rate was also better in the bevacizumab arm (31% compared to 13%) [21].

13.4.5 Malignant Glioma Increased understanding of the biology of malignant glioma has led to the study of novel regimens. VEGF plays a critical role in tumor angiogenesis, thereby forming a promising target for directed therapies. A phase II trial conducted at Duke University examined bevacizumab and irinotecan in patients with recurrent malignant gliomas. Preliminary data revealed an overall response rate of 59%, much superior to nitrosoureabased chemotherapy [22].

13.4.6 Ovarian Cancer Bevacizumab was studied in platinum-refractory, recurrent epithelial cancer and primary peritoneal cancer in a Phase II trial. Single agent bevacizumab demonstrated a 21% response rate and 40% of enrolled patients had no disease progression at 6 months [23]. However, large studies to more precisely define the role of bevacizumab in the treatment of ovarian cancer remain to be completed.

13.4.7 Other Tumors Bevacizumab is also being studied in a variety of other tumor types including lymphoma, prostate cancer, metastatic head and neck cancer, gastric cancer, GIST, and high risk carcinoid. Although NSABP Protocol C-08 did not show any benefit with the addition of bevacizumab, trials are underway in breast, ovarian

S. Shanbhag and B. Burtness

and lung cancer patients to define the role of antiangiogenic therapy in the adjuvant setting.

13.4.8 Side Effects The utility of bevacizumab comes at the cost of side effects which are quite dissimilar from those of standard cytotoxic agents. Common side effects seen with bevacizumab include proteinuria and a rate of Grade 3 and 4 hypertension of over 10%. Venous thrombosis occurs in fewer than 10% of treated patients. Other more catastrophic side effects include GI perforation (particularly in colon and ovarian carcinomas, where the rates are approximately 1.5%), and arterial thrombotic events (transient ischemic attack, stroke, myocardial infarction). Risk for the latter is increased in those older than age 65, or with a personal, especially a recent personal, history of arterial thrombotic event. In such patients, the risk is above 15%, and bevacizumab is relatively contraindicated. There is also an increased rate of bleeding noted with the use of the drug. Particularly in the NSCLC population, an increased death rate attributable to pulmonary hemorrhage precluded enrolling patients with squamous cell histologies. Also, concerns about CNS bleeding precluded patients with brain metastases from enrolling in the lung cancer trials. However, considering that the drug is safe to use in malignant brain tumors, specific trials are looking at bevacizumab in patients with treated brain metastases.

13.5 Trastuzumab In the late 1980s the Slamon laboratory conducted studies which led to the discovery that the HER2/neu proto-oncogene (also called c-erb-B2, ERBB-2 or HER2) was amplified in over 20% of primary breast cancers [24]. Amplification and expression of Her2/neu correlated with early relapse and worse survival [25, 26]. The gene encodes for the HER2 receptor, a member of the Epidermal Growth Factor Receptor (EGFR) family, which also includes HER1, HER3 and HER4. The HER family of receptors play important roles in cell proliferation, migration, differentiation and survival.

13 Antibody-Based Therapies for Solid Tumors

Hudziak, Ullrich and colleagues at the biotechnology company Genentech in California, U.S.A developed a monoclonal antibody directed against the extracellular domain of HER2, specifically inhibiting the growth of breast tumor-derived cell lines overexpressing the HER2 gene product [27]. The in vitro activity of the drug specific for HER2-overexpressing tumor cells led to the development of trastuzumab, a humanized monoclonal antibody directed against HER2. Multiple mechanisms of action for the in vivo activity of the drug have been hypothesized. Inhibition of HER2 shedding, inhibition of downstream signalling pathways, and inhibition of tumor angiogenesis are also thought to be involved. However the cytotoxic in vivo activity of trastuzumab has been thought to be related to ADCC (Antibody-dependent cellular cytotoxicity). ADCC is an immunological phenomenon due to the activation of natural killer (NK) cells; cancer cells bound by trastuzumab are lysed when NK cells expressing the Fc gamma receptor bind to the Fc domain of trastuzumab [28]. Compelling evidence has emerged in the neoadjuvant setting where Her2 expressing tumors treated with trastuzumab have shown infiltration by lymphocytes; the strength of infiltration correlates directly with response to therapy [29].

13.5.1 Metastatic Breast Cancer The pivotal trial which proved the utility of trastuzumab evaluated 234 patients randomly assigned to receive standard chemotherapy alone with 235 patients to receive standard chemotherapy plus trastuzumab. The cytotoxic backbone was anthracycline (doxorubicin or epirubicin) and cyclophosphamide in those who had not received adjuvant

249

chemotherapy, and paclitaxel in those who had. The addition of trastuzumab to chemotherapy was associated with a higher response rate (50% vs. 32%, P < 0.001), longer duration of response (median 9.1 vs. 6.1 months; P < 0.001) and improved time to disease progression (median, 7.4 vs. 4.6 months; P < 0.001). Most significantly, patients receiving trastuzumab had longer survival (median survival 25.1 vs. 20.3 months; P = 0.046) despite the fact that the patients who were on the control arm were allowed to cross over to receive the drug on progression. Benefit was observed in combination with either cytotoxic regimen (anthracycline-based or paclitaxel). The study also revealed a significant incidence of cardiotoxicity, especially when trastuzumab was given with an anthracycline [30]. Similarly, trastuzumab has been studied in combination with other cytotoxic agents including vinorelbine and capecitabine and found to be active [31, 32]. Trastuzumab also has significant activity as a single agent with response rates of 15% for pretreated patients and up to 30% for patients being treated first-line (Table 13.2) [33, 34].

13.5.2 Adjuvant Therapy The role of trastuzumab in the adjuvant setting in patients with HER2-overexpressing tumors has been well established in multiple trials. HERA, FinHer, NSABP B31, N9831 and BCIRG 006 all showed benefit from addition of trastuzumab to cytotoxic chemotherapy in node-positive or high-risk node negative breast cancer [35–38]. Trastuzumab in the adjuvant treatment of HER2positive breast cancer has had the most significant impact of all the antibody-based therapies used in

Table 13.2 Trastuzumab with adjuvant chemotherapy compared to chemotherapy alone HERA B31 / N9831 FinHER Cytotoxic regimen with trastuzumab

Any adjuvant chemotherapy

Doxorubicin, cyclophosphamide and paclitaxel

Vinorelbine or docetaxel with trastuzumab followed by FEC

Trastuzumab duration Disease-free survival (hazard ratio) Overall survival (hazard ratio)

1 year/2 years 0.64 (0.54–0.76)

1 year 0.49 (0.41–0.58)

9 weeks 0.42 (0.21–0.83)

0.66 (0.47–0.91)

0.63 (0.49–0.81)

0.41 (0.47–1.08)

BCIRG 006 Docetaxel + carboplatin (or) Doxorubicin, cyclophosphamide and docetaxel 1 year 0.61 (0.48–0.76) (or) 0.67 (0.54–0.83) 0.59 (0.42–0.85) (or) 0.66 (0.47–0.93)

250

solid tumors. For example, in the combined analysis of NCCTG N9831 and NSABP B-31, adding trastuzumab to adjuvant chemotherapy improved the 4 year disease-free survival rate from 73.1% (95% CI: 70.6–75.8%) to 85.9% (95% CI: 84.0–87.8%) [35]. Listed above are the various trials examining the role of adjuvant trastuzumab in HER2-overexpressing breast cancer which, although varying in cytotoxic chemotherapy backbones, clearly show the significance of addition of trastuzumab [35–38]. This clearly reflects the strongest impact trastuzumab has had on the health system as a whole, improving cure rates and abrogating the adverse prognostic impact of HER2 overexpression.

13.5.3 Side Effect Profile/Cardiac Toxicity The cardiac toxicity of trastuzumab was manifest during the pivotal trial in metastatic breast cancer [30]. The incidence of cardiac dysfunction with trastuzumab plus the anthracycline-based regimen was 27% vs. 8% with the anthracycline alone. Trastuzumab also increased the cardiac side effects of the taxane arm of the trial from 1 to 13%. However, single agent trastuzumab has a cardiac dysfunction rate of only about 7%, suggesting a synergism against cardiac muscle when given with cytotoxic chemotherapy. The exact pathophysiology is still a subject of debate, but cardiac dysfunction seems to be higher in patients with medical comorbidities such as diabetes mellitus, hypertension and preexisting cardiac disease. Fortunately, trastuzumab’s cardiac toxicity is usually reversible (often presenting as asymptomatic drop in the measured left ventricular ejection fraction) compared to anthracycline-induced cardiac injury. Therefore, patients receiving trastuzumab need to have their cardiac function closely monitored while on therapy.

13.6 Antibodies to the Epidermal Growth Factor Receptor (EGFR) Two monoclonal antibodies which target epitopes in the ligand-binding domain of EGFR are currently commercially available in the United States. Several

S. Shanbhag and B. Burtness

other monoclonal antibodies to this or other sites on EGFR are in early clinical development.

13.6.1 EGFR Biology and Expression in Cancer EGFR is a 170 kD transmembrane receptor tyrosine kinase with an extensively described role in mediating pleiotropic cellular responses. Binding by a number of ligands prompts the receptor to enter into homo- and heterodimers or oligomers; the resulting conformational change leads to autophosphorylation of a tyrosine residue on the intracellular portion of the molecule. The phosphorylated receptor can then recruit docking proteins and signal transduction molecules, resulting in activation of cascades which are anti-apoptotic and proliferative, and which contribute to metastasis and angiogenesis [39, 40]. Overexpression of EGFR, often associated with increased production of ligands such as transforming growth factor alpha, has been reported in many human epithelial malignancies, where such overexpression is associated with worse prognosis and reduced sensitivity to radiation and chemotherapy. Thus, EGFR represents a high-value therapeutic target in cancer. Less well-characterized and understood is the presence of EGFR in the nuclei of highly proliferative normal and malignant cells; however, there is now sufficient biological evidence to suggest that there is a nuclear EGFR signaling network which transmits growth factor signals directly from the cytoplasmic membrane to transcriptional targets in the nucleus, bypassing the traditional protein phosphorylation cascades [41].

13.6.2 Antibody vs. Tyrosine Kinase Inhibitor Inhibition of EGFR signalling can be achieved either by competitive targeting of the ligand-binding domain, to prevent ligand-determined activation of the receptor, or by use of aminoquinazoline inhibitors of the ATP binding site in the kinase domain. Both strategies are associated with anticancer responses, and impact survival in some cancers. The scope of this discussion is limited to the antibodies studied or under study.

13 Antibody-Based Therapies for Solid Tumors

13.7 Cetuximab Cetuximab (ErbituxTM , C225, IMC-225) was developed as a human:murine chimeric antibody derived from the murine antibody M225, which binds specifically to the ligand-binding domain of EGFR [42]. Cetuximab-bound EGFR is not available for binding by natural ligand, and ligand-dependent signaling is reduced. Antibody-bound receptor is internalized by an alternate and possibly slower process than ligand-bound receptor. Reduced proliferation, substantial antitumor effect and enhanced apoptosis are observed in cetuximab-treated A431 vulvar carcinoma xenografts. The murine anti-epidermal growth factor antibody M225, from which cetuximab was derived by chimerization, enhanced the antitumor effects of chemotherapy in established xenografts of EGFRexpressing tumor cells [43]. Phase I testing of cetuximab established that cetuximab is well-tolerated; acneiform rash and hypersensitivity reactions are the predominant toxicities [44]. Numerous studies have now correlated the appearance and severity of this rash with overall survival for patients treated with this and many other EGFR inhibitors. Subsequently, hypomagnesemia has also been recognized as an adverse effect of cetuximab. Recommended doses are a loading dose of cetuximab 400 mg/m2 in week 1, followed by a weekly dose of 250 mg/m2 . Clearance was saturated at this dose and schedule, but an optimum biologic dose was not demonstrated, formal determination of the maximum tolerated dose was not achieved, and alternate schedules such as every other week dosing are only now being explored.

13.7.1 Head and Neck Cancer Squamous cell cancers of the head and neck are rich in EGFR expression, and objective responses to cetuximab were observed in head and neck cancer patients enrolled in the phase I trials. These findings have now been confirmed in randomized studies. Cetuximab contributes significantly to disease control and survival when it is added to definitive radiotherapy for locally advanced squamous cell cancer of the head and neck [45]. Subgroup analyses suggested the effect was greatest for oropharynx cancers and among

251

patients treated with altered fractionation schedules. Cetuximab did not measurably increase high grade infield or long-term toxicity or degrade long-term quality of life. The clinical application of this finding is complicated by the emergence – since the initial design but prior to the report of the study – of chemoradiation as the treatment of choice for patients with locally advanced squamous cell cancer of the head and neck. In practice, cetuximab is often added to definitive radiation in patients who are considered poor candidates for high dose cisplatin. The Radiation Therapy Oncology Group is currently conducting a large randomized study to compare chemoradiation with altered fractionation to the same therapy plus cetuximab. Cetuximab also has a role in the treatment of metastatic/recurrent head and neck cancer. First-line therapy of such patients with cisplatin was compared to cisplatin/cetuximab combination [46]. The addition of cetuximab significantly improved the objective response rate and was associated with a hazard ratio for progression of 0.78, but the study was inadequately powered for progression and survival. First-line use of cetuximab was also studied in a randomized trial utilizing 6 cycles of platinoid plus 5-fluorouracil; this study demonstrated a significant improvement in overall survival when cetuximab is added to a first-line platin-doublet [47]. Cetuximab also has activity in previously treated patients. Phase II trials in both the US and Europe tested addition of cetuximab to cisplatin in patients who were already refractory to platinoid chemotherapy [48, 49]. Each study demonstrated an objective response rate of 10%. Cetuximab monotherapy was tested in 103 patients with recurrent/metastatic HNSCC who had progressed on platinum-based chemotherapy [50]. Patients were treated with cetuximab until disease progression; cetuximab might then be continued with the addition of a platin. The objective response rate for cetuximab was 13%; no objective responses were observed among the 53% of patients who subsequently had a platinoid added back to the therapy, although the disease control rate for this phase of the study was 26% and median time to progression was 50 days. The similarity of the results with cetuximab alone or in combination with cisplatin suggest cetuximab may be used alone in second line; however, crossover therapy in the monotherapy trial was presumably used for the fittest patients and thus the excluded patients may have had the most aggressive

252

disease, perhaps with the highest tumoral EGFR or ligand content. Current studies add cetuximab to induction therapy for high risk patients also receiving chemoradiation and combine cetuximab with other targeted therapies.

13.7.2 Colorectal Cancer Cetuximab significantly delays time to progression when given together with chemotherapy in the firstor second-line treatment of metastatic colorectal cancer; however, use in second-line is not demonstrated to impact on survival in unselected patients, likely because there is also benefit when the agent is given after progression on second-line chemotherapy. Standard first-line therapy has generally been doublet chemotherapy in combination with bevacizumab. Thus, in practice, cetuximab is often given firstline only to patients with a clinical contraindication to the use of bevacizumab, and in second-line it is given with chemotherapy predominantly for those patients who are symptomatic and will benefit from the slightly higher response rate described with cetuximab/chemotherapy combination in this setting. For patients with a lesser disease and symptom burden, addition of cetuximab at the time of disease progression on second-line chemotherapy is widely accepted. These practice patterns emerged in response to data from cetuximab trials which did not use molecularly guided patient selection. Data will be reviewed below which indicate that K-ras status is predictive of benefit from cetuximab; as K-ras data are used in the design of future studies, it is likely these practices will be further refined. Irinotecan-refractory patients represent the first group of patients in whom the activity of cetuximab was convincingly demonstrated. Three hundred twenty-nine such patients were randomly assigned to receive either cetuximab and irinotecan (218 patients) or cetuximab monotherapy (111 patients). Objective responses were observed in 22.9% of patients treated with the combination compared with 10.8% who received cetuximab alone (P = 0.007). Median time to progression was 4.1 months for patients who received combination, compared with 1.5 for those who received monotherapy, (P<0.001). Overall survival median was 8.6 months in the combination-therapy

S. Shanbhag and B. Burtness

group and 6.9 for patients who received cetuximab alone (P = 0.48) [51]. Blocks from archived tumor material were available from 587 of 1,198 of the population enrolled in the CRYSTAL first-line randomized trial. K-ras mutations were detected in 35.6% of patients with evaluable samples. A statistically significant difference in favor of cetuximab was seen in K-ras wild type patients for progression-free survival (P = 0.0167; hazard ratio estimate 0.68) and response. These data confirm findings from smaller cohorts treated in non-randomized settings, and indicate that cetuximab in colon cancer therapy should be reserved for patients with wild type K-ras [52].

13.7.3 Other Tumor Types Under Study Clinical trials are underway or completed but not finally reported studying the addition of cetuximab to chemotherapy or chemoradiation in a number of epithelial cancers. A preliminary report of a large randomized trial in lung cancer demonstrates an improvement of slightly more than 1 month in overall survival for doublet chemotherapy with cetuximab over chemotherapy alone [53]. An Intergroup study [C80403/E1206] currently randomizes previously untreated patients with metastatic/recurrent esophagogastric cancer among 3 chemotherapy regimens, each given with cetuximab. Cetuximab was studied in metastatic pancreatic cancer, but a randomized trial failed to demonstrate a meaningful improvement in time to progression or death for the addition of cetuximab to gemcitabine.

13.8 Panitumumab Panitumumab is a fully humanized IgG2 antibody which also targets EGFR. It is raised in mice genetically engineered without functional murine immunoglobulin expression, into which human immunoglobulin genes are introduced. Side effects are similar to those described with cetuximab, but high grade hypersensitivity reactions are much rarer with this agent. It appears to have a similar spectrum of activity preclinically, and has been developed in colorectal cancer. Objective responses

13 Antibody-Based Therapies for Solid Tumors

are observed in 9% of previously treated metastastic colorectal cancer patients [54]. A randomized trial comparing panitumumab to best supportive care was conducted among 463 patients. The study permitted cross-over following progression, confounding any survival analysis and perhaps also impacting time to progression in this open label study. Panitumumab significantly delayed progression (hazard ratio 0.54; P < 0.0001) and also results in objective responses in 10% of panitumumab treated and 0% of best supportive care patients [55]. Panitumumab with FOLFOX4 was compared with FOLFOX4 alone in the first line in patients with metastatic colorectal carcinoma. The progression-free survival in patients with wild-type KRAS status was prolonged from 8 months to 9.6 months with the addition of panitumumab [56]. When added to secondline FOLFIRI in patients with metastatic colorectal carcinoma (wild type K-ras), median PFS was 5.9 months in the combination group and 3.9 months in the control (HR 0.73, P = 0.004) [57]. There are no indications that panitumumab will be active when a patient has progressed on cetuximab or the inverse.

13.8.1 Predictors of Resistance As described in the colon cancer section above, cetuximab should only be prescribed in patients with wild type K-ras. The frequency of K-ras mutation is very high in pancreatic cancer, perhaps explaining the futility of cetuximab therapy in many patients with that disease. Such mutations are not common however in all diseases in which cetuximab has activity or an established role; for example, the frequency of K-ras mutations is likely less than 5% in head and neck cancer and gastric cancer. Nonetheless, the principle illustrated by the findings regarding K-ras in colon cancer is likely to hold in other cancers – namely that, if there is constitutive signalling from an EGFR target, reduced EGFR activation will not reduce signalling from its activated targets. Thus, in each cancer, correlative studies will be needed to relate outcome to the mutation and activation status of molecules in the EGFR signalling stream. These studies will be invaluable in defining appropriate patient populations for study and treatment, and may well identify the next generation of important targets, perhaps for dual

253

therapy with an EGFR targeting agent and one which inactivates the molecule responsible for resistance.

13.8.2 Management of Toxicity Hypersensitivity reactions that are grade 3 or higher are observed in approximately 3% of cetuximabtreated patients, although in the southeastern United States an approximately 20% rate of high grade hypersensitivity reactions has been identified. These severe reactions manifest within several minutes of exposure to the agent, and are IgE mediated [58]. They are managed as anaphylactic reactions and represent an absolute contraindication to re-challenge with cetuximab. Lower grade hypersensitivity reactions are often easily managed with slower infusion times and steroid premedication. The rate of hypersensitivity reactions is lower with panitumumab, and cetuximab-allergic patients may be treated with panitumumab. Skin toxicity is the most frequent clinically significant adverse reaction to both cetuximab and panitumumab. This manifests as a sterile acneiform eruption on the face and trunk, xerosis, or paronychia. It is somewhat responsive to topical steroids. Superinfection can occur and is responsive to oral antibiotics. Hypomagnesemia is related to impaired magnesium renal reabsorption, worsens with longer courses of therapy, and may persist after discontinuation of cetuximab or panitumumab. Oral replacement therapy has the advantage of sustained duration, but may be complicated by diarrhea, particularly in patients with prior bowel resection or those receiving irinotecan, and thus intravenous replacement may be required. This is rarely an indication for treatment discontinuation.

13.9 Dual Antibody Therapy Preclinical and correlative science data suggest that upregulation of VEGF is associated with resistance to EGFR inhibition. Experiments in xenograft models supported the hypothesis that therapeutic synergy would result from the combination of an antiangiogenic therapy with EGFR inhibition, and this

254

is currently being tested in phase II and III trials in several cancers. A large study conducted in the Netherlands examined the combination of cetuximab with bevacizumab in previously untreated metastatic colorectal cancer patients who were to receive a standard capecitabine/oxaliplatin/bevacizumab regimen for management of their cancer [59]. At a median follow up of 14.7 months, a disadvantage for the addition of cetuximab was observed, with a worsening in median time to progression from 10.7 to 9.8 months. A similar effect was seen with panitumumab and bevacizumab combination in first-line treatment of metastatic colon cancer The similarity of the effect of dual antibody therapy in the two studies, with each of the EGFR targeted antibodies in current usage, is compelling, and current recommendations are that the two antibodies not be prescribed together outside the context of a clinical trial. The mechanism for interference is not explained.

13.10 Conclusion Antibody based therapy has heralded a new era in the systemic treatment of solid tumors. Its impact is perhaps the strongest in the use of adjuvant trastuzumab in the treatment of HER2 overexpressing breast cancer and concurrent cetuximab with radiation in head and neck cancer in effecting more cures. Conjugated monoclonal antibodies (with cytotoxic drugs, toxins or radioisotopes) promise a targeted delivery vehicle which minimizes systemic toxicity. Antibodies against novel targets such as Insulin-like Growth Factor 1 (IGF-1) receptor herald a widening field of antibody based cancer therapeutics in the near future.

References 1. McLaughlin P, Grillo-López AJ, Link BK, Levy R, Czuczman MS, Williams ME et al (1998) Rituximab chimeric anti-CD20 monoclonal antibody therapy for relapsed indolent lymphoma: half of patients respond to a four-dose treatment program. J Clin Oncol 16(8): 2825–2833 2. Carter P (2001) Improving the efficacy of antibody-based cancer therapies. Nat Rev Cancer 1(2):118–129

S. Shanbhag and B. Burtness 3. Weidner N, Semple JP, Welch WR, Folkman J (1991) Tumor angiogenesis and metastasis: correlation in invasive breast carcinoma. N Engl J Med 324(1):1–8 4. Prager GW, Breuss JM, Steurer S, Mihaly J, Binder BR (2004) Vascular endothelial growth factor (VEGF) induces rapid prourokinase (pro-uPA) activation on the surface of endothelial cells. Blood 103(3):955–962 5. Dvorak HF, Brown LF, Detmar M, Dvorak AM (1995) Vascular permeability factor/vascular endothelial growth factor, microvascular hyperpermeability, and angiogenesis. Am J Pathol 146(5):1029–1039 6. Giralt J, Navalpotro B, Hermosilla E, de Torres I, Espin E, Reyes V et al (2006). Prognostic significance of vascular endothelial growth factor and cyclooxygenase-2 in patients with rectal cancer treated with preoperative radiotherapy. Oncology 71(5–6):312–319 7. Noda E, Maeda K, Inoue T, Nishihara T, Nishiguchi Y, Ohira M et al (2007) Predictive value of vascular endothelial growth factor-C expression for local recurrence of rectal carcinoma. Oncol Rep 17(6):1327–1331 8. Tokunaga T, Oshika Y, Abe Y, Ozeki Y, Sadahiro S, Kijima H et al (1998). Vascular endothelial growth factor (VEGF) mRNA isoform expression pattern is correlated with liver metastasis and poor prognosis in colon cancer. Br J Cancer 77:998–1002 9. Ding S, Li C, Lin S, Han Y, Yang Y, Zhang Y et al (2007). Distinct roles of VEGF-A and VEGF-C in tumour metastasis of gastric carcinoma. Oncol Rep 17(2):369–375 10. Folkman J. (2002) Role of angiogenesis in tumor growth and metastasis. Sem Oncol 29(6 Suppl 16):15–18 11. Hurwitz H, Fehrenbacher L, Novotny W, Cartwright T, Hainsworth J, Heim W et al (2004) Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med 350(23):2335–2342 12. Fuchs CS, Marshall J, Mitchell E, Wierzbicki R, Ganju V, Jeffery M et al (2007) Randomized, controlled trial of irinotecan plus infusional, bolus, or oral fluoropyrimidines in first-line treatment of metastatic colorectal cancer: results from the BICC-C Study. J Clin Oncol 25(30): 4779–4786 13. Giantonio BJ, Catalano PJ, Meropol NJ, O’Dwyer PJ, Mitchell EP, Alberts SR et al (2007) Bevacizumab in combination with oxaliplatin, fluorouracil, and leucovorin (FOLFOX4) for previously treated metastatic colorectal cancer: results from the eastern cooperative oncology group study E3200. J Clin Oncol 25(12):1539–1544 14. Wolmark N, Yothers G, O’Connell M.J, Sharif S, Atkins JN et al (2009) A phase III trial assessing bevacizumab in stage II and III carcinoma of the colon: results of NSABP protocol C-08. J Clin Oncol 27:18s (suppl; abstr LBA4) 15. Miller K, Wang M, Gralow J, Dickler M, Cobleigh M, Perez EA et al (2007) Paclitaxel plus bevacizumab versus paclitaxel alone for metastatic breast cancer. N Engl J Med 357(26):2666–2676 16. Miller KD, Chap LI, Holmes FA, Cobleigh MA, Marcom PK, Fehrenbacher L et al (2005) Randomized phase III trial of capecitabine compared with bevacizumab plus capecitabine in patients with previously treated metastatic breast cancer. J Clin Oncol 23(4):792–799 17. Sandler A, Gray R, Perry MC, Brahmer J, Schiller JH, Dowlati A et al (2006) Paclitaxel–carboplatin alone or with

13 Antibody-Based Therapies for Solid Tumors

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

bevacizumab for non–small-cell lung cancer. N Engl J Med 355(24):2542–2550 Manegold C, von Pawel J, Zatloukal P, Ramlau R, Gorbounova V, Hirsch V et al (2007) Randomised, doubleblind multicentre phase III study of bevacizumab in combination with cisplatin and gemcitabine in chemotherapynaïve patients with advanced or recurrent non-squamous non-small cell lung cancer (NSCLC): BO17704. J Clin Oncol, ASCO Annual Meeting Proc Part I. 25(18S) (Supplement) Motzer RJ, Hutson TE, Tomczak P, Michaelson MD, Bukowski RM, Rixe O et al (2007) Sunitinib versus interferon alfa in metastatic renal-cell carcinoma. N Engl J Med 356(2):115–124 Escudier B, Eisen T, Stadler WM, Szczylik C, Oudard S, Siebels M et al (2007) Sorafenib in advanced clear-cell renal-cell carcinoma. N Engl J Med 356(2):125–134 Escudier B, Pluzanska A, Koralewski P, Ravaud A, Bracarda S, Szczylik C et al (2008) Bevacizumab plus interferon alfa-2a for treatment of metastatic renal cell carcinoma: a randomised, double-blind phase III trial. Lancet 370(9605):2103–2111 Wagner SA, Desjardins A, Reardon DA, Marcello J, Herndon JE, II, Quinn JA et al (2008) Update on survival from the original phase II trial of bevacizumab and irinotecan in recurrent malignant gliomas. J Clin Oncol 26 (suppl; abstr 2021) Burger RA, Sill MW, Monk BJ, Greer BE, Sorosky JI (2007) Phase II trial of bevacizumab in persistent or recurrent epithelial ovarian cancer or primary peritoneal cancer: a gynecologic oncology group study. J Clin Oncol 25(33):5165–5171 Slamon DJ, Godolphin W, Jones LA, Holt JA, Wong SG, Keith DE et al (1989) Studies of the HER-2/neu protooncogene in human breast and ovarian cancer. Science 244(4905):707–712 Slamon DJ, Clark GM, Wong SG, Levin WJ, Ullrich A, McGuire WL et al (1987) Human breast cancer: correlation of relapse and survival with amplification of the HER-2/neu oncogene. Science 235(4785):177–182 Tandon AK, Clark GM, Chamness GC, Ullrich A, McGuire WL et al (1989) HER-2/neu oncogene protein and prognosis in breast cancer. J Clin Oncol 7(8): 1120–1128 Hudziak RM, Lewis GD, Winget M, Fendly BM, Shepard HM, Ullrich A et al. (1989) p185HER2 monoclonal antibody has antiproliferative effects in vitro and sensitizes human breast tumor cells to tumor necrosis factor. Mol Cell Biol 9(3):1165–1172 Valabrega G, Montemurro F, Aglietta M et al (2007) Trastuzumab: mechanism of action, resistance and future perspectives in HER2-overexpressing breast cancer. Ann Oncol 18:977–984 Gennari R, Menard S, Fagnoni F, Ponchio L, Scelsi M, Tagliabue E (2004) Pilot study of the mechanism of action of preoperative trastuzumab in patients with primary operable breast tumors overexpressing HER2. Clin Cancer Res 10:5650–5655 Slamon DJ, Leyland-Jones B, Shak S, Fuchs H, Paton V, Bajamonde A et al (2001) Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic

255

31.

32.

33.

34.

35.

36.

37.

38.

39.

40. 41.

42.

43.

44.

breast cancer that overexpresses HER2. N Engl J Med 344(11):783–792 Burstein HJ, Harris LN, Marcom PK, Lambert-Falls R, Havlin K, Overmoyer B et al (2003) Trastuzumab and vinorelbine as first-line therapy for HER2-overexpressing metastatic breast cancer: multicenter phase II trial with clinical outcomes, analysis of serum tumor markers as predictive factors, and cardiac surveillance algorithm. J Clin Oncol 21(15):2889–2895 Bartsch R, Wenzel C, Altorjai G, Pluschnig U, Rudas M, Mader RM et al (2007) Capecitabine and trastuzumab in heavily pretreated metastatic breast cancer. J Clin Oncol 25(25):3853–3858 Cobleigh MA et al (1999) Multinational study of the efficacy and safety of humanized anti-HER2 monoclonal antibody in women who have HER2-overexpressing metastatic breast cancer that has progressed after chemotherapy for metastatic disease. J Clin Oncol 17(9):2639–2648 Vogel CL, Cobleigh MA, Tripathy D, Gutheil JC, Harris LN, Fehrenbacher L et al (2002) Efficacy and safety of trastuzumab as a single agent in first-line treatment of HER2-overexpressing metastatic breast cancer. J Clin Oncol 20(3):719–726 Smith I, Procter M, Gelber RD, Guillaume S, Feyereislova A, Dowsett M et al (2007) 2-year follow-up of trastuzumab after adjuvant chemotherapy in HER2-positive breast cancer: a randomised controlled trial. Lancet 369(9555): 29–36 Perez EA, Romond EH, Suman VJ, Jeong J, Davidson NE et al (2007) Updated results of the combined analysis of NCCTG N9831 and NSABP B-31 adjuvant chemotherapy with/without trastuzumab in patients with HER2-positive breast cancer. J Clin Oncol ASCO Annual Meeting Proc Part I. 25(18S) (June 20 Supplement), 512 Joensuu H, Kellokumpu-Lehtinen PL, Bono P, Alanko T, Kataja V, Asola R et al (2006) Adjuvant docetaxel or vinorelbine with or without trastuzumab for breast cancer. N Engl J Med 354(8):809–820 Slamon DJ (2006) BCIRG 006; 2nd interim analysis presented at SABCS 2006. http://www.bcirg.org/Internet/ CIRG+Achievements/CIRG+at+SABCS+2006.htm. Retrieved 17 Sep 2008 Lemmon MA, Bu Z, Ladbury JE, Zhou M, Pinchasi D, Lax I et al (1997) Two EGF molecules contribute additively to stabilization of the EGFR dimer. Embo J 16:281–294 Ullrich A, Schlessinger J. (1990) Signal transduction by receptors with tyrosine kinase activity. Cell; 61:203–212 Lo H-W, Hsu SC, Hung MC (2006). EGFR signaling pathway in breast cancers: from traditional signal transduction to direct nuclear translocation. Breast Cancer Res Treat 95:211–218 Fan Z, Maui H, Altas I et al (1993) Blockade of epidermal growth factor receptor function by bivalent and monovalent fragments of 225 anti-epidermal growth factor receptor monoclonal antibodies. Cancer Res 53:4322–4328 Fan Z, Baselga J, Masui H et al (1993) Antitumor effect of anti-epidermal growth factor receptor monoclonal antibodies plus cis-diamminedichloroplatinum on well established A431 cell xenografts. Cancer Res 53:4637–4642 Baselga J, Pfister D, Cooper MR et al (2000) Phase I studies of anti-epidermal growth factor chimeric antibody

256

45.

46.

47.

48.

49.

50.

51.

52.

S. Shanbhag and B. Burtness C225 alone and in combination with cisplatin. J Clin Oncol 18(4):904–914 Bonner JA, Harari PM, Giralt J et al (2006) Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. N Engl J Med 354:567–578 Burtness B, Goldwasser MA, Flood W et al (2005) Phase III randomized trial of cisplatin plus placebo compared with cisplatin plus cetuximab in metastatic/recurrent head and neck cancer: an eastern cooperative oncology group study. J Clin Oncol 23:8646–8654 Vermorken J, Mesia R, Vega V et al (2007) Cetuximab extends survival of patients with recurrent or metastatic SCCHN when added to first line platinum based therapy – results of a randomized phase III (extreme) study. J Clin Oncol 25(18 S); abstr 6091 Herbst RS, Arquette M, Shin DM et al (2005) Phase II multicenter study of the epidermal growth factor receptor antibody cetuximab and cisplatin for recurrent and refractory squamous cell carcinoma of the head and neck. J Clin Oncol 23:5578–5587 Baselga J, Trigo JM, Bourhis J et al (2005): Phase II multicenter study of the antiepidermal growth factor receptor monoclonal antibody cetuximab in combination with platinum-based chemotherapy in patients with platinumrefractory metastatic and/or recurrent squamous cell carcinoma of the head and neck. J Clin Oncol 23:5568–5577 Vermorken JB, Trigo J, Hitt R et al (2007). Open-label, uncontrolled, multicenter phase II study to evaluate the efficacy and toxicity of cetuximab as a single agent in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck who failed to respond to platinum-based therapy. J Clin Oncol 25(16):2171–2177 Cunningham D, Humblet Y, Siena S et al (2004) Cetuximab monotherapy and cetuximab plus irinotecan in irinotecanrefractory metastatic colorectal cancer. N Engl J Med 351(4):337–345 Van Cutsem I, Lang G, D’haens et al (2008) KRAS status and efficacy in the first-line treatment of patients with

53.

54.

55.

56.

57.

58.

59.

metastatic colorectal cancer (mCRC) treated with FOLFIRI with or without cetuximab: the CRYSTAL experience. J Clin Oncol 26(15S) (May 20 Supplement), 2 Pirker R, Szczesna A, von Pawel J et al (2008) FLEX: A randomized, multicenter, phase III study of cetuximab in combination with cisplatin/vinorelbine (CV) versus CV alone in the first-line treatment of patients with advanced non-small cell lung cancer (NSCLC). J Clin Oncol 26(15S) (May 20 Supplement), 3 Hecht JR, Patnaik A, Berlin J et al (2007) Panitumumab monotherapy in patients with previously treated metastatic colorectal cancer. Cancer 110(5):980–988 Van Cutsem E, Peeters M, Siena S et al (2007). Openlabel phase III trial of panitumumab plus best supportive care compared with best supportive care alone in patients with chemotherapy-refractory metastatic colorectal cancer. J Clin Oncol 25(13):1658–1664 Douillard J, Siena S, Cassidy J, Tabernero J, Burkes J (2009) Randomized phase 3 study of panitumumab with FOLFOX4 compared to FOLFOX4 alone as 1st-line treatment (tx) for metastatic colorectal cancer (mCRC): the PRIME trial ESMO 34 presidential session IV: Thursday 24 September 2009 Peeters M, Price T, Hotko Y, Cervantes A, Ducreux M et al (2009) Randomized phase 3 study of panitumumab with FOLFIRI vs FOLFIRI alone as second-line treatment (tx) in patients (pts) with metastatic colorectal cancer (mCRC); ESMO 34 Gastro-intestinal malignancies – Colorectal II 22 September 2009 Chung CH, Mirakhur B, Chan E et al (2008) Cetuximabinduced anaphylaxis and IgE specific for galactose-alpha1,3-galactose. N Engl J Med 358:1109–1117 Punt CJ, Tol J, Rodenburg CJ, Cats A et al (2008) Randomized phase III study of capecitabine, oxaliplatin, and bevacizumab with or without cetuximab in advanced colorectal cancer (ACC), the CAIRO2 study of the Dutch colorectal cancer group (DCCG). J Clin Oncol 26(5S) (May 20 Supplement), LBA4011

Chapter 14

Cancer Vaccines Stephanie Schroter, Melanie Hayden, Wenxue Ma, Nellia Fleurov, Neha Rahan, and Boris R. Minev

14.1 Introduction The possibility for the development of cancer vaccines was first recognized in 1893 by the New York surgeon William Coley who reported the regression of several human sarcomas following immune stimulation with a bacterial toxin. Renewed interest in cancer vaccines today is based on two recent advances which have allowed the design of more specific vaccine approaches: improved molecular techniques for the identification of genes encoding tumor-associated antigens, and better understanding of the mechanisms involved in antigen processing, presentation, and T cell activation. T cells expressing CD4 molecules recognize peptides of 12–25 amino acids presented by MHC class II molecules [1]. The cytotoxic Tlymphocytes (CTL) expressing CD8 molecules recognize class I restricted peptides of 8–10 residues which are the products of intracellularly processed proteins [2]. Cytosolic peptides are transported across the endoplasmic reticulum (ER) membrane with the help of the ATP-dependent transporters associated with antigen processing (TAP) [3]. Peptides complexed with class I molecules in the ER are then transported to the cell surface for recognition by CTL [2]. The interaction between CTL and the target tumor cells begins with the binding of the peptide antigen associated with MHC class I molecule to the T cell antigen

B.R. Minev () Moores UCSD Cancer Center and UCSD Division of Neurosurgery, La Jolla, CA 92093-0820, USA; Genelux Corporation, San Diego Science Center, San Diego, CA 92109, USA e-mail: [email protected]

receptor. Lymphocyte-mediated cytolysis is further enhanced by accessory molecules such as lymphocyte function antigens LFA-1 and LFA-3, co-stimulatory molecules (CD28, B7), and intercellular adhesion molecule ICAM-1 [4]. The realization that MHC class I restricted tumor antigens can act as targets for cytotoxic T lymphocytes (CTL) [5] promoted the search for tumor antigen genes [6, 7]. CTL appear to be among the most direct and effective elements of the immune system that are capable of generating antitumor immune responses [8]. Tumor cells expressing the appropriate tumorassociated antigens can be effectively recognized and destroyed by these immune effector cells, which may result in dramatic clinical responses [9–11]. Both the adoptive transfer of tumor-reactive CTL and active immunization designed to elicit CTL responses have been reported to lead to significant therapeutic antitumor responses in some patients [9–11]. However, these promising approaches and their applicability to many tumor types are restricted because of the limited number of tumor-associated antigens or epitopes for CTL.

14.2 Tumor-Associated Antigens A variety of approaches have been used for the identification of tumor-associated antigens (TAA) recognized by CTL. Most of the melanoma antigens have been identified by screening cDNA expression libraries with CTL reactive against melanoma [8]. Another approach for the identification of TAA involves testing of known proteins for recognition by CTL. With this approach, Kawakami et al. found that

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_14, © Springer Science+Business Media B.V. 2011

257

258

the expression of tyrosinase and gp100 correlated with lysis by HLA-A2-restricted, melanoma-reactive CTL [12]. The same investigators demonstrated later that HLA-A2+ cell lines transfected with the gene encoding gp100 can be recognized by melanoma-reactive CTL [13]. Tyrosinase gene product was also recognized by HLA-A2-restricted CTL [14]. Direct isolation and sequencing of peptides eluted from the tumor cells is another method of identifying tumor-associated peptide antigens. Several groups have used this approach to isolate peptides recognized by melanoma-specific CTL [15], as well as to sequence the peptides with a triple quadrupole mass spectrometer [16]. This technique is complementary to the genetic approach because it allows measurement of the abundance of the antigenic peptides derived from the gene sequence. This is very important for the recognition of tumor cells by CTL, because at least 200 molecules of a peptide must occupy MHC class I molecules in order for CTL to lyse cancer cells [17]. Another advantage of this technique is the direct identification of peptides naturally processed and presented on the tumor cell surface. More recently, computer programs have been used to identify peptide sequences of known proteins based on their binding affinity for selected HLA molecules [18]. We analyzed the sequence of human telomerase reverse transcriptase (hTRT) [19] for peptide sequences containing known binding motifs for the HLA-A2.1 molecule [20]. We also used the software of the Bioinformatics & Molecular Analysis Section (National Institutes of Health, Washington, DC), which ranks 8–10 mer peptides based on a prediction half-time dissociation coefficient from HLA class I molecules [21]. We tested whether two of the highestranking peptides can generate in vitro CTL able to recognize peptide-pulsed targets and HLA-A2+ cancer cells. We demonstrated in this study that the hTRTspecific CTL of normal individuals and patients with cancer specifically lysed a variety of HLA-A2+ cancer cell lines, suggesting the existence of precursor CTL for hTRT in both normal individuals and in cancer patients [22]. Since telomerase activity is increased in the vast majority of melanomas and most other human tumors, our findings could contribute to the generation of universal telomerase-based cancer vaccines. Using different computer-based algorithms, we identified six epitopes recognized by human CTL within the sequence of the new tumor-associated

S. Schroter et al.

antigen MG50, which we described previously [23]. There are no obvious similarities in structure between MG50 and any of the melanoma antigens described previously. Thus, MG50 differs from published sequences of MAGE, BAGE, GAGE, PRAME, and NY-ESO-1 (the cancer/testis-specific antigens), gpl00, tyrosinase, MART-l/Melan-A, TRP-1 and TRP-2 (the melanocyte differentiation antigens), and CDK4, b-catenin, and MUM-1 (mutated or aberrantly expressed antigens). MG50 protein is one of the few melanoma-associated antigens that is not a melanocyte differentiation antigen or a mutated protein. The MG50 gene may be important not only because of its novelty, but because it is a large gene encoding at least six HLA class I-restricted epitopes recognized by human CTL in the context of HLA-A2.1 [23]. Importantly, we found that all six peptides immunized CD8+ T cells to react against both long-term and short-term HLA-A2.1+ melanoma cell lines. These data indicated that the epitopes are naturally expressed on melanoma cells, and therefore MG50 may be an excellent target for immunotherapy of melanoma. Serological analysis of recombinant cDNA expression library of human tumors with autologous serum (SEREX) is another approach used to isolate human tumor antigens [24]. Examples are tyrosinase, MAGE, NY-ESO-1, SSX2, SCB-1, and CT7 [8]. Some of these antigens are T-cell defined antigens, which emphasizes the usefulness of SEREX analysis in identifying new tumor antigens.

14.2.1 Melanoma Antigens Human melanoma antigens can be classified into three groups: (i) antigens expressed in melanoma, normal melanocytes, and retina; (ii) antigens expressed in several cancers and testis; and (iii) antigens specific for individual tumors. The first group consists of nonmutated shared tumor antigens. An interesting correlation between depigmentation of skin and hair and good clinical responses to chemotherapy and immunotherapy [25], suggests that the same population of CTL recognizes both melanoma antigens and nonmutated shared antigens on melanocytes. Rosenberg et al. observed tumor regression in patients who developed vitiligo after interleukin 2 (IL-2)-related immunotherapy, suggesting that autoreactive CTL may be involved in

14 Cancer Vaccines

tumor regression [26]. Tyrosinase, MART-1/Melan-A, gp100, TRP1/gp75, and TRP2 have been identified as shared melanoma antigens recognized by CTL [8]. These antigens may form the basis for the development of effective vaccines, but their expression on normal tissues raises concerns about the possible development of immunological tolerance and autoimmunity associated with the immunotherapy. The second group includes several families of antigens, specifically: MAGE, BAGE, GAGE, RAGE, and NY-ESO-1. The MAGE genes are silent in a large panel of healthy adult tissues, with the exception of testis and placenta [27]. Recently, 5 MAGE-A1 epitopes recognized by CTL were identified by in vitro stimulation with dendritic cells transduced with a recombinant canarypoxvirus (ALVAC) containing the entire MAGE-A1 gene [28]. Like the MAGE genes, BAGE [29] and GAGE [30] genes are predominantly expressed in melanomas. Another gene called RAGE (renal carcinoma antigen gene) [31] is also expressed in melanomas, sarcomas and bladder tumors. Another antigen in this group is NY-ESO-1. It is not expressed in normal human tissues except testis but is frequently expressed in melanoma, breast, prostate, bladder, lung carcinoma, and other types of cancers [32]. Interestingly, both HLA-A2 and HLA-A31 restricted T-cell epitopes have been identified from its primary open reading frame [33]. More recently, Jeager et al. identified 3 NY-ESO-1 epitopes presented by HLA class II molecules and recognized by CD4+ T lymphocytes of 2 melanoma patients [34]. Since these antigens are expressed in a variety of cancers but not in healthy tissues, they may be appropriate targets for immunotherapy. Finally, some antigens unique to individual tumors appear through tumor-specific mutations, deletions or recombination events. A point mutation might change a normal peptide unable to bind to MHC molecules into a peptide capable of binding to MHC and, therefore, presented to the immune system. Natural tolerance eliminates any CTL recognizing normal peptides capable of binding to MHC. In case of a point mutation however, the modified peptide may become a target detected by existing CTL. Several antigens generated by point mutations on a murine tumor were recognized by autologous CTL [35]. Point mutations were also found to encode human tumor antigens recognized by CTL [36–38]. This group of antigens should be recognized by melanoma-specific CTL because

259

their precursors should not have been depleted by the process of natural self-tolerance. From the clinical perspective, however, these antigens may not be useful for development of cancer vaccines because of their restriction to very few individual tumors. The identification of these melanoma antigens has made possible a number of Phase I–II clinical trials with some promising immunological and clinical results. Although the melanoma-specific vaccines have altogether failed to prove their efficacy in the few large Phase III randomized clinical trials, the new knowledge of the intricate cellular and molecular mechanisms that regulate the immune function and tumor-host interactions may allow the development of new clinically relevant melanoma vaccination strategies [39].

14.2.2 Other Tumor-Associated Antigens In breast cancer and other adenocarcinomas, a polymorphic epithelial mucin (PEM) has been characterized as a tumor antigen [40–43]. Mucins are high molecular weight glycoproteins. The MUC-1 mucin consists of a heavily glycosylated tandemly repeating 20-amino acid sequence, specifically PDTRPAPGSTAPPAHGVTSA [40]. Aberrant glycosylation of mucins on carcinomatous epithelial cells leads to the exposure of novel core epitopes that are recognized by cytotoxic T cells [41]. Even though HLA-unrestricted recognition of MUC-1 has been reported [41, 42], the establishment of mucin-specific cytotoxic T cell lines [42, 43] was a very important achievement in the attempts to develop cancer vaccines targeting this antigen. More recently, MHC-restricted CTL epitopes from non-variable number of tandem repeat sequence of MUC-1 have been identified [44]. Since PEM is much more highly expressed on carcinomas than on normal tissues, it could be a suitable target for immunotherapy. The HER2/neu protooncogene, expressed in breast cancer and other human cancers, encodes a tyrosine kinase with homology to epidermal growth factor receptor, with a relative molecular mass of 185 kd [45]. HER2/neu protein is a receptor-like transmembrane protein comprising a large cysteine-rich extracellular domain that functions in ligand binding, a short transmembrane domain, and a small cytoplasmic domain [45]. HER2/neu is amplified and expressed in many

260

human cancers, largely adenocarcinomas of breast, ovary, colon, and lung. In breast cancer, HER2/neu overexpression is associated with aggressive disease and is an independent predictor of poor prognosis [46]. Several class I restricted HER2/neu-derived peptides which were recognized by breast and ovarian cancerspecific cytotoxic T lymphocytes have been described [47–49]. In contrast to class I TAA, little attention has been paid to the identification of class II TAA, mostly because of the difficulties in their identification. However, a growing number of studies confirm the important role of CD4+ T cells in controlling tumor growth [50]. In addition to tyrosinase [51], MAGE3 was also recognized by CD4+ T cells, which were generated by in vitro stimulation of peripheral blood mononuclear cells (PBMC) with dendritic cells (DC) pulsed with synthetic peptides or purified MAGE-3 protein [52]. A genetic approach was developed for cloning genes encoding MHC class II restricted tumor antigens. This approach allows for the screening of an invariant chain-cDNA fusion library in a genetically engineered cell line expressing the essential components of the MHC class II processing pathways. The first antigen identified with this approach was CDC27, which is recognized by CD4+ HLA-DR4-restricted tumor infiltrating lymphocytes [53]. It was reported that a MART-1-derived peptide presented by HLADR4 was able to induce the in vitro expansion of specific CD4+ T cells derived from normal DR4+ donors or from DR4+ patients with melanoma when pulsed onto autologous DC [54]. This study found that CD4+ T cell immunoreactivity against this peptide coexisted with a high frequency of anti-MART-127–35 reactive CD8+ T cells in freshly isolated blood harvested from HLA-A2+/DR4+ patients with melanoma. Another study with cancer patients demonstrated the essential role of DC that are activated by CD4+ Th cells for optimal CTL induction [55]. These findings confirm that tumor-specific CD4+ T lymphocytes from cancer patients are required for optimal induction of CTL against the autologous tumors. Therefore, both class I and class II peptides could be used to optimize the therapeutic effect of the cancer vaccines. Promising novel approaches for identification of tumor-associated antigens have been developed recently. Applying a combination of techniques, such as “suppression subtractive hybridization” and “transmembrane trapping”, Di Cristina et al. identified a

S. Schroter et al.

large panel of cDNA fragments encoding a variety of tumor-associated antigens, representing novel tumorspecific targets [56]. Furukawa et al. studied the roles of ganglioside GD3 in human malignant melanomas and those of GD2 in small cell lung cancer (SCLC) as modulators of the malignant properties of cancer, suggesting their function as novel targets for cancer therapy [57]. Newly identified TAA-derived peptides also demonstrated a strong potential to be particularly useful in the treatment of hematologic malignancies [58, 59].

14.3 Novel Vaccine Approaches 14.3.1 Peptide Vaccines The identification of peptide sequences recognized by CTL has led to attempts to directly induce CTLresponses in vivo [60, 61]. Successful immunization of mice has been accomplished with peptides formulated with immunostimulating complex (ISCOM) [62], entrapped in liposomes [63], encapsulated in microspheres [64], osmotically loaded into syngeneic splenocytes [65] or coated on their surface [66]. Effective immune responses were also elicited in mice with a mutant p53 peptide in adjuvant [67], or with either mutant or wild type p53 peptides loaded on dendritic cells [68]. We showed in two murine antigenic systems that fusion peptides with a synthetic ER-signal sequence at the NH2 -terminus of the minimal peptide were more effective than the minimal peptide alone in generating specific CTL-responses [69]. Furthermore, we found that the CTL response was MHC Class II independent, could not be attributed to increased hydrophobicity of the fusion peptides and was very effective in prolonging the survival of tumorchallenged mice. More recently, we identified two HLA-A2.1 restricted peptides from telomerase reverse transcriptase (hTRT) and demonstrated that in vivo immunization of HLA-A2.1 transgenic mice generated a specific CTL response against both hTRT peptides [22]. Based on the induction of CTL responses in vitro and in vivo, and the susceptibility to lysis of tumor cells of various origins by hTRT-specific CTL, we suggested that hTRT could serve as a universal cancer vaccine. Increasing number of studies report peptide vaccination of cancer patients. Spontaneous CTL reactivity

14 Cancer Vaccines

against the melanoma antigens Melan A/MART-1, tyrosinase and gp100 is frequently detected in melanoma patients and healthy individuals [70–72]. These finding suggest that CTL responses against “self” antigens are induced spontaneously in patients and healthy individuals and may be boosted by appropriate vaccination. Immunizations with a MAGE-3derived peptide without any adjuvant induced limited tumor regressions in five out of 17 patients with melanoma [73]. More recently the same group used an HLA-A1-restricted MAGE-3 peptide to immunize 39 patients with metastatic melanoma. Of the 25 patients who received the complete treatment, 7 displayed significant tumor regressions: three regressions were complete and 2 led to a disease-free state, which persisted for more than 2 years after the beginning of treatment [74]. Salgaller et al. reported generation of CTL specific for one of three gp100-derived peptides in patients vaccinated with peptide in incomplete Freund’s adjuvant [75]. Immunization of three patients with advanced melanoma with peptide-pulsed autologous antigen presenting cells led to induction of peptide specific CTL [76]. The peptide used in this study was derived from MAGE-1 and was restricted to HLA-A1.1. The lack of any therapeutic response observed in this trial might be explained by the advanced stage of the disease in these patients. In another study nine melanoma patients were vaccinated weekly for four weeks with a combination of peptides derived from the MART-1, tyrosinase, and gp100 proteins [77]. Successful immunization against peptides could be detected in vitro in two of six patients against the tyrosinase peptide, three of six patients against the MART-1 peptide, and none of six patients receiving the gp100 peptide. More recently, eighteen patients with melanoma were immunized with a peptide derived from MART-1, emulsified with incomplete Freund’s adjuvant [61]. An enhancement of cytotoxic activity against MART-1 was detected with minimal toxicity for the patients consisting of local irritation at the site of vaccination. Serial administrations of this peptide appeared to boost the level of cytotoxicity in vitro, although clinical regression of the tumor was not observed. Peptides derived from NY-ESO-1, one of the most immunogenic tumor antigens, were used to immunize 12 patients with metastatic NYESO-1 expressing cancers, including melanoma [78]. This trial demonstrated induction of primary NY-ESO1-specific CTL responses as well as stabilization of

261

disease and regression of individual metastases in three patients. In another trial, patients with advanced pancreatic carcinoma were vaccinated with a synthetic ras peptide pulsed on antigen presenting cells isolated from peripheral blood [79]. This procedure led to generation of cancer cell-specific cellular response, without side effects. However, in all patients tumor progression was observed after the vaccination. Several strategies for modifying peptides have been attempted to improve their efficiency as cancer vaccines. The clinical use of peptides is limited by their rapid proteolytic digestion. To overcome this limitation Celis et al. designed a peptide construct containing a pan-reactive DR epitope, a CTL epitope and a fatty-acid moiety [80]. A lipopeptide-based therapeutic vaccine was able to induce strong CTL responses both in humans and animals [81]. Several studies demonstrated a correlation between MHC binding affinity and peptide immunogenicity [82]. Peptides derived from gp100, whose anchor residues were modified to fit the optimal HLA-A2 binding motif, stimulated tumorreactive CTL more efficiently than the natural epitopes [83]. An unmodified, gp100-derived peptide, failed to elicit peptide-specific CTL in melanoma patients after subcutaneous administration with incomplete Freund’s adjuvant (IFA). In contrast, vaccination with the modified peptide induced CTL responses in 91% of cases [10]. None of the 11 patients immunized with the modified peptide in IFA alone experienced an objective tumor response. Interestingly, administration of the modified peptide along with high dose interleukin2 led to a clinical response rate of 42% in a group of 31 patients. More recently, two modified gp100 peptides were combined with an antibody that abrogated cytotoxic T lymphocyte antigen-4 (CTLA-4) signaling to augment T-cell reactivity [84]. In that trial there were two complete responses and one partial response in 14 patients with stage IV melanoma that were maintained beyond 12 months. Another group also utilized the same anti-CTLA-4 antibody in combination with three melanoma peptides [85]. Nineteen patients with stage III and IV melanoma were immunized. Nine of 11 patients without autoimmune symptoms have experienced disease relapse, and 3 of 8 patients with autoimmune symptoms experienced relapse. These findings suggest possible correlation between development of autoimmunity and lack of relapse. Several groups reported clinical trials with melanoma patients immunized with the

262

immunogenic peptide MART-127–35 (AAGIGILTV) [86–88]. Wang et al. immunized patients with highrisk resected melanoma with MART-127–35 complexed with incomplete Freund’s adjuvants, or with Freund’s adjuvants mixed with CRL1005, a blocked co-polymer adjuvant. Ten of 22 patients demonstrated an immune response to peptide-pulsed targets or tumor cells by ELISA assay after vaccination, as did 12 of 20 patients by ELISPOT. Immune response by ELISA correlated with prolonged relapse-free survival [86]. This data suggests that a significant proportion of patients with resected melanoma mount an antigen-specific immune response against MART-127–35 . Another study analyzed antigen-specific T-cell responses induced in the skin and in peripheral blood lymphocytes in a HLAA2+ melanoma patient. The patient showed major regression of metastatic melanoma under continued immunization with peptides derived from the antigens MART-1, tyrosinase and gp100 [87]. The authors demonstrated that intradermal (i.d.) immunization with peptides alone leads to oligoclonal expansion of MART-1-specific CTL. These findings provide strong evidence for the effective induction of specific T-cell responses to MART-1 by i.d. immunization with peptide alone, which accounts for specific cytotoxicity against MART-1-expressing melanoma cells and clinical tumor regression. Brinckerhoff et al. evaluated the stability of the same peptide – MART-127–35 in fresh normal human plasma and possible peptide modifications that convey protection against enzymatic destruction without loss of immunogenicity [88]. When this peptide was incubated in plasma prior to pulsing on target cells, CTL reactivity was lost within 3 hours. The stability of MART-127–35 was markedly prolonged by C-terminal amidation and/or N-terminal acetylation, or by polyethylene-glycol modification of the C-terminus. These modified peptides were recognized by CTL. This study suggests that the immunogenicity of the peptide vaccines might be enhanced by creating modifications that increase their stability. We investigated the effectiveness of several synthetic insertion signal sequences in enhancing the presentation of the HLA-A2.1 restricted melanoma epitope MART-127–35 [89]. An important step in presentation of the class I-restricted antigens is the translocation of processed proteins from the cytosol across the endoplasmic reticulum membrane mediated by transporter associated with antigen processing proteins (TAP), or as an alternative, by endoplasmic

S. Schroter et al.

reticulum-insertion signal sequences located at the NH2 -terminus of the precursor molecules [90]. Using a technique known as osmotic lysis of pinocytic vesicles [91], we loaded several synthetic peptide constructs into the cytosol of antigen processing deficient T2 cells, TAP-expressing human melanoma cells, and dendritic cells. We examined whether the natural signal sequences ES (derived from the adenovirus E3/19 K glycoprotein) [92], and IS (derived from IFN-b) [93] could enhance and prolong presentation of MART127–35 . We found that the addition of a signal sequence at the N-terminus, but not at the C-terminus, of MART127–35 greatly enhanced its presentation in both TAPdeficient and TAP-expressing cells. A newly designed peptide construct, composed of the epitope replacing the hydrophobic part of a natural signal sequence, was also effective. Interestingly, an artificial signal sequence containing the epitope was the most efficient construct for enhancing its presentation. These peptide constructs facilitated epitope presentation in a TAPindependent manner when loaded into the cytosol of TAP-deficient T2 cells. In addition, loading of these constructs into TAP-expressing melanoma cells also led to a more efficient presentation than the loading of the minimal peptide. Most importantly, loading of human dendritic cells with the same constructs resulted in a prolonged presentation of this melanoma epitope [89]. The efficient presentation of MART-127–35 , loaded into TAP-expressing tumor cells and DC, may be explained by the availability of intact TAP transporters in these cells. In this case, some of the loaded MART-127–35 may have been translocated by TAP from the cytosol even 8 days after loading. The size of MART-127–35 (9 amino acids) is appropriate for optimal translocation by TAP [3]. Still, fusion peptides were more effective than MART-127–35 , probably because of their translocation by both TAP-dependent and TAP-independent pathway. The later mechanism of peptide translocation may be important for antigen presentation especially in cancers that fail to utilize the classical MHC class I pathway [94]. These findings may be of practical significance for the development of synthetic anticancer vaccines and in vitro immunization of CTL for adoptive immunotherapy. Various methods have been exploited to improve the peptide vaccine antigenicity. The most common are a combination of the peptide administered with cytokines and/or with an adjuvant. Slingluff et al. implemented a phase II trial to test whether low-dose

14 Cancer Vaccines

IL-2 is capable of enhancing T-cell immune responses to a multipeptide melanoma vaccine [95]. Forty melanoma patients were randomly vaccinated with four gp100- and tyrosinase-derived peptides that were restricted by HLA-A1, -A2, and -A3. After either one week or 28 days a tetanus helper peptide as well as IL-2 were administered daily. A higher response was found in the second group (tetanus helper peptide and IL-2 administered after 28 days). This study also found that the tyrosinase peptides DAEKSDICTDEY and YMDGTMSQV were more immunogenic than the gp100 peptides YLEPGPVTA and ALLAVGATK. The disease-free survival estimates were 39% for the first group and 50% for the second group at two years. In another trial, the effect of IL-12 on the immune response to a resected metastatic melanoma multipeptide vaccine was studied in 48 patients with melanoma [96]. The patients were immunized with two peptides derived from gp100 (209–217) (210 M) and tyrosinase (368–376) (370D) emulsified with IFA. The peptide/adjuvant was either administered with or without IL-12. Out of forty patients, thirty-four developed a positive skin test response to only the gp100 peptide and not the tyrosinase peptide. Out of 38 patients, 33 showed an immune response as determined by ELISA, and 37 of 42 patients showed a response by a tetramer assay. These findings indicate that IL-12 may augment the immune response to certain peptides. These findings were confirmed by Peterson et al. who found in a phase II study that recombinant IL-12 when administered with Mart1/Melan-A, is effective as an adjuvant in melanoma patients [97]. Another recent trial determined that the melanoma peptides MAGE-A1 (96–104), MAGE-A10 (254–262), and gp 100 (614–622) are immunogenic when combined with granulocyte-macrophage colonystimulating factor (GM-CSF) and montanide ISA-51 adjuvant and administered as part of a multipeptide vaccine [98]. Hersey et al. undertook a phase I/II trial with 36 patients with melanoma half of which were given peptides derived from gp100, MART-1, tyrosinase, and MAGE-3 in the Montanide-ISA-720 adjuvant, and half the patients were given GM-CSF s.c. for 4 days following each injection [99]. The authors concluded that the peptides were more effective when given with the adjuvant Montanide-ISA-720. In another trial the peptides MART-1 (26–35 (27L)), gp100 (209–217 (210 M)),and tyrosinase (368–376 (370D)) were emulsified with incomplete Freund’s

263

adjuvant and administered with SD-9427 (progenipoietin) – an agonist of granulocyte colony-stimulating factor and the FLT-3 receptor [100]. This study found that the SD-9427 combined with a multipeptide vaccine was generally well tolerated, and that the majority of patients with resected melanoma mounted an antigen-specific immune response against the multipeptide vaccine. Butterfield et al. studied the induction of T-cell responses to HLA-A∗ 0201 immunodominant peptides derived from alpha-fetoprotein (AFP) in patients with hepatocellular cancer [101]. In this study the authors tested the immunological paradigm that high concentrations of soluble protein contribute to the maintenance of peripheral tolerance/ignorance to self-protein. They confirmed that the patients’ T-cell repertoire was capable of recognizing AFP in the context of MHC class I even in an environment of high circulating levels of this oncofetal protein. Our group identified two HLA-A2-restricted peptides derived from human telomerase reverse transcriptase (hTRT), and induced hTRT-specific CTL in vitro [22]. Importantly, we also demonstrated that the hTRT-specific CTL lysed a variety of HLA-A2positive cancer cell lines, but not HLA-A2-negative cancer cell lines. All of these cancer cell lines were hTRT positive as determined by the TRAPeze assay (Intergen). A Phase I clinical trial was performed by Vonderheide et al. to evaluate the clinical and immunological impact of vaccinating advanced cancer patients with the HLA-A2-restricted hTRT I540 peptide presented with keyhole limpet hemocyanin by ex vivo generated autologous dendritic cells [102]. It was found that hTRT-specific T lymphocytes were induced in 4 of 7 patients with advanced breast or prostate carcinoma after vaccination with dendritic cells pulsed with hTRT peptide. It is important to note that no significant toxicity was observed despite concerns of telomerase activity in rare normal cells. These results demonstrated the immunological feasibility of vaccinating patients against telomerase and provided rationale for targeting self-antigens with critical roles in oncogenesis. An interesting study utilized the flt3 ligand as a systemic vaccine adjuvant with the E75 HLA-A2 epitope from HER-2/neu [103]. Twenty patients with advanced stage prostate cancer were enrolled in this study. Dendritic cells were markedly increased in the peripheral blood of subjects receiving flt3 ligand with each repetitive cycle, but augmentation of antigen-presenting cells

264

within the dermis was not observed. No significant peptide-specific T-cell responses were detected. The authors concluded that the inability of fit3 ligand to augment the number of peripheral skin antigenpresenting cells may have contributed to the absence of robust peptide-specific immunity detectable in the peripheral blood of immunized subjects treated with flt3 ligand. A difficulty with the use of peptide vaccines is the fact that the T cell responses usually do not last long enough to have a significant effect on the tumor. To address this issue Davila et al. examined the role of synthetic oligodeoxynucleotide (ODN) adjuvants containing unmethylated cytosine-guanine motifs (CpGODN) and CTLA-4 blockade in enhancing the antitumor effectiveness of peptide vaccines intended to elicit CTL responses [104]. This study found that combination immunotherapy consisting of vaccination with a synthetic peptide corresponding to an immunodominant CTL epitope derived from tyrosinase-related protein-2 administered with CpG-ODN adjuvant and followed by systemic injection of anti-CTLA-4 antibodies increased the survival of mice against the poorly immunogenic B16 melanoma. These findings suggest that peptide vaccination applied in combination with a strong adjuvant and CTLA-4 blockade, is capable of eliciting durable antitumor T cell responses that provide survival benefit. These findings bear clinical significance for the design of peptide-based therapeutic vaccines for human cancer patients. From a clinical perspective, immunization with peptides may be preferable to immunization with recombinant vaccinia viruses because of its safety and because it is not associated with diminished immune responses in patients immunized against smallpox. Immunizing with minimal determinant constructs may avoid the possible oncogenic effect of full-length proteins containing ras, p53 or other potential oncogenes. In addition to their safety, peptide vaccines can be designed to induce well-defined immune responses, and synthesized in large quantities with very high purity and reproducibility. Another potential advantage of peptide vaccines over whole proteins or DNA vaccines is the ability to identify the specific epitopes of the tumor antigens to which an individual is able to mount an immune response, but not a state of immune tolerance [105]. In addition, in vivo or in vitro immunization with peptide antigens “packaged” in dendritic cells or other antigen-presenting cells (discussed below)

S. Schroter et al.

opens an exciting opportunity for eliciting powerful CTL-responses. A disadvantage of peptide vaccines is their poor immunogenicity and monospecificity of the induced immune response. Another limiting factor for the use of peptide vaccines in outbred populations is that T cells from individuals expressing different MHC molecules recognize different peptides from tumor or viral antigens in the context of self-MHC. However, the use of synthetic peptides from tumorassociated antigens that are presented by common MHC molecules may overcome this problem. Poor immunogenicity caused by rapid degradation of the peptides by serum peptidases may be corrected by modifications or incorporation of the peptides into controlled release formulations. Overall, personalized peptide vaccines may serve as an efficient therapeutic modality for cancer [106].

14.3.2 Recombinant Viruses as Vaccines Many different viruses have been used to construct recombinant vaccines. These vaccines have the advantage of inducing both humoral and cell-mediated immune responses, in some cases even after a single application. However, possible disadvantages of recombinant viruses include recombinantion with wild type viruses, conversion to virulence, oncogenic potential, or immunosuppression. We will briefly discuss current strategies to overcome some of these obstacles in order to develop efficient recombinant viral vaccines. Vaccinia virus (VV) was demonstrated to be a safe and very effective immunogen in the smallpox eradication campaign, where it was administered to over one billion people. Large amounts of foreign DNA can be stably inserted into the VV genome by homologous recombination [107]. Another advantage of this vector is a very efficient post-translational processing of the inserted genes within host cell cytoplasm. However, due to the induction of high titers of antivaccinia antibodies, recombinant vaccinia viruses may be given only once or twice [108]. It was demonstrated that intratumoral inoculation of vaccinia virus induced very high levels of antivaccinia antibodies in serum. Surprisingly however, it was possible to sustain viral gene function by repeatedly injecting vaccinia in

14 Cancer Vaccines

the tumor site [109]. A promising strategy to increase the efficiency of recombinant viral vaccines is to use two different vectors for priming and boosting vaccinations [110]. This approach was much more effective in generating antigen-specific CTL responses than the use of one vector for both priming and boosting. In a recent study, a recombinant vaccinia virus (rVV) expressing CD40 ligand or CD154 (CD154rVV) was constructed and the effects of CD154rVV infection on antigen presenting cells (APC) activation and its consequences on T cell stimulation were evaluated. In the presence of CD154rVV-activated APC, significantly higher numbers of specific cytotoxic CD8+ T cells were detected, as compared with cultures performed in the presence of wild type vaccinia virus or in the absence of virus. The authors concluded that functional CD154 expression from rVV-infected cells could promote APC activation, thereby enhancing antigen-specific T cell generation. Therefore, this vector might help bypass the requirement for activated helper cells during CTL priming, thus qualifying as a potentially relevant vector in the generation of CD8+ T cell responses in cancer immunotherapy [111]. Since vaccinia is a replication competent virus, it may cause disseminated viremia especially in immunosuppressed individuals [112]. Therefore, several research groups attempted to develop recombinant vaccines based on non-replicating viruses [113]. Utilizing recombinant fowlpox virus, which does not replicate in mammalian cells, Wang et al. were able to treat established tumors in mice [114]. An important aspect of this work was the finding that prior immunization with vaccinia virus did not abrogate the immune responses elicited by the recombinant fowlpox virus. A different non-replicating virus, canarypox virus (ALVAC), was used to generate recombinant viruses, able to elicit immune responses against a variety of antigens [115]. A clinical trial with vaccinia-CEA in patients with colorectal cancer resulted in eliciting of cell-mediated immune responses against CEA-derived peptide [116]. In this study rejection of the vaccinia virus itself was not observed. More recently, the same group performed the first clinical trial with a nonreplicating ALVACCEA vector in patients with advanced carcinoma [117]. Although no objective antitumor responses were observed, the vaccine was very well tolerated and no significant toxicity was reported. In 7 of 9 patients evaluated, statistically significant increases in CTL

265

precursors specific for CEA were observed in PBMC after vaccination. T cell responses elicited by patients before and after vaccination with the ALVAC-CEA recombinants were further characterized in another study [118]. This study demonstrated the ability to vaccinate cancer patients with an avipox recombinant as well as to derive T cells that are capable of lysing allogenic and autologous tumor cells in a MHC-restricted manner. A Phase I trial of a recombinant vaccinia virus encoding CEA in 20 patients with metastatic adenocarcinoma showed that the toxicity was limited to local inflamation as well as low grade fever, each affecting fewer than 20% of the patients [119]. No objective clinical responses to the vaccine were observed among this population of patients with widely metastatic andenocarcinoma. The antibody response to CEA in patients was studied by Conry et al. [120]. This group used recombinant vaccinia viruses encoding full-length of internally deleted cDNAs for human CEA to vaccinate 32 patients with CEA-expressing adenocarcinomas of colorectal origin. The detected CEA autoantibodies were predominantly IgG1, with a minority of patients also demonstrating IgM autoantibodies. A non-replicating vaccinia virus, known as modified vaccinia virus Ankara (MVA), is avirulent in normal and immunosuppressed animals and was shown to have no significant side effects after inoculation of 120,000 humans [121]. Since replication of MVA is blocked at a step of virion assembly [122], rather than at an early stage, MVA vectors produce recombinant proteins in amounts similar to those of wild type viruses. In addition, the immunogenicity of MVA recombinants in mice is similar to that of virulent strains [123]. Therefore, MVA is a very promising vector for the development of recombinant vaccines for cancer. This vector was recently used for expression of human tyrosinase, a melanoma specific differentiation antigen [124]. Stable recombinant viruses (MVA-hTyr) were constructed that have the deleted selection marker lacZ and efficiently expressed human tyrosinase in primary human cells and cell lines. An efficient tyrosinase- and melanoma-specific CTL response was induced in vitro using MVA-hTyrinfected autologous dendritic cells as activators for PBMCs derived from HLA-A2.1-positive melanoma patients, despite prior vaccination against smallpox. A new recombinant poxvirus vaccine that codes for 10 HLA-A2-restricted epitopes derived from 5 melanoma antigens conjoined in an artificial polyepitope or

266

polytope construct was recently designed [125]. Multiple epitopes within the polytope construct were shown to be individually immunogenic, which illustrated the feasibility of the polytope approach for melanoma immunotherapy. Tumor escape from CTL surveillance, through down regulation of individual tumor antigens and MHC alleles, might be overcome by polytope vaccines, which simultaneously target multiple cancer antigens. Fifty-four patients with metastatic melanoma were immunized with recombinant adenoviruses encoding MART-1 and gp100 melanoma antigens alone, or followed by the administration of IL2 [126]. One of 16 patients receiving the recombinant adenovirus MART-1 alone, experienced a complete clinical response. However, immunologic assays showed no consistent immunization to the MART-1 or gp100 transgenes expressed by the recombinant adenoviruses. This study found that high doses of recombinant adenoviruses could be safely administered to cancer patients. Another study tested a recombinant adeno-associated virus expressing human papillomavirus type 16 E7 peptide DNA fused with heat shock protein DNA as a potential vaccine for cervical cancer [127]. It was demonstrated that this vaccine can eliminate tumor cells in syngeneic animals and induce CD4- and CD8dependant CTL activity in vitro. This study indicates that this chimeric gene delivered by adenoassociated virus has potential as a cervical cancer vaccine. Prostate cancer recurrence, evidenced by rising PSA levels after radical prostatectomy, is an increasingly prevalent clinical problem. A clinical study was undertaken to evaluate the safety and biologic effects of vaccinia-PSA (PROSTVAC) administered to 6 patients with post-prostatectomy recurrence of prostate cancer [128]. Toxicity was minimal, and primary anti-PSA IgG antibody activity was induced after vaccinia-PSA immunization in one subject, although such antibodies were detectable in several subjects at baseline. More recently, a phase I/II clinical trial in metastatic melanoma patients was performed using a UV-inactivated nonreplicating recombinant vaccinia virus expressing three endoplasmic reticulum-targeted HLA-A0201-restricted epitopes (Melan-A/MART-1(27–35), gp100(280–288), and tyrosinase(1–9)), together with CD80 and CD86 costimulatory molecules. No major clinical toxicity was reported. Of the 17 patients, three demonstrated

S. Schroter et al.

regression of individual metastases, seven had stable disease, and progressive disease was observed in seven patients. These results, in terms of safety and immunogenicity, support the use of this reagent in active specific immunotherapy [129]. In recent years, the use of recombinant virus vaccines has tremendously influenced advances in the fight against prostate cancer. A clinical trial was performed that sought to analyze toxicity, immunogenicity and time to treatment failure using vaccine, anti-androgen therapy or their sequential use [130]. The vaccine consisted of recombinant vaccinia viruses containing the PSA and B7.1 costimulatory genes as prime vaccinations, and avipox-PSA as boosters. Although the results did not definitively support the use of one method over another, they served to warrant further investigations on the role of combining vaccine with anti-androgen therapy or vaccine followed by vaccine plus anti-androgen therapy in this patient population. Another trial involving patients with intermediate to high risk prostate cancer was performed to determine the safety of intra-prostatic administration of a replication-competent, oncolytic adenovirus containing a cytosine deaminase (CD)/herpes simplex virus thymidine kinase (HSV-1 TK) fusion gene concomitant with increasing durations of 5-fluorocytosine and valganciclovir prodrug therapy and conventional-dose three-dimensional conformal radiation therapy (3D-CRT). Results demonstrated that replication-competent adenovirus-mediated doublesuicide gene therapy can be combined safely with conventional-dose 3D-CRT to augment the antitumor effects as seen by the decrease in the PSA halflife [131]. A phase I trial of antigen-specific gene therapy using a recombinant vaccinia virus encoding MUC-1 and IL-2 in MUC-1-positive patients with advanced prostate cancer showed increased immune responses [132]. Recent data suggests that the measles virus Edmonston strain (MV-Edm) expressing carcinoembryonic antigen (CEA) has potential for the treatment of hepatocellular carcinoma [133]. Another recent study showed that the treatment of several patients with recombinant vaccinia and fowlpox viruses carrying the cancer/testis antigen NY-ESO-1 lead to a favorable response [134]. Also, utilizing recombinant viruses to actually engineer superior T cells could have benefit when combined with specific vaccine strategies [135]. The results of these and other ongoing clinical trials

14 Cancer Vaccines

will help to direct the future use of the recombinant virus-based vaccines. These early clinical studies with recombinant viruses as vaccine vectors are very encouraging. In contrast to other vaccine vectors, viruses elicit strong and long-lasting immune response, and are able to infect nearly all host cells, as well as to ensure intracellular translation, degradation and efficient trafficking of peptide antigens to the cell surface. The potential drawbacks of the viral vectors are related to their safety and pre-existing immunity, particularly to vaccinia virus and adenoviruses. However, the safety of the viral vaccines can be ensured by using nonreplicating, highly attenuated or genetically modified viruses, while the problem of pre-existing immunity may be circumvented by the use of non-mammalian viruses, such as the avian poxviruses. It is now established that recombinant viruses can be useful to break immune tolerance against tumor-associated antigens specifically expressed by human cancers [136]. Therefore, the use of recombinant viruses as cancer vaccines is very promising.

14.3.3 DNA-Based Vaccines This novel approach involves direct inoculation of expression plasmids, which results in the induction of long-lasting immune responses against the expressed antigens. Fynan et al. compared six routes of inoculation of naked DNA for their relative efficacies [137]. In this study, intramuscular injection of DNA generated the best response, whereas inoculation of DNA-coated gold particles using “gene gun” required significantly lower doses of DNA. It was found that the uptake of the injected DNA is an active energy-dependent process [138]. Once inside the cell, plasmid DNA can get through the nuclear membrane and persists as a non-replicating episomal molecule, which explains the long-lived foreign gene expression [139]. The low, but long-lasting expression of the encoded antigens is an important feature of this approach [140]. The duration of expression seems to be more important than the dose of the antigen for induction of CTL responses, although DNA immunization has been shown to result in both cellular and humoral immune responses, and in generation of antigen-specific CD8+ and CD4+ T cells [141, 142]. Irvine et al. reported effective

267

treatment of established pulmonary metastases, using a “gene gun” for DNA immunization [143]. In this study, recombinant cytokines enhanced the therapeutic effects of this approach. Enhancement of the immune response against a model tumor antigen was also observed after cotransfection of the genes coding for the cytokine GM-CSF and the costimulatory molecule B7–1 [144]. Several elegantly designed studies addressed the important question of the mechanism of DNA immunization [145–147]. Results demonstrate that the antigen presenting cells can be transfected directly or they can acquire the antigens expressed by other transfected cells. However, only professional APCs are able to initiate primary immune responses as a result of DNA immunization. These findings are extremely important in the development of DNAbased vaccines for clinical application. A promising DNA vaccine has been developed against a B-cell lymphoma [148]. Another plasmid for clinical application encodes human CEA and the HBV surface antigen (HbsAg), each of them under a separate CMV promoter [144]. Recent clinical trials have supported the continued research of DNA vaccines for cancer treatment. In a Phase I/II trial of patients with follicular lymphoma, 7 of 12 patients mounted either humoral or T-cell-proliferative responses after vaccination with plasmids encoding tumor-specific idiotypes [149]. In a safety study of human CEA DNA vaccine, patients had no objective clinical response with mild toxicity. However, 4 of 17 patients did have induction of lymphoproliferative response [150]. DNA vaccines may be particularly useful in combination with conventional chemotherapy treatment. In animal studies, the injection of recombinant DNA and modified vaccinia virus, in combination with metronomic dosing of alkylating agent cyclophosphamide (CTX), initiated a specific CTL response in mice, leading to increased resistance to challenge with the murine melanoma B16 compared to CTX alone [151]. Similar findings occurred with the combination of 5-Aza and DNA vaccine treatment. Intradermal injection of plasmids encoding hsp70 and a suicide gene transcriptionally targeted to melanocytes led to CD8+ T cell response eradicating systemically established melanoma B16 tumors. When combined with 5-Aza this immunotherapy led to a significant decrease in tumors compared to the use of the demethylating agent alone [152].

268

Interesting work has recently been completed utilizing DNA vaccines as anti-angiogenic agents to target cancer metastases and primary tumors. One specific study looked at attenuated Salmonella typhimurium directed against vascular endothelial growth factor receptor-2, or fetal liver kinase-1 (FLK-1), and transcription factor Fos-related antigen-1 (Fra-1) [153]. It was found that the FLK-1 and Fra-1 vaccines circumvented T-cell tolerance in order to suppress the tumor angiogenesis and stimulate cell-mediated immunity. Another study, combining suppression of angiogenesis with apoptosis found that CTL induced by a DNA vaccine encoding secretory chemokine CCL21 and survivin specifically targeted proliferating endothelial cells in the tumor vasculature and tumor cells. Surprisingly, this anti-tumor effect in the treated mice did not inhibit wound healing or fertility [154]. While DNA vaccines elicit sustained cellular and humoral immune responses, their overall immune stimulation remains weak. To boost the immune response Bronte et al. utilized CD40 agonist as an adjuvant to sustain tumor-specific T lymphocyte survival, leading to a dramatic increase in the number of specific CD8+ T lymphocytes, in a phase dependent manner [155]. Others have attempted to enhance the immune response with DNA fusion vaccines and electroporation, leading to a “homologous prime/boost approach” [156]. Electroporation (EP) appears to effectively increase expression without introducing additional competing antigens [157]. Specifically, Zhang et al injected micron-size gold particles and DNA intramuscularly into mice, followed by EP of the vaccine, leading to protection against tumor challenge with HbsAg+ cancer cells [158]. Yet another option are the polytope DNA vaccines, which elicit powerful immune responses. For example, Doan et al. demonstrated significant increases of CTL responses against HPV 16 oncoprotein E7 following vaccination with murine (H-2b) and human (HLA-A∗ 0201)-restricted epitopes [159]. Likewise, blocking CTLA-4 interaction with APC’s B7 augments T-cell responses and tumor immunity elicited by DNA vaccines [160]. Finally, increases in the suppressive effects of DNA vaccines has been described through the use of Pan-IA DNA vaccines [161]. Occasionally, tolerance may lead to decreased efficacy of plasmid DNA vaccines. Jia et al. overcame this difficulty through neutralization of TGF-beta, enhancing the response to DNA vaccine and successfully

S. Schroter et al.

inducing anti-tumor immunity against melanomaassociated antigens [162]. DNA vaccination alone led to partial breaking of tolerance in ErbB-2 tolerant mice [163]. This result was confirmed when Pupa et al reported that xenogeneic DNA immunization could brake tolerance to the mouse (m) neu proto-oncogene product m-p185(neu). This led to significant inhibition of mammary carcinoma development in HER-2/neu transgenic mice [164]. Tumor immunogenicity may also be increased through the use of specific cytokines. The combination of antibodies and T cells releasing specific cytokines (such as IFN-gamma) is essential for tumor clearance [165]. Also, over expression of intratumoral CCL5, a chemokine involved in the recruitment of a wide spectrum of immunocompetent cells, lead to increased recruitment of immunocompetent cells and effector function, hinting at the usefulness of chimeric CCL5-Ig DNA in cancer treatment [166]. Yet, the effects of dual cytokine use have proven unpredictable. For example, genetic engineering of tumor cells expressing both granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin (IL)-2 may enhance or inhibit immune response [167]. Interestingly, the fusion of GM-CSF and IL-2 led to a significant antitumor effect, greater than the GMCSF/IL-2 combination [167]. A recent study showed that the targeting of transcription factor Fos-related antigen 1 (Fra-1) by co-expressing secretory cytokines led to the induction of specific CD8+ T cell-mediated immunity. This immune response led to the elimination of pulmonary and breast cancer metastases [168]. While research into DNA vaccines for melanoma, cervical cancer, colon cancer, and lymphomas has been well established, encouraging studies have been recently completed on the use of DNA vaccines for treatment of brain tumors. Immunogene therapy with the improved Sindbis virus vector expressing xenogeneic gp100 and syngenic IL-18 may be an excellent approach for developing a new treatment protocol. Thus, the Sindbis DNA system may represent a novel approach for the treatment of malignant brain tumors [169]. Likewise, a DNA vaccine expressing tyrosinaserelated protein-2 (a melanoma-associated antigen) induced T-cell-mediated partial protection against subcutaneous, intravenous, or intracerebral challenge with mouse glioblastoma cells. This effect was augmented by the addition of IL-12 [170].

14 Cancer Vaccines

More recently, Fest et al. reported that immunization with DNA vaccines encoding for cyclic disialoganglioside (GD2)-mimicking decapeptides was effective against neuroblastoma [171]. DNA vaccines have several potential advantages over peptide and recombinant viral vaccines. DNA vaccines are simpler and cheaper to produce. DNA immunization is not associated with an anamnestic immune response, which is responsible for the rapid clearance of viral constructs. Another major advantage is that DNA vaccination induces very long-lasting immune responses. Addressing a major concern for the clinical use of DNA-based vaccines – their safety – Kurth et al. calculated that the probability of tumorpromoting events by plasmid DNA integration was below the statistical events leading to a mutation within the lifetime of an individual [172]. In all, DNA-based vaccines seem to be a promising approach for the treatment of cancer.

14.3.4 Dendritic Cell-Based Vaccines Dendritic cells (DCs) play multiple roles in the immune system. They capture, process and present antigens, stimulate lymphocytes, migrate from the periphery to lymphoid organs, and secrete cytokines. In fact, dendritic cells have already been proven to be the most potent antigen presenting cells for T cell priming [173]. In many cases the patients with cancer are profoundly immunosuppressed, making it essential to activate both innate and acquired immunity for optimal tumor immunotherapy [174]. DC-based vaccines effectively accomplish this end. In addition to their ability to efficiently acquire and process antigens [175, 176], DC express high levels of MHC Class I and Class II molecules as well as costimulatory molecules [177, 178] essential in antigen presentation. Therefore, many investigators attempted to immunize with peptide-pulsed DC. It was found that immunization with peptide-pulsed DC is superior to injection of peptide in adjuvant in inducing potent cytotoxic T-cell responses [179]. A similar strategy was also reported by others to be successful in eliciting T lymphocyte-mediated protective anti-tumor immunity [180–182]. A possible disadvantage of peptide pulsing is the short half-life (2–10 h) of most MHC-restricted epitopes [183], which creates

269

the requirement for several injections of peptide-pulsed DC to achieve effective immune responses [182, 184, 185]. Therefore, development of different methods for loading of antigens allowing DC to utilize their own intracellular pathways is highly desirable. The antigens of interest must be present in the cytosol of the DC in order to enter the intracellular pathway leading to their loading onto MHC class I molecules and the subsequent activation of CD8+ T cells. Surprisingly, Paglia et al. were able to prime murine CTL against tumor antigen by incubating DC with whole protein in vitro [186]. Another group reported the generation of specific CTL in mice vaccinated with DC pulsed with RNA from an ovalbumin-expressing tumor [187]. In this approach however, rapid degradation of RNA limits the duration of antigen expression. Knowing that Flt3 ligand mobilizes DC into blood, Davis et al. developed a novel overnight method to produce DC for cancer immunotherapy. Flt3 ligandmobilized DC (FLDC) were isolated, activated with CD40L, loaded with antigenic peptides, and injected into patients with resected melanoma. This study demonstrated that vaccination with FLDC pulsed with peptides is safe and primes immune responses to cancer antigens [188]. Many researchers have utilized viral vectors for the introduction of antigen to dendritic cells. One study showed that treatment of pulmonary metastases in mice with bone marrow-derived DC, transduced with retroviral vector encoding a model antigen was very effective [189]. The reduction of the metastatic nodules was associated with induction of antigen-specific CTL. Adenovirus vectors were also used to transduce DC with genes coding for tumor antigens. It was demonstrated in a murine breast cancer model that a single injection with transduced DC provided complete protection against tumor cell challenge [190]. This approach was not limited by hepatic toxicity and the development of neutralizing antibodies associated with the direct administration of the adenoviral vectors [191, 192]. It was also demonstrated that adenoviral vectors are a promising vehicle for genetically engineering of human DC [193]. A comparison of various gene transfer methods in human DC showed that adenoviral vectors were the most efficient in transducing human DC, with transduction efficiencies exceeding 95% at higher multiplicity of infection. Bronte et al. studied the antigen expression by DC infected with a panel of recombinant vaccinia viruses in which a

270

murine model tumor antigen was expressed under different promoters [194]. Interestingly, DC were found to express the model antigen only under the control of early promoters, even though late promoters were more active in other cell types. This study suggests that the use of promoters capable of driving the expression of tumor-associated antigens in DC is essential in the development of recombinant anti-cancer vaccines. Another group described the effective generation of DC expressing tumor-associated antigens by particlemediated gene transfer [195]. These DC were able to induce antigen-specific CTL in vivo and to reduce the growth of murine tumors expressing tumor-associated viral or “self” antigens. With our signal sequence method, we showed that human DC could be loaded successfully with fusion peptides incorporating the melanoma epitope MART-127–35 [89]. We found that the addition of a signal sequence at the NH2 -terminus, but not at the COOH-terminus, of this epitope greatly prolonged its presentation in DC. A newly designed peptide construct, composed of the MART-127–35 epitope replacing the hydrophobic part of a natural signal sequence, was also effective. Interestingly, as with our earlier work with T2 cells, an artificial signal sequence containing the epitope was the most efficient construct for enhancing its presentation. These findings may be of practical significance for the development of synthetic anticancer vaccines and in vitro immunization of CTL for adoptive immunotherapy. Although viral vectors are efficient vehicles for gene transfer into DC, non-viral delivery of antigens has its advantages too. Fusion peptides can be readily produced in large quantities, and are very stable. In addition their application is not associated with immune responsiveness to vector-derived immunogens, or with risk of recombination. Recent methods have been devised to improve the immunogenicity of DC vaccines. RNA-transfected DC could induce immune reactions against a variety of epitopes [196]. For example, tumor cells from patients with acute myeloid leukemia as well as other malignant hemopoietic cell lines were effectively targeted by CTL stimulated with autologous dendritic cells transfected with survivin-RNA [197]. Exosomes have recently received attention for their activity on DC and tumor cells alike. The tumor cell exosomes coated in tumor antigens, and released by DC were found to be very immunogenic [198]. In DC, exosomes present molecules required for antigen presentation,

S. Schroter et al.

such as MHC class I, MHC class II, and costimulatory molecules. These MHC molecules contained in the DC exosomes were immunogenic when loaded either directly or indirectly with antigenic peptides [199]. Another study suggests that the potency of DC vaccines can be improved by linking the antigen gene of interest to an endosomal/lysosomal targeting signal [200]. Yasuda et al. demonstrated that DC-tumor cell fusion hybrids were more potent inducers of protection against solid tumors, such as colon cancer, than other antigen-loading strategies using whole tumor cell materials [201]. DC-tumor fusion cell-derived heat shock protein (HSP) 70 also possesses superior immunogenic properties over its counterpart isolated from tumor cells [202]. One key step in the process of cancer vaccine development is ensuring the maturation of DC. This process potentiates T cell activation and leads to increased migration of DC. For example, a recent prospective randomized phase II trial of patients with metastatic melanoma showed that, when comparing peptide-loaded immature and mature DC, only the mature cells were effective in stimulating antigenspecific cytolytic effector responses [203]. This lack of maturation may explain the non-immunogenic nature of apoptotic tumor cells (ATC). To avoid the restriction of working only with identified antigens, DC loading could occur instead with ATC, exposing the DC to a plethora of yet undescribed tumor antigens. To overcome the non-immunogenic nature of ATC and allow DC to efficiently stimulate the immune system with a variety of unknown tumor-associated antigens, Akiyama et al. took advantage of ATC that have been opsonized with IgG (ATC-immune complexes, ATC-ICs) so as to target them to the FcR for IgG (FcgammaReceptors) on DC. The result was a prominent internalization of ATC-ICs by DC via the Fcgamma receptors. This process effectively induced maturation of DC [204]. Importantly, ATC-IC loading was shown to be more efficient than ATC alone in its capacity for inducing antitumor immunity in vivo, in terms of cytotoxic T cell induction and tumor rejection. These results show that using ATC-ICs may overcome the limitations and may enhance the immune response of current ATC-based DC vaccination therapy. Cytokines play an essential role in the maturation and efficacy of DC vaccines. DC expressing TNFalpha genes have improved cellular maturation and consequent robust T-cell activation [205]. Likewise,

14 Cancer Vaccines

IFN-beta and IL-3 appear to enhance mature dendritic cells priming of CTL [206]. IL-12 continues to play an essential role in DC vaccines, enhancing in vivo antitumor immunity [207]. Positive results were also demonstrated using a gene construct simultaneously expressing tumor-associated antigens and IL-12 [208]. Exogenous soluble CD40 ligand (sCD40L) augmented DC IL-12 secretion and melanoma specific CTL induction in RNA-transfected DC preparations [209]. Vujanovic et al. engineered human DC to secrete high levels of the IFN-gamma-inducing cytokines, which rendered the DC very effective at stimulating tumor antigen-specific Th1-type CD4(+) T-cell responses [210]. The encouraging pre-clinical results as well as improved techniques for in vitro immunization and expansion of DC support the initial attempts to immunize patients with DC expressing tumor antigens. Development of an efficient method for isolation and partial purification of DC [211, 212] led to the infusion of antigen-pulsed DC into four patients with follicular low-grade B cell lymphoma [213]. Complete remission was observed in two patients, one patient had a partial response, and one patient had stable disease. In contrast, immunization with the antigen (monoclonal surface immunoglobulin) alone or emulsified in adjuvants did not induce regression of lymphoma [214]. Another clinical study showed that DC pulsed with idiotypic protein derived from serum in patients with multiple myeloma induced a specific CTL response in one patient [215]. DC infected with poxviruses encoding MART-1 were able to sensitize T lymphocytes from melanoma patients in vitro [216]. This study suggests that the prolonged endogenous expression of tumor-associated antigens by the DC might be utilized for induction of CTL responses in patients. A recent study strongly suggests that NK responses following DC vaccination may correlate more closely with clinical outcome than do T cell responses [217]. Therefore, monitoring NK responses during vaccine studies should be routinely performed. The source of the DC for vaccination and the frequency of the CTL precursors in cancer patients should be carefully evaluated. In patients with a low frequency of peptide-specific precursors, the efficient activation of antigen-specific CTL required the use of peptideloaded CD34+-derived, but not monocyte-derived, DC [218]. This suggested that DC derived from CD34+

271

cells and monocytes were not functionally equivalent for the activation of CTL in patients with a low CTL precursor frequency. Antimelanoma CTL were generated in vitro from healthy donors [219] and melanoma patients [220] with DC pulsed with melanoma-derived peptides. It was also shown that vaccination of patients with melanoma with DC pulsed with MAGE-1-derived peptide elicited melanoma-specific CTL in vivo [76]. In another clinical study sixteen melanoma patients were immunized with peptide-pulsed or tumor lysatepulsed DC [221]. Vaccination was well tolerated in all patients. Objective clinical responses were observed in 5 out of 16 patients with regression of metastases in various organs. These encouraging clinical trials suggest that a variety of tumor types may be responsive to DC-based immunotherapy. Mixed but encouraging clinical trial results have been achieved with minimal toxicity. The kinetics of DC vaccine’s induction of the tumor specific CTL is rapid. In a study of 18 HLA A∗ 0201 patients with stage IV melanoma, even a single injection of CD34+ progenitor-derived dendritic cell vaccine could lead to induction of T-cell immunity [222]. This reaction may have been brief, but could be observed in 7 of 11 patients, and the induced memory response lasted over a six-month period [223]. Thirty-five renal cell carcinoma (RCC) and metastatic melanoma patients were vaccinated with autologous tumor and allogeneic dendritic hybrid cells. Almost 75% of the patients had stable disease for over one and a half years following immunization. Fourteen percent of the patients suffering from RCC had objective responses [224]. Immunization with autologous dendritic cells pulsed with human recombinant prostate-specific antigen (PSA) (Dendritophage-rPSA) was attempted in a phase I trial of complementary vaccine treatment for twenty-four prostate cancer patients. This study found that six patients with circulating prostate cancer cells, had undetectable levels at 6 and 12 months. Likewise, the PSA decreased anywhere from 6 to 39% [225]. Another still ongoing study involves the use of human telomerase reverse transcriptase (hTRT) transfected DC vaccines for the treatment of patients with metastatic prostate cancer [226]. DCs pulsed with necrotic pulmonary tumor cells were injected intranodally to lung cancer patients. Modest increases in T-cell response occurred in six of eight patients. Of these six patients, the two patients with superior T-cell responses also had more sustained

272

disease control [227]. In a study for the treatment of non-small cell lung cancer, patients received surgery, chemoradiation or multimodality treatment including DC-based vaccines. Independent of clinical outcome five of the sixteen patients immunized with DC vaccines showed a tumor-antigen independent response and six of sixteen showed an antigen specific response [228]. In a phase I/II trial, breast cancer patients with metastatic disease received ex vivo expanded DCs from CD34+ progenitor cells. Toxicity was mild, with two patients showing a partial response to therapy, and two others producing tumor specific CTLs [229]. A newly developed fusion cell vaccine was given to patients with metastatic breast cancer or metastatic renal cancer. Disease regression occurred in two of ten patients with breast cancer and five of thirteen patients with renal cancer [230]. In another study, patients with colorectal cancer were immunized intranodally with DCs pulsed with HLA-A∗ 0201- or HLAA∗ 2402-restricted carcinoembryonic antigen (CEA)derived peptides. CEA-specific T cells were found in 70% of patients, and 20% of patients had three months of stable disease [231]. Immunotherapy of cancer has also been proven to be safe for children. In a Phase I study of 11 pediatric neuroblastoma patients, dendritic cells pulsed with tumor RNA were found to be both safe and feasible [232]. Immune therapy has recently been used to treat one of the most aggressive and devastating cancers, malignant glioma. The DC immunizations for brain tumors have began to address the questions of central nervous system immune privilege and suppression of the immune system by the glioma itself [233]. We reported recently that gliomas and malignant melanomas share common antigens [234]. In a study by Prins et al, two murine glioma cell lines expressing melanoma antigens gp100 and tyrosinase-related protein 2 were effectively targeted to immune therapy [235]. DC pulsed with tumor lysate appeared to considerably benefit survival of mice with glioblastomas [236]. Most of the immunized rats with the glioblastoma 9L showed substantial immune response to a DC vaccine injected with processed GM-CSF secreting 9L cells. Not surprisingly, the curative responses corresponded to CTL activity and IFN-gamma production. All of the rats with remission efficiently withstood a rechallenge with the parental cells [237]. Another recent study suggests that DC engineered to express IL-12 and pulsed with a tumor lysate could be used in a

S. Schroter et al.

new immunotherapeutic strategy for malignant glioma [238]. Fifteen patients with malignant glioma were immunized with fusions of dendritic and glioma cells augmented with recombinant human interleukin 12. After treatment, four patients had decreased tumor size by more than a half, as determined by MRI [239]. Another Phase I study of ten patients with glioblastoma multiforme and anaplastic astrocytoma looked at tumor lysate-pulsed DC immunization. Six of these patients manifested aggressive cytotoxicity, and of the six that underwent tumor resection after treatment, three had intratumoral T-cell infiltrate [240]. Phase 1 trials found that MART-127–35 -peptide-pulsed immature dendritic cells had both immunologic and clinical results. An interesting phase II study found that sequential CTLA4 blockade was beneficial for DC vaccination [241]. As with other vaccine approaches, the attack of tumor angiogenesis remains crucial to the tumor’s defeat. One specific study monitored vascular endothelial growth factor, platelet-derived endothelial cell growth factor, and thrombospondin-1, to determine the effect of DC immunization. In fact, the detectable amount of circulating angiogenic factors was sufficiently sensitive to DC immunotherapy, and was increased in patients with more advanced disease [242]. Some of the early clinical trials may have been suboptimal secondary to the fact that tumor cells secrete various immunosuppressive factors. These include TGF-beta, which significantly reduces the potency of DC vaccines. It is suggested that the vaccine effectiveness may be increased by neutralizing TGF-beta [243]. It also appears that allogeneic DC vaccines help to recover cancer patient immune function [244]. While DC vaccines have made great advances over the last decade, multiple hurdles still remain. Significant research is still required in the areas of DC loading, maturation, and migration. This treatment approach is time and resource expensive, not to mention the difficulty in constructing a universal vaccine rather than one for an individual tumor/patient. Difficulties such as T cell “exhaustion” and tumor antigen regulatory T cells have yet to be surmounted [245]. There is still a great deal of discussion regarding the optimal antigen loading protocols. In summary, the completed clinical trials have shown that this form of vaccination is feasible and safe but the future trials should address the technical difficulties of

14 Cancer Vaccines

manipulating human DC, as well as the development of standardized clinical protocols.

14.3.5 Sipuleucel-T (Provenge) One of the most important developments in the cancer vaccine field is the recent approval of the cancer vaccine Sipuleucel-T by the U.S. Food and Drug Administration (FDA). Sipuleucel-T was approved by the FDA on April 29, 2010 for treatment of asymptomatic or minimally symptomatic metastatic hormone-refractory prostate cancer (HRPC) [246, 247]. Sipuleucel-T is marketed by the company Dendreon under the brand name Provenge, and is the first therapeutic cancer vaccine to demonstrate effectiveness in Phase III trials by prolonging life of patients who have advanced to late stage HRPC [248–250]. Shortly after the FDA approval, Sipuleucel-T was added to the Compendium of cancer treatments published by the National Comprehensive Cancer Network (NCCN) as a “category 1” (highest recommendation) treatment for HRPC. A course of Sipuleucel-T treatment consists of three basic steps: (i) a leukapheresis procedure to isolate patient’s own antigen-presenting cells (APC); (ii) the APC are then incubated with a fusion protein consisting of two parts, the antigen prostatic acid phosphatase (PAP) which is present in most prostate cancer cells and an immune signaling factor granulocytemacrophage colony stimulating factor (GM-CSF) that helps the APC to mature; and (iii) the activated APC are re-infused into the patient to induce an immune response against cancer cells carrying the PAP antigen. A complete Sipuleucel-T treatment consists of three courses with 2 weeks between successive courses. Sipuleucel-T showed Overall Survival benefit to patients in three double blind randomized phase III clinical trials, D9901 [249], D9902a [251], and IMPACT [248]. The IMPACT trial served as the basis for licensing approval of Sipuleucel-T by the FDA. This trial enrolled 512 patients with asymptomatic or minimally symptomatic metastatic HRPC. The median survival time for Sipuleucel-T patients was 25.8 months comparing to 21.7 months for placebo-treated patients. Overall Survival was statistically significant with P-value 0.032. The side effects of Sipuleucel-T were mostly limited to chills, fever, fatigue, nausea and

273

headache, which usually occurred within the first few days of treatment. In addition, more serious cardiovascular events were observed at a rate of 2.4% in patients treated with Sipuleucel-T vs. 1.8% in placebo-treated patients [248]. Although no effect on the time to disease progression was observed, Sipuleucel-T prolonged overall survival among men with advanced metastatic castrationresistant prostate cancer – a patient population without any other available effective treatment options.

14.4 Prospects The growing number of TAA identified in many tumor types becomes a solid basis for vaccine development. However, the antigenic profile of human tumors is very complex, and consists of many peptides originating from various classes of protein. This fact should be considered carefully in designing anti-cancer vaccines. An important question is which tumor antigens are the most important in tumor regression in vivo. Differentiation antigens may play an important role in tumor regression, which is suggested by the positive correlation between the development of vitiligo and a good clinical response to immunotherapy in melanoma patients [252]. Promising candidates are also MAGE, BAGE, and GAGE antigens since they are expressed in a variety of cancer cells, but not in normal cells except testis. Mutated epitopes such as CDK-4 and b-Catenin are tumor specific, but immunotherapy using these antigens is likely to be applicable only to individual patients. Most recent vaccine studies focused on class I-restricted antigens as targets for cancer-specific CTL. The characterization of class II-restricted antigens as targets for CD4+ T cell responses will allow concurrent immunization with class I and class II epitopes in order to generate more potent immune responses. In any case, the ideal vaccine most likely will consists of a cocktail of tumor antigens or proteins. However, the number of epitopes in the vaccine cocktail should be evaluated carefully since CTL responses in AIDS patients directed to fewer epitopes are associated with better clinical outcome [253]. In this case it appears that the stimulation of multiple simultaneous CTL responses is clinically inefficient. Very important is also the dose of antigen and the speed of antigen release in the vaccine formulations. High doses

274

of antigen released faster may induce T-cell tolerance [254]. Immune tolerance may be due to fast expansion and subsequent elimination of specific T-cell clones, or to apoptosis induced by repeated stimulation of already stimulated T-cells in cell cycle [255, 256]. Therefore, it is essential to select as immunogens those epitopes against which tolerance has not been induced [257, 258]. Future cancer vaccine strategies will most likely focus on more potent approaches for immunization. The use of the entire antigenic proteins might well be superior to peptide vaccines. A whole protein may provide several T-cell epitopes presented by different MHC molecules. An additional advantage of the whole protein vaccines may be the induction of humoral immune responses [259]. Alone, or in conjunction with surgery, radiotherapy and/or chemotherapy, immunotherapy of cancer can be effective in eliminating micro-metastases, in decreasing the immunosuppressive effects of the chemotherapy or radiotherapy, and in increasing the resistance to viral or bacterial infections frequently occurring in cancer patients. Recent advances in the design of polyvalent vaccines targeting several antigens is also very promising. In addition, the possibility to treat patients with vaccines earlier in the course of the disease and to combine vaccines with other treatment modalities may also improve the vaccine efficacy. As a result, immunotherapy may become a major treatment modality of cancer in the near future.

S. Schroter et al.

7.

8. 9.

10.

11.

12.

13.

14.

References 1. Rammensee HG (1996) Antigen presentation – recent developments. Int Arch Allergy Immunol 110:299–307 2. Yewdell JW, Bennink JR (1992) Cell biology of antigen processing and presentation to major histocompatibility complex class I molecule-restricted T lymphocytes. Adv Immunol 52:1–123 3. Heemels MT, Ploegh H (1995) Generation, translocation, and presentation of MHC class I- restricted peptides. Annu Rev Biochem 64:463–491 4. Liu CC, Young LH, Young JD (1996) Lymphocytemediated cytolysis and disease. N Engl J Med 335: 1651–1659 5. Van Pel A, van der Bruggen P, Coulie PG, Brichard VG, Lethe B, van den Eynde B, Uyttenhove C, Renauld JC, Boon T (1995) Genes coding for tumor antigens recognized by cytolytic T lymphocytes. Immunol Rev 145:229–250 6. De Plaen E, Lurquin C, Lethe B, van der Bruggen P, Brichard V, Renauld JC, Coulie P, Van Pel A, Boon

15.

16.

17.

18.

19.

T (1997) Identification of genes coding for tumor antigens recognized by cytolytic T lymphocytes. Methods 12:125–142 Rosenberg SA (1997) Cancer vaccines based on the identification of genes encoding cancer regression antigens. Immunol Today 18:175–182 Wang RF (1999) Human tumor antigens: implications for cancer vaccine development. J Mol Med 77:640–655 Nestle FO, Alijagic S, Gilliet M, Sun M, Grabbe S, Dummer R, Burg G, Schadendorf D (1998) Vaccination of melanoma patients with peptide- or tumor lysate-pulsed dendritic cells. Nat Med 4:328–332 Rosenberg SA, Yang JC, Schwartzentruber DJ, Hwu P, Marincola FM, Topalian SL, Restifo NP, Dudley ME, Schwarz SL, Spiess PJ, Wunderlich JR, Parkhurst MR, Kawakami Y, Seipp CA, Einhorn JH, White DE (1998) Immunologic and therapeutic evaluation of a synthetic peptide vaccine for the treatment of patients with metastatic melanoma. Nat Med 4: 321–327 Thurner B, Haendle I, Reoder C, Dieckmann D, Keikavoussi P, Jonuleit H, Bender A, Maczek C, Schreiner D, von den Driesch P, Breocker EB, Steinman RM, Enk A, Keampgen E, Schuler G (1999) Vaccination with mage-3A1 peptide-pulsed mature, monocyte-derived dendritic cells expands specific cytotoxic T cells and induces regression of some metastases in advanced stage IV melanoma. J Exp Med 190:1669–1678 Kawakami Y, Nishimura MI, Restifo NP, Topalian SL, O’Neil BH, Shilyansky J, Yannelli JR, Rosenberg SA (1993) T-cell recognition of human melanoma antigens. J Immunother 14:88–93 Kawakami Y, Eliyahu S, Delgado CH, Robbins PF, Sakaguchi K, Appella E, Yannelli JR, Adema GJ, Miki T, Rosenberg SA (1994) Identification of a human melanoma antigen recognized by tumor-infiltrating lymphocytes associated with in vivo tumor rejection. Proc Natl Acad Sci USA 91:6458–6462 Brichard V, Van Pel A, Wölfel T, Wölfel C, De Plaen E, Lethé B, Coulie P, Boon T (1993) The tyrosinase gene codes for an antigen recognized by autologous cytolytic T lymphocytes on HLA-A2 melanomas. J Exp Med 178:489–495 Storkus WJ, Zeh HJD, Maeurer MJ, Salter RD, Lotze MT (1993) Identification of human melanoma peptides recognized by class I restricted tumor infiltrating T lymphocytes. J Immunol 151:3719–3727 Cox AL, Skipper J, Chen Y, Henderson RA, Darrow TL, Shabanowitz J, Engelhard VH, Hunt DF, Slingluff CLJ (1994) Identification of a peptide recognized by five melanoma-specific human cytotoxic T cell lines. Science 264:716–719 Christinck ER, Luscher MA, Barber BH, Williams DB (1991) Peptide binding to class I MHC on living cells and quantitation of complexes required for CTL lysis. Nature 352:67–70 Rammensee HG, Friede T, Stevanoviic S (1995) MHC ligands and peptide motifs: first listing. Immunogenetics 41:178–228 Nakamura TM, Morin GB, Chapman KB, Weinrich SL, Andrews WH, Lingner J, Harley CB, Cech TR (1997)

14 Cancer Vaccines

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

Telomerase catalytic subunit homologs from fission yeast and human [see comments]. Science 277:955–959 Ruppert J, Sidney J, Celis E, Kubo RT, Grey HM, Sette A (1993) Prominent role of secondary anchor residues in peptide binding to HLA-A2.1 molecules. Cell 74:929–937 Parker KC, Bednarek MA, Coligan JE (1994) Scheme for ranking potential HLA-A2 binding peptides based on independent binding of individual peptide side-chains. J Immunol 152:163–175 Minev B, Hipp J, Firat H, Schmidt JD, LangladeDemoyen P, Zanetti M (2000) Cytotoxic T cell immunity against telomerase reverse transcriptase in humans. Proc Natl Acad Sci USA 97:4796–4801 Mitchell MS, Kan-Mitchell J, Minev BR, Edman C, Deans RJ (2000) A novel melanoma gene (MG50) encoding the interleukin 1 receptor antagonist and six epitopes recognized by human cytolytic T lymphocytes. Cancer Res 60:6448–6456 Sahin U, Teureci O, Pfreundschuh M (1997) Serological identification of human tumor antigens. Curr Opin Immunol 9:709–716 Bystryn JC, Rigel D, Friedman RJ, Kopf A (1987) Prognostic significance of hypopigmentation in malignant melanoma. Arch Dermatol 123:1053–1055 Rosenberg SA, White DE (1996) Vitiligo in patients with melanoma: normal tissue antigens can be targets for cancer immunotherapy. J Immunother Emphasis Tumor Immunol 19:81–84 van der Bruggen P, Traversari C, Chomez P, Lurquin C, De Plaen E, Van den Eynde B, Knuth A, Boon T (1991) A gene encoding an antigen recognized by cytolytic T lymphocytes on a human melanoma. Science 254:1643–1647 Chaux P, Luiten R, Demotte N, Vantomme V, Stroobant V, Traversari C, Russo V, Schultz E, Cornelis GR, Boon T, van der Bruggen P (1999) Identification of five MAGE-A1 epitopes recognized by cytolytic T lymphocytes obtained by in vitro stimulation with dendritic cells transduced with MAGE-A1. J Immunol 163:2928–2936 Boel P, Wildmann C, Sensi ML, Brasseur R, Renauld JC, Coulie P, Boon T, van der Bruggen P (1995) BAGE: a new gene encoding an antigen recognized on human melanomas by cytolytic T lymphocytes. Immunity 2: 1167–175 Van den Eynde B, Peeters O, De Backer O, Gaugler B, Lucas S, Boon T (1995) A new family of genes coding for an antigen recognized by autologous cytolytic T lymphocytes on a human melanoma. J Exp Med 182:689–698 Gaugler B, Brouwenstijn N, Vantomme V, Szikora JP, Van der Spek CW, Patard JJ, Boon T, Schrier P, Van den Eynde BJ (1996) A new gene coding for an antigen recognized by autologous cytolytic T lymphocytes on a human renal carcinoma. Immunogenetics 44:323–330 Lee L, Wang RF, Wang X, Mixon A, Johnson BE, Rosenberg SA, Schrump DS (1999) NY-ESO-1 may be a potential target for lung cancer immunotherapy [see comments]. Cancer J Sci Am 5:20–25 Jeager E, Chen YT, Drijfhout JW, Karbach J, Ringhoffer M, Jeager D, Arand M, Wada H, Noguchi Y, Stockert E, Old LJ, Knuth A (1998) Simultaneous humoral and cellular immune response against cancer-testis antigen NYESO-1: definition of human histocompatibility leukocyte

275

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

antigen (HLA)-A2-binding peptide epitopes. J Exp Med 187:265–270 Jeager E, Jeager D, Karbach J, Chen YT, Ritter G, Nagata Y, Gnjatic S, Stockert E, Arand M, Old LJ, Knuth A (2000) Identification of NY-ESO-1 epitopes presented by human histocompatibility antigen (HLA)DRB4∗ 0101–0103 and recognized by CD4(+) T lymphocytes of patients with NY-ESO-1-expressing melanoma. J Exp Med 191:625–630 De Plaen E, Lurquin C, Van Pel A, Mariame’ B, Szikora J-P., Wölfel T, Sibille C, Chomez P, Boon T (1988) Immunogenic (tum- ) variants of mouse tumor P815: cloning of the gene of tum- antigen P91A and identification of the tum- mutation. Proc Natl Acad Sci USA 85:2274–2278 Wolfel T, Hauer M, Schneider J, Serrano M, Wolfel C, Klehmann-Hieb E, De Plaen E, Hankeln T, Meyer zum Buschenfelde KH, Beach D (1995) A p16INK4ainsensitive CDK4 mutant targeted by cytolytic T lymphocytes in a human melanoma. Science 269:1281–1284 Coulie PG, Lehmann F, Lethe B, Herman J, Lurquin C, Andrawiss M, Boon T (1995) A mutated intron sequence codes for an antigenic peptide recognized by cytolytic T lymphocytes on a human melanoma. Proc Natl Acad Sci USA 92:7976–7980 Robbins PF, el-Gamil M, Li YF, Kawakami Y, Loftus D, Appella E, Rosenberg SA (1996) A mutated betacatenin gene encodes a melanoma-specific antigen recognized by tumor infiltrating lymphocytes. J Exp Med 183: 1185–1192 Pilla L, Valenti R, Marrari A, Patuzzo R, Santinami M, Parmiani G, Rivoltini L (2006) Vaccination: role in metastatic melanoma. Expert Rev Anticancer Ther 6:1305–1318 Gendler S, Taylor-Papadimitriou J, Duhig T, Rothbard J, Burchell J (1988) A highly immunogenic region of a human polymorphic epithelial mucin expressed by carcinomas is made up of tandem repeats. J Biol Chem 263:12820–12823 Magarian-Blander J, Domenech N, Finn OJ (1993) Specific and effective T-cell recognition of cells transfected with a truncated human mucin cDNA. Ann NY Acad Sci 690:231–243 Takahashi T, Makiguchi Y, Hinoda Y, Kakiuchi H, Nakagawa N, Imai K, Yachi A (1994) Expression of MUC1 on myeloma cells and induction of HLA- unrestricted CTL against MUC1 from a multiple myeloma patient. J Immunol 153:2102–2109 Jerome KR, Barnd DL, Bendt KM, Boyer CM, TaylorPapadimitriou J, McKenzie IF, Bast RC Jr, Finn OJ (1991) Cytotoxic T-lymphocytes derived from patients with breast adenocarcinoma recognize an epitope present on the protein core of a mucin molecule preferentially expressed by malignant cells. Cancer Res 51:2908–2916 Pietersz GA, Li W, Osinski C, Apostolopoulos V, McKenzie IF (2000) Definition of MHC-restricted CTL epitopes from non-variable number of tandem repeat sequence of MUC1. Vaccine 18:2059–2071 Coussens L, Yang-Feng TL, Liao YC, Chen E, Gray A, McGrath J, Seeburg PH, Libermann TA, Schlessinger J, Francke U (1985) Tyrosine kinase receptor with extensive

276

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

58.

S. Schroter et al. homology to EGF receptor shares chromosomal location with neu oncogene. Science 230:1132–1139 Toikkanen S, Helin H, Isola J, Joensuu H (1992) Prognostic significance of HER-2 oncoprotein expression in breast cancer: a 30-year follow-up. J Clin Oncol 10:1044–1048 Disis ML, Smith JW, Murphy AE, Chen W, Cheever MA (1994) In vitro generation of human cytolytic Tcells specific for peptides derived from the HER-2/neu protooncogene protein. Cancer Res 54:1071–1076 Fisk B, Blevins TL, Wharton JT, Ioannides CG (1995) Identification of an immunodominant peptide of HER2/neu protooncogene recognized by ovarian tumorspecific cytotoxic T lymphocyte lines. J Exp Med 181:2109–2117 Lustgarten J, Theobald M, Labadie C, LaFace D, Peterson P, Disis ML, Cheever MA, Sherman LA (1997) Identification of Her-2/Neu CTL epitopes using double transgenic mice expressing HLA-A2.1 and human CD.8. Hum Immunol 52:109–118 Toes RE M., Ossendorp F, Offringa R, Melief CJM (1999) CD4 T cells and their role in antitumor immune responses. J Exp Med 189:753–756 Topalian SL, Rivoltini L, Mancini M, Markus NR, Robbins PF, Kawakami Y, Rosenberg SA (1994) Human CD4+ T cells specifically recognize a shared melanomaassociated antigen encoded by the tyrosinase gene. Proc Natl Acad Sci USA 91:9461–9465 Chaux P, Vantomme V, Stroobant V, Thielemans K, Corthals J, Luiten R, Eggermont AM, Boon T, van der Bruggen P (1999) Identification of MAGE-3 epitopes presented by HLA-DR molecules to CD4(+) T lymphocytes [see comments]. J Exp Med 189:767–778 Wang RF, Wang X, Atwood AC, Topalian SL, Rosenberg SA (1999) Cloning genes encoding MHC class IIrestricted antigens: mutated CDC27 as a tumor antigen. Science 284:1351–1354 Zarour HM, Kirkwood JM, Kierstead LS, Herr W, Brusic V, Slingluff CL Jr, Sidney J, Sette A, Storkus WJ (2000) Melan-A/MART-1(51–73) represents an immunogenic HLA-DR4-restricted epitope recognized by melanomareactive CD4(+) T cells. Proc Natl Acad Sci USA 97: 400–405 Baxevanis CN, Voutsas IF, Tsitsilonis OE, Gritzapis AD, Sotiriadou R, Papamichail M (2000) Tumor-specific CD4+ T lymphocytes from cancer patients are required for optimal induction of cytotoxic T cells against the autologous tumor. J Immunol 164:3902–3912 Di Cristina M, Minenkova O, Pavoni E, Beghetto E, Spadoni A, Felici F, Gargano N (2007) A novel approach for identification of tumor-associated antigens expressed on the surface of tumor cells. Int J Cancer 120: 1293–1303 Furukawa K, Hamamura K, Aixinjueluo W (2006) Biosignals modulated by tumor-associated carbohydrate antigens: novel targets for cancer therapy. Ann NY Acad Sci 1086:185–198 Kawahara M, Hori T, Matsubara Y, Okawa K, Uchiyama T (2006) Identification of HLA class I-restricted tumorassociated antigens in adult T cell leukemia cells by mass spectrometric analysis. Exp Hematol 34:1496–1504

59. Greiner J, Schmitt M, Li L, Giannopoulos K, Bosch K, Schmitt A, Dohner K, Schlenk RF, Pollack JR, Dohner H, Bullinger L (2006) Expression of tumor-associated antigens in acute myeloid leukemia: implications for specific immunotherapeutic approaches. Blood 108: 4109–4117 60. Schulz M, Zinkernagel RM, Hengartner H (1991) Peptideinduced antiviral protection by cytotoxic T cells. Proc Natl Acad Sci USA 88:991–993 61. Cormier JN, Salgaller ML, Prevette T, Barracchini KC, Rivoltini L, Restifo NP, Rosenberg SA, Marincola FM (1997) Enhancement of cellular immunity in melanoma patients immunized with a peptide from MART-1/Melan A [see comments]. Cancer J Sci Am 3:37–44 62. Lipford GB, Hoffman M, Wagner H, Heeg K (1993) Primary in vivo responses to ovalbumin. Probing the predictive value of the Kb binding motif. J Immunol 150:1212–1222 63. Zhou F, Rouse BT, Huang L (1992) Prolonged survival of thymoma-bearing mice after vaccination with a soluble protein antigen entrapped in liposomes: a model study. Cancer Res 52:6287–6291 64. Mossman SP, Evans LS, Fang H, Staas J, Tice T, Raychaudhuri S, Grabstein KH, Cheever MA, Johnson ME (2005) Development of a CTL vaccine for Her2/neu using peptide-microspheres and adjuvants. Vaccine 23:3545–3554 65. Zhou F, Rouse BT, Huang L (1992) Induction of cytotoxic T lymphocytes in vivo with protein antigen entrapped in membranous vehicles. J Immunol 149:1599–1604 66. Harty JT, Bevan MJ (1992) CD8+ T cells specific for a single nonamer epitope of Listeria monocytogenes are protective in vivo. J Exp Med 175:1531–1538 67. Noguchi Y, Chen YT, Old LJ (1994) A mouse mutant p53 product recognized by CD4+ and CD8+ T cells. Proc Natl Acad Sci USA 91:3171–3175 68. Mayordomo JI, Zorina T, Storkus WJ, Zitvogel L, GarciaPrats MD, DeLeo AB, Lotze MT (1997) Bone marrowderived dendritic cells serve as potent adjuvants for peptide-based antitumor vaccines. Stem Cells 15:94–103 69. Minev BR, McFarland BJ, Spiess PJ, Rosenberg SA, Restifo NP (1994) Insertion signal sequence fused to minimal peptides elicits specific CD8+ T-cell responses and prolongs survival of thymoma-bearing mice. Cancer Res 54:4155–4161 70. Jager E, Ringhoffer M, Arand M, Karbach J, Jager D, Ilsemann C, Hagedorn M, Oesch F, Knuth A (1996) Cytolytic T cell reactivity against melanoma-associated differentiation antigens in peripheral blood of melanoma patients and healthy individuals. Melanoma Res 6: 419–425 71. Rivoltini L, Kawakami Y, Sakaguchi K, Southwood S, Sette A, Robbins PF, Marincola FM, Salgaller ML, Yannelli JR, Appella E et al (1995) Induction of tumorreactive CTL from peripheral blood and tumor-infiltrating lymphocytes of melanoma patients by in vitro stimulation with an immunodominant peptide of the human melanoma antigen MART-1. J Immunol 154:2257–2265 72. Visseren MJ, van Elsas A, van der Voort EI, Ressing ME, Kast WM, Schrier PI, Melief CJ (1995) CTL specific for the tyrosinase autoantigen can be induced from

14 Cancer Vaccines

73.

74.

75.

76.

77.

78.

79.

80.

81.

82.

83.

healthy donor blood to lyse melanoma cells. J Immunol 154:3991–3998 Marchand M, Weynants P, Rankin E, Arienti F, Belli F, Parmiani G, Cascinelli N, Bourlond A, Vanwijck R, Humblet Y (1995) Tumor regression responses in melanoma patients treated with a peptide encoded by gene MAGE-3 [letter]. Int J Cancer 63:883–885 Marchand M, van Baren N, Weynants P, Brichard V, Dreno B, Tessier MH, Rankin E, Parmiani G, Arienti F, Humblet Y, Bourlond A, Vanwijck R, Lienard D, Beauduin M, Dietrich PY, Russo V, Kerger J, Masucci G, Jager E, De Greve J, Atzpodien J, Brasseur F, Coulie PG, van der Bruggen P, Boon T (1999) Tumor regressions observed in patients with metastatic melanoma treated with an antigenic peptide encoded by gene MAGE-3 and presented by HLA-A1. Int J Cancer 80:219–230 Salgaller ML, Afshar A, Marincola FM, Rivoltini L, Kawakami Y, Rosenberg SA (1995) Recognition of multiple epitopes in the human melanoma antigen gp100 by peripheral blood lymphocytes stimulated in vitro with synthetic peptides. Cancer Res 55:4972–4979 Mukherji B, Chakraborty NG, Yamasaki S, Okino T, Yamase H, Sporn JR, Kurtzman SK, Ergin MT, Ozols J, Meehan J (1995) Induction of antigen-specific cytolytic T cells in situ in human melanoma by immunization with synthetic peptide-pulsed autologous antigen presenting cells. Proc Natl Acad Sci USA 92:8078–8082 Jaeger E, Bernhard H, Romero P, Ringhoffer M, Arand M, Karbach J, Ilsemann C, Hagedorn M, Knuth A (1996) Generation of cytotoxic T-cell responses with synthetic melanoma- associated peptides in vivo: implications for tumor vaccines with melanoma-associated antigens. Int J Cancer 66:162–169 Jager E, Gnjatic S, Nagata Y, Old LJ, Knuth A (2000) Induction of primary NY-ESO-1 immunity: CD8+ T lymphocyte and antibody responses in peptidevaccinated patients with NY-ESO-1+ cancers. PNAS 97: 12198–12202 Gjertsen MK, Bakka A, Breivik J, Saeterdal I, GeddeDahl T 3rd, Stokke KT, Solheim BG, Egge TS, Soreide O, Thorsby E, Gaudernack G (1996) Ex vivo ras peptide vaccination in patients with advanced pancreatic cancer: results of a phase I/II study. Int J Cancer 65: 450–453 Celis E, Tsai V, Crimi C, DeMars R, Wentworth PA, Chesnut RW, Grey HM, Sette A, Serra HM (1994) Induction of anti-tumor cytotoxic T lymphocytes in normal humans using primary cultures and synthetic peptide epitopes. Proc Natl Acad Sci USA 91:2105–2109 Vitiello A, Ishioka G, Grey HM, Rose R, Farness P, LaFond R, Yuan L, Chisari FV, Furze J, Bartholomeuz R (1995) Development of a lipopeptide-based therapeutic vaccine to treat chronic HBV infection. I. Induction of a primary cytotoxic T lymphocyte response in humans. J Clin Invest 95:341–349 Sette A, Alexander J, Ruppert J, Snoke K, Franco A, Ishioka G, Grey HM (1994) Antigen analogs/MHC complexes as specific T cell receptor antagonists. Annu Rev Immunol 12:413–431 Parkhurst MR, Salgaller ML, Southwood S, Robbins PF, Sette A, Rosenberg SA, Kawakami Y (1996) Improved

277

84.

85.

86.

87.

88.

89.

90.

91.

92.

93.

94.

induction of melanoma-reactive CTL with peptides from the melanoma antigen gp100 modified at HLA-A∗ 0201binding residues. J Immunol 157:2539–2548 Phan GQ, Yang JC, Sherry RM, Hwu P, Topalian SL, Schwartzentruber DJ, Restifo NP, Haworth LR, Seipp CA, Freezer LJ, Morton KE, Mavroukakis SA, Duray PH, Steinberg SM, Allison JP, Davis TA, Rosenberg SA (2003) Cancer regression and autoimmunity induced by cytotoxic T lymphocyte-associated antigen 4 blockade in patients with metastatic melanoma. Proc Natl Acad Sci USA 100:8372–8377 Sanderson K, Scotland R, Lee P, Liu D, Groshen S, Snively J, Sian S, Nichol G, Davis T, Keler T, Yellin M, Weber J (2005) Autoimmunity in a phase I trial of a fully human anti-cytotoxic T-lymphocyte antigen-4 monoclonal antibody with multiple melanoma peptides and Montanide ISA 51 for patients with resected stages III and IV melanoma. J Clin Oncol 23:741–750 Wang F, Bade E, Kuniyoshi C, Spears L, Jeffery G, Marty V, Groshen S, Weber J (1999) Phase I trial of a MART-1 peptide vaccine with incomplete Freund’s adjuvant for resected high-risk melanoma. Clin Cancer Res 5:2756–2765 Jeager E, Maeurer M, Heohn H, Karbach J, Jeager D, Zidianakis Z, Bakhshandeh-Bath A, Orth J, Neukirch C, Necker A, Reichert TE, Knuth A (2000) Clonal expansion of Melan A-specific cytotoxic T lymphocytes in a melanoma patient responding to continued immunization with melanoma-associated peptides. Int J Cancer 86:538–547 Brinckerhoff LH, Kalashnikov VV, Thompson LW, Yamshchikov GV, Pierce RA, Galavotti HS, Engelhard VH, Slingluff CL Jr (1999) Terminal modifications inhibit proteolytic degradation of an immunogenic MART-1(27– 35) peptide: implications for peptide vaccines. Int J Cancer 83:326–334 Minev BR, Chavez FL, Dudouet BM, Mitchell MS (2000) Synthetic insertion signal sequences enhance MHC class I presentation of a peptide from the melanoma antigen MART-1. Eur J Immunol 30:2115–2124 Anderson K, Cresswell P, Gammon M, Hermes J, Williamson A, Zweerink H (1991) Endogenously synthesized peptide with an endoplasmic reticulum signal sequence sensitizes antigen processing mutant cells to class I-restricted cell-mediated lysis. J Exp Med 174: 489–492 Okada CY, Rechsteiner M (1982) Introduction of macromolecules into cultured mammalian cells by osmotic lysis of pinocytic vesicles. Cell 29:33–41 Persson H, Jornvall H, Zabielski J (1980) Multiple mRNA species for the precursor to an adenovirus-encoded glycoprotein: identification and structure of the signal sequence. Proc Natl Acad Sci USA 77:6349–6353 Houghton M, Stewart AG, Doel SM, Emtage JS, Eaton MA, Smith JC, Patel TP, Lewis HM, Porter AG, Birch JR, Cartwright T, Carey NH (1980) The amino-terminal sequence of human fibroblast interferon as deduced from reverse transcripts obtained using synthetic oligonucleotide primers. Nucleic Acids Res 8:1913–1931 Restifo NP, Esquivel F, Kawakami Y, Yewdell JW, Mule JJ, Rosenberg SA, Bennink JR (1993) Identification of

278

95.

96.

97.

98.

99.

100.

101.

102.

103.

104.

S. Schroter et al. human cancers deficient in antigen processing. J Exp Med 177:265–272 Slingluff CL, Jr., Petroni GR, Yamshchikov GV, Hibbitts S, Grosh WW, Chianese-Bullock KA, Bissonette EA, Barnd DL, Deacon DH, Patterson JW, Parekh J, Neese PY, Woodson EM, Wiernasz CJ, Merrill P (2004) Immunologic and clinical outcomes of vaccination with a multiepitope melanoma peptide vaccine plus low-dose interleukin-2 administered either concurrently or on a delayed schedule. J Clin Oncol 22:4474–4485 Lee P, Wang F, Kuniyoshi J, Rubio V, Stuges T, Groshen S, Gee C, Lau R, Jeffery G, Margolin K, Marty V, Weber J (2001) Effects of interleukin-12 on the immune response to a multipeptide vaccine for resected metastatic melanoma. J Clin Oncol 19:3836–3847 Peterson AC, Harlin H, Gajewski TF (2003) Immunization with Melan-A peptide-pulsed peripheral blood mononuclear cells plus recombinant human interleukin-12 induces clinical activity and T-cell responses in advanced melanoma. J Clin Oncol 21:2342–2348 Chianese-Bullock KA, Pressley J, Garbee C, Hibbitts S, Murphy C, Yamshchikov G, Petroni GR, Bissonette EA, Neese PY, Grosh WW, Merrill P, Fink R, Woodson EM, Wiernasz CJ, Patterson JW, Slingluff CL Jr (2005) MAGE-A1-, MAGE-A10-, and gp100derived peptides are immunogenic when combined with granulocyte-macrophage colony-stimulating factor and montanide ISA-51 adjuvant and administered as part of a multipeptide vaccine for melanoma. J Immunol 174: 3080–3086 Hersey P, Menzies SW, Coventry B, Nguyen T, Farrelly M, Collins S, Hirst D, Johnson H (2005) Phase I/II study of immunotherapy with T-cell peptide epitopes in patients with stage IV melanoma. Cancer Immunol Immunother 54:208–218 Pullarkat V, Lee PP, Scotland R, Rubio V, Groshen S, Gee C, Lau R, Snively J, Sian S, Woulfe SL, Wolfe RA, Weber JS (2003) A phase I trial of SD-9427 (progenipoietin) with a multipeptide vaccine for resected metastatic melanoma. Clin Cancer Res 9:1301–1312 Butterfield LH, Ribas A, Meng WS, Dissette VB, Amarnani S, Vu HT, Seja E, Todd K, Glaspy JA, McBride WH, Economou JS (2003) T-cell responses to HLAA∗ 0201 immunodominant peptides derived from alphafetoprotein in patients with hepatocellular cancer. Clin Cancer Res 9:5902–5908 Vonderheide RH, Domchek SM, Schultze JL, George DJ, Hoar KM, Chen DY, Stephans KF, Masutomi K, Loda M, Xia Z, Anderson KS, Hahn WC, Nadler LM (2004) Vaccination of cancer patients against telomerase induces functional antitumor CD8+ T lymphocytes. Clin Cancer Res 10:828–839 McNeel DG, Knutson KL, Schiffman K, Davis DR, Caron D, Disis ML (2003) Pilot study of an HLA-A2 peptide vaccine using flt3 ligand as a systemic vaccine adjuvant. J Clin Immunol 23:62–72 Davila E, Kennedy R, Celis E (2003) Generation of antitumor immunity by cytotoxic T lymphocyte epitope peptide vaccination CpG-oligodeoxynucleotide adjuvant, and CTLA-4 blockade. Cancer Res 63:3281–3288

105. Celis E, Sette A, Grey HM (1995) Epitope selection and development of peptide based vaccines to treat cancer. Semin Cancer Biol 6:329–336 106. Itoh K, Yamada A (2006) Personalized peptide vaccines: a new therapeutic modality for cancer. Cancer Sci 97: 970–976 107. Moss B (1991) Vaccinia virus: a tool for research and vaccine development. Science 252:1662–1667 108. Etlinger HM, Altenburger W (1991) Overcoming inhibition of antibody responses to a malaria recombinant vaccinia virus caused by prior exposure to wild type virus. Vaccine 9:470–472 109. Mastrangelo MJ, Maguire HC, McCue P (1995) A pilot study demonstrating the feasibility of using intratumoral vaccinia injections as a vector for gene transfer. Vaccine Res 4:55–69 110. Irvine KR, Chamberlain RS, Shulman EP, Surman DR, Rosenberg SA, Restifo NP (1997) Enhancing efficacy of recombinant anticancer vaccines with prime/boost regimens that use two different vectors. J Natl Cancer Inst 89:1595–1601 111. Feder-Mengus C, Schultz-Thater E, Oertli D, Marti WR, Heberer M, Spagnoli GC, Zajac P (2005) Nonreplicating recombinant vaccinia virus expressing CD40 ligand enhances APC capacity to stimulate specific CD4+ and CD8+ T cell responses. Hum Gene Ther 16:348–360 112. McElrath MJ (1995) Selection of potent immunological adjuvants for vaccine construction. Semin Cancer Biol 6:375–385 113. Baxby D, Paoletti E (1992) Potential use of nonreplicating vectors as recombinant vaccines. Vaccine 10:8–9 114. Wang M, Bronte V, Chen PW, Gritz L, Panicali D, Rosenberg SA, Restifo NP (1995) Active immunotherapy of cancer with a nonreplicating recombinant fowlpox virus encoding a model tumor-associated antigen. J Immunol 154:4685–4692 115. Cox WI, Tartaglia J, Paoletti E (1993) Induction of cytotoxic T lymphocytes by recombinant canarypox (ALVAC) and attenuated vaccinia (NYVAC) viruses expressing the HIV-1 envelope glycoprotein. Virology 195:845–850 116. Tsang KY, Zaremba S, Nieroda CA, Zhu MZ, Hamilton JM, Schlom J (1995) Generation of human cytotoxic T cells specific for human carcinoembryonic antigen epitopes from patients immunized with recombinant vaccinia-CEA vaccine. J Natl Cancer Inst 87:982–990 117. Marshall JL, Hawkins MJ, Tsang KY, Richmond E, Pedicano JE, Zhu MZ, Schlom J (1999) Phase I study in cancer patients of a replication-defective avipox recombinant vaccine that expresses human carcinoembryonic antigen. J Clin Oncol 17:332–337 118. Zhu MZ, Marshall J, Cole D, Schlom J, Tsang KY (2000) Specific cytolytic T-cell responses to human CEA from patients immunized with recombinant avipox-CEA vaccine. Clin Cancer Res 6:24–33 119. Conry RM, Khazaeli MB, Saleh MN, Allen KO, Barlow DL, Moore SE, Craig D, Arani RB, Schlom J, LoBuglio AF (1999) Phase I trial of a recombinant vaccinia virus encoding carcinoembryonic antigen in metastatic adenocarcinoma: comparison of intradermal versus subcutaneous administration. Clin Cancer Res 5:2330–2337

14 Cancer Vaccines 120. Conry RM, Allen KO, Lee S, Moore SE, Shaw DR, LoBuglio AF (2000) Human autoantibodies to carcinoembryonic antigen (CEA) induced by a vaccinia-CEA vaccine. Clin Cancer Res 6:34–41 121. Meyer H, Sutter G, Mayr A (1991) Mapping of deletions in the genome of the highly attenuated vaccinia virus MVA and their influence on virulence. J Gen Virol 72:1031–1038 122. Sutter G, Moss B (1992) Nonreplicating vaccinia vector efficiently expresses recombinant genes. Proc Natl Acad Sci USA 89:10847–10851 123. Sutter G, Wyatt LS, Foley PL, Bennink JR, Moss B (1994) A recombinant vector derived from the host rangerestricted and highly attenuated MVA strain of vaccinia virus stimulates protective immunity in mice to influenza virus. Vaccine 12:1032–1040 124. Drexler I, Antunes E, Schmitz M, Weolfel T, Huber C, Erfle V, Rieber P, Theobald M, Sutter G (1999) Modified vaccinia virus Ankara for delivery of human tyrosinase as melanoma-associated antigen: induction of tyrosinaseand melanoma-specific human leukocyte antigen A∗ 0201restricted cytotoxic T cells in vitro and in vivo. Cancer Res 59:4955–4963 125. Mateo L, Gardner J, Chen Q, Schmidt C, Down M, Elliott SL, Pye SJ, Firat H, Lemonnier FA, Cebon J, Suhrbier A (1999) An HLA-A2 polyepitope vaccine for melanoma immunotherapy. J Immunol 163:4058–4063 126. Rosenberg SA, Zhai Y, Yang JC, Schwartzentruber DJ, Hwu P, Marincola FM, Topalian SL, Restifo NP, Seipp CA, Einhorn JH, Roberts B, White DE (1998) Immunizing patients with metastatic melanoma using recombinant adenoviruses encoding MART-1 or gp100 melanoma antigens. J Natl Cancer Inst 90:1894–1900 127. Liu DW, Tsao YP, Kung JT, Ding YA, Sytwu HK, Xiao X, Chen SL (2000) Recombinant adeno-associated virus expressing human papillomavirus type 16 E7 peptide DNA fused with heat shock protein DNA as a potential vaccine for cervical cancer. J Virol 74:2888–2894 128. Sanda MG, Smith DC, Charles LG, Hwang C, Pienta KJ, Schlom J, Milenic D, Panicali D, Montie JE (1999) Recombinant vaccinia-PSA (PROSTVAC) can induce a prostate-specific immune response in androgenmodulated human prostate cancer. Urology 53:260–266 129. Zajac P, Oertli D, Marti W, Adamina M, Bolli M, Guller U, Noppen C, Padovan E, Schultz-Thater E, Heberer M, Spagnoli G (2003) Phase I/II clinical trial of a nonreplicative vaccinia virus expressing multiple HLAA0201-restricted tumor-associated epitopes and costimulatory molecules in metastatic melanoma patients. Hum Gene Ther 14:1497–1510 130. Arlen PM, Gulley JL, Todd N, Lieberman R, Steinberg SM, Morin S, Bastian A, Marte J, Tsang KY, Beetham P, Grosenbach DW, Schlom J, Dahut W (2005) Antiandrogen, vaccine and combination therapy in patients with nonmetastatic hormone refractory prostate cancer. J Urol 174:539–546 131. Freytag SO, Stricker H, Pegg J, Paielli D, Pradhan DG, Peabody J, DePeralta-Venturina M, Xia X, Brown S, Lu M, Kim JH (2003) Phase I study of replication-competent adenovirus-mediated double-suicide gene therapy in combination with conventional-dose three-dimensional

279

132.

133.

134.

135.

136.

137.

138.

139.

140.

141.

142.

143.

conformal radiation therapy for the treatment of newly diagnosed, intermediate- to high-risk prostate cancer. Cancer Res 63:7497–7506 Pantuck AJ, van Ophoven A, Gitlitz BJ, Tso CL, Acres B, Squiban P, Ross ME, Belldegrun AS, Figlin RA (2004) Phase I trial of antigen-specific gene therapy using a recombinant vaccinia virus encoding MUC-1 and IL-2 in MUC-1-positive patients with advanced prostate cancer. J Immunother 27:240–253 Blechacz B, Splinter PL, Greiner S, Myers R, Peng KW, Federspiel MJ, Russell SJ, LaRusso NF (2006) Engineered measles virus as a novel oncolytic viral therapy system for hepatocellular carcinoma. Hepatology 44:1465–1477 Jager E, Karbach J, Gnjatic S, Neumann A, Bender A, Valmori D, Ayyoub M, Ritter E, Ritter G, Jager D, Panicali D, Hoffman E, Pan L, Oettgen H, Old LJ, Knuth A (2006) Recombinant vaccinia/fowlpox NY-ESO1 vaccines induce both humoral and cellular NY-ESO-1specific immune responses in cancer patients. Proc Natl Acad Sci USA 103:14453–14458 Jiang HR, Gilham DE, Mulryan K, Kirillova N, Hawkins RE, Stern PL (2006) Combination of vaccination and chimeric receptor expressing T cells provides improved active therapy of tumors. J Immunol 177: 4288–4298 Bonnet MC, Tartaglia J, Verdier F, Kourilsky P, Lindberg A, Klein M, Moingeon P (2000) Recombinant viruses as a tool for therapeutic vaccination against human cancers. Immunol Lett 74:11–25 Fynan EF, Webster RG, Fuller DH, Haynes JR, Santoro JC, Robinson HL (1993) DNA vaccines: protective immunizations by parenteral, mucosal, and gene-gun inoculations. Proc Natl Acad Sci USA 90:11478–11482 Wolff JA, Dowty ME, Jiao S, Repetto G, Berg RK, Ludtke JJ, Williams P, Slautterback DB (1992) Expression of naked plasmids by cultured myotubes and entry of plasmids into T tubules and caveolae of mammalian skeletal muscle. J Cell Sci 103:1249–1259 Wolff JA, Ludtke JJ, Acsadi G, Williams P, Jani A (1992) Long-term persistence of plasmid DNA and foreign gene expression in mouse muscle. Hum Mol Genet 1: 363–369 Yankauckas MA, Morrow JE, Parker SE, Abai A, Rhodes GH, Dwarki VJ, Gromkowski SH (1993) Long-term antinucleoprotein cellular and humoral immunity is induced by intramuscular injection of plasmid DNA containing NP gene. DNA Cell Biol 12:771–776 Fuller DH, Haynes JR (1994) A qualitative progression in HIV type 1 glycoprotein 120- specific cytotoxic cellular and humoral immune responses in mice receiving a DNA-based glycoprotein 120 vaccine. AIDS Res Hum Retroviruses 10:1433–1441 Pertmer TM, Eisenbraun MD, McCabe D, Prayaga SK, Fuller DH, Haynes JR (1995) Gene gun-based nucleic acid immunization: elicitation of humoral and cytotoxic T lymphocyte responses following epidermal delivery of nanogram quantities of DNA. Vaccine 13: 1427–1430 Irvine KR, Rao JB, Rosenberg SA, Restifo NP (1996) Cytokine enhancement of DNA immunization leads to

280

144.

145.

146.

147.

148.

149.

150.

151.

152.

153.

154.

155.

156.

S. Schroter et al. effective treatment of established pulmonary metastases. J Immunol 156:238–245 Conry RM, Widera G, LoBuglio AF, Fuller JT, Moore SE, Barlow DL, Turner J, Yang NS, Curiel DT (1996) Selected strategies to augment polynucleotide immunization. Gene Ther 3:67–74 Corr M, Lee DJ, Carson DA, Tighe H (1996) Gene vaccination with naked plasmid DNA: mechanism of CTL priming. J Exp Med 184:1555–1560 Ulmer JB, Deck RR, Dewitt CM, Donnhly JI, Liu MA (1996) Generation of MHC class I-restricted cytotoxic T lymphocytes by expression of a viral protein in muscle cells: antigen presentation by non-muscle cells. Immunology 89:59–67 Condon C, Watkins SC, Celluzzi CM, Thompson K, Falo LDJ (1996) DNA-based immunization by in vivo transfection of dendritic cells. Nat Med 2:1122–1128 Syrengelas AD, Chen TT, Levy R (1996) DNA immunization induces protective immunity against B-cell lymphoma. Nat Med 2:1038–1041 Timmerman JM, Singh G, Hermanson G, Hobart P, Czerwinski DK, Taidi B, Rajapaksa R, Caspar CB, Van Beckhoven A, Levy R (2002) Immunogenicity of a plasmid DNA vaccine encoding chimeric idiotype in patients with B-cell lymphoma. Cancer Res 62: 5845–5852 Conry RM, Curiel DT, Strong TV, Moore SE, Allen KO, Barlow DL, Shaw DR, LoBuglio AF (2002) Safety and immunogenicity of a DNA vaccine encoding carcinoembryonic antigen and hepatitis B surface antigen in colorectal carcinoma patients. Clin Cancer Res 8: 2782–2787 Hermans IF, Chong TW, Palmowski MJ, Harris AL, Cerundolo V (2003) Synergistic effect of metronomic dosing of cyclophosphamide combined with specific antitumor immunotherapy in a murine melanoma model. Cancer Res 63:8408–8413 Sanchez-Perez L, Kottke T, Diaz RM, Ahmed A, Thompson J, Chong H, Melcher A, Holmen S, Daniels G, Vile RG (2005) Potent selection of antigen loss variants of B16 melanoma following inflammatory killing of melanocytes in vivo. Cancer Res 65:2009–2017 Reisfeld RA, Niethammer AG, Luo Y, Xiang R (2004) DNA vaccines suppress tumor growth and metastases by the induction of anti-angiogenesis. Immunol Rev 199:181–190 Xiang R, Mizutani N, Luo Y, Chiodoni C, Zhou H, Mizutani M, Ba Y, Becker JC, Reisfeld RA (2005) A DNA vaccine targeting survivin combines apoptosis with suppression of angiogenesis in lung tumor eradication. Cancer Res 65:553–561 Bronte V, Cingarlini S, Apolloni E, Serafini P, Marigo I, De Santo C, Macino B, Marin O, Zanovello P (2003) Effective genetic vaccination with a widely shared endogenous retroviral tumor antigen requires CD40 stimulation during tumor rejection phase. J Immunol 171:6396–6405 Buchan S, Gronevik E, Mathiesen I, King CA, Stevenson FK, Rice J (2005) Electroporation as a “prime/boost” strategy for naked DNA vaccination against a tumor antigen. J Immunol 174:6292–6298

157. Stevenson FK, Ottensmeier CH, Johnson P, Zhu D, Buchan SL, McCann KJ, Roddick JS, King AT, McNicholl F, Savelyeva N, Rice J (2004) DNA vaccines to attack cancer. Proc Natl Acad Sci USA 101(Suppl 2):14646–14652 158. Zhang L, Widera G, Bleecher S, Zaharoff DA, Mossop B, Rabussay D (2003) Accelerated immune response to DNA vaccines. DNA Cell Biol 22:815–822 159. Doan T, Herd K, Ramshaw I, Thomson S, Tindle RW (2005) A polytope DNA vaccine elicits multiple effector and memory CTL responses and protects against human papillomavirus 16 E7-expressing tumour. Cancer Immunol Immunother 54:157–171 160. Gregor PD, Wolchok JD, Ferrone CR, Buchinshky H, Guevara-Patino JA, Perales MA, Mortazavi F, Bacich D, Heston W, Latouche JB, Sadelain M, Allison JP, Scher HI, Houghton AN (2004) CTLA-4 blockade in combination with xenogeneic DNA vaccines enhances T-cell responses, tumor immunity and autoimmunity to self antigens in animal and cellular model systems. Vaccine 22:1700–1708 161. Teramoto K, Kontani K, Ozaki Y, Sawai S, Tezuka N, Nagata T, Fujino S, Itoh Y, Taguchi O, Koide Y, Asai T, Ohkubo I, Ogasawara K (2003) Deoxyribonucleic acid (DNA) encoding a pan-major histocompatibility complex class II peptide analogue augmented antigen-specific cellular immunity and suppressive effects on tumor growth elicited by DNA vaccine immunotherapy. Cancer Res 63:7920–7925 162. Jia ZC, Zou LY, Ni B, Wan Y, Zhou W, Lv YB, Geng M, Wu YZ (2005) Effective induction of antitumor immunity by immunization with plasmid DNA encoding TRP-2 plus neutralization of TGF-beta. Cancer Immunol Immunother 54:446–452 163. Piechocki MP, Ho YS, Pilon S, Wei WZ (2003) Human ErbB-2 (Her-2) transgenic mice: a model system for testing Her-2 based vaccines. J Immunol 171:5787–5794 164. Pupa SM, Iezzi M, Di Carlo E, Invernizzi A, Cavallo F, Meazza R, Comes A, Ferrini S, Musiani P, Menard S (2005) Inhibition of mammary carcinoma development in HER-2/neu transgenic mice through induction of autoimmunity by xenogeneic DNA vaccination. Cancer Res 65:1071–1078 165. Quaglino E, Iezzi M, Mastini C, Amici A, Pericle F, Di Carlo E, Pupa SM, De Giovanni C, Spadaro M, Curcio C, Lollini PL, Musiani P, Forni G, Cavallo F (2004) Electroporated DNA vaccine clears away multifocal mammary carcinomas in her-2/neu transgenic mice. Cancer Res 64:2858–2864 166. Lavergne E, Combadiere C, Iga M, Boissonnas A, Bonduelle O, Maho M, Debre P, Combadiere B (2004) Intratumoral CC chemokine ligand 5 overexpression delays tumor growth and increases tumor cell infiltration. J Immunol 173:3755–3762 167. Stagg J, Wu JH, Bouganim N, Galipeau J (2004) Granulocyte-macrophage colony-stimulating factor and interleukin-2 fusion cDNA for cancer gene immunotherapy. Cancer Res 64:8795–8799 168. Luo Y, Zhou H, Mizutani M, Mizutani N, Liu C, Xiang R, Reisfeld RA (2005) A DNA vaccine targeting Fosrelated antigen 1 enhanced by IL-18 induces long-lived

14 Cancer Vaccines

169.

170.

171.

172. 173.

174.

175.

176.

177.

178.

179.

180.

181.

T-cell memory against tumor recurrence. Cancer Res 65:3419–3427 Yamanaka R, Xanthopoulos KG (2005) Induction of antigen-specific immune responses against malignant brain tumors by intramuscular injection of sindbis DNA encoding gp100 and IL-18. DNA Cell Biol 24: 317–324 InSug O, Blaszczyk-Thurin M, Shen CT, Ertl HC (2003) A DNA vaccine expressing tyrosinase-related protein2 induces T-cell-mediated protection against mouse glioblastoma. Cancer Gene Ther 10:678–688 Fest S, Huebener N, Weixler S, Bleeke M, Zeng Y, Strandsby A, Volkmer-Engert R, Landgraf C, Gaedicke G, Riemer AB, Michalsky E, Jaeger IS, Preissner R, Forster-Wald E, Jensen-Jarolim E, Lode HN (2006) Characterization of GD2 peptide mimotope DNA vaccines effective against spontaneous neuroblastoma metastases. Cancer Res 66:10567–10575 Kurth R (1995) Risk potential of the chromosomal insertion of foreign DNA. Ann NY Acad Sci 772:140–151 Figdor CG, de Vries IJ, Lesterhuis WJ, Melief CJ (2004) Dendritic cell immunotherapy: mapping the way. Nat Med 10:475–480 Ikeda H, Chamoto K, Tsuji T, Suzuki Y, Wakita D, Takeshima T, Nishimura T (2004) The critical role of type1 innate and acquired immunity in tumor immunotherapy. Cancer Sci 95:697–703 Nijman HW, Kleijmeer MJ, Ossevoort MA, Oorschot VM, Vierboom MP, van de Keur M, Kenemans P, Kast WM, Geuze HJ, Melief CJ (1995) Antigen capture and major histocompatibility class II compartments of freshly isolated and cultured human blood dendritic cells. J Exp Med 182:163–174 Sallusto F, Cella M, Danieli C, Lanzavecchia A (1995) Dendritic cells use macropinocytosis and the mannose receptor to concentrate macromolecules in the major histocompatibility complex class II compartment: downregulation by cytokines and bacterial products [see comments]. J Exp Med 182:389–400 Kiertscher SM, Roth MD (1996) Human CD14+ leukocytes acquire the phenotype and function of antigenpresenting dendritic cells when cultured in GM-CSF and IL-4. J Leukoc Biol 59:208–218 Zhou F, Huang L (1995) Delivery of protein antigen to the major histocompatibility complex class I-restricted antigen presentation pathway. J Drug Target 3:91–109 Porgador A, Gilboa E (1995) Bone marrow-generated dendritic cells pulsed with a class I- restricted peptide are potent inducers of cytotoxic T lymphocytes. J Exp Med 182:255–260 Ossevoort MA, Feltkamp MC, van Veen KJ, Melief CJ, Kast WM (1995) Dendritic cells as carriers for a cytotoxic T-lymphocyte epitope- based peptide vaccine in protection against a human papillomavirus type 16-induced tumor. J Immunother Emphasis Tumor Immunol 18:86–94 Mayordomo JI, Zorina T, Storkus WJ, Zitvogel L, Celluzzi C, Falo LD, Melief CJ, Ildstad ST, Kast WM, Deleo AB et al (1995) Bone marrow-derived dendritic cells pulsed with synthetic tumour peptides elicit protective and therapeutic antitumour immunity. Nat Med 1: 1297–1302

281 182. Celluzzi CM, Mayordomo JI, Storkus WJ, Lotze MT, Falo LDJ (1996) Peptide-pulsed dendritic cells induce antigenspecific CTL- mediated protective tumor immunity [see comments]. J Exp Med 183:283–287 183. Eberl G, Widmann C, Corradin G (1996) The functional half-life of H-2Kd-restricted T cell epitopes on living cells. Eur J Immunol 26:1993–1999 184. Zitvogel L, Mayordomo JI, Tjandrawan T, DeLeo AB, Clarke MR, Lotze MT, Storkus WJ (1996) Therapy of murine tumors with tumor peptide-pulsed dendritic cells: dependence on T cells B7 costimulation, and T helper cell 1-associated cytokines [see comments]. J Exp Med 183:87–97 185. Mayordomo JI, Zorina T, Storkus WJ, Zitvogel L, Celluzzi C, Falo LD, Melief CJ, Ildstad ST, Kast WM, DeLeo AB (1995) Bone marrow-derived dendritic cells pulsed with synthetic tumour peptides elicit protective and therapeutic antitumour immunity. Nat Med 1:1297–1302 186. Paglia P, Chiodoni C, Rodolfo M, Colombo MP (1996) Murine dendritic cells loaded in vitro with soluble protein prime cytotoxic T lymphocytes against tumor antigen in vivo [see comments]. J Exp Med 183:317–322 187. Boczkowski D, Nair SK, Snyder D, Gilboa E (1996) Dendritic cells pulsed with RNA are potent antigenpresenting cells in vitro and in vivo. J Exp Med 184: 465–472 188. Davis ID, Chen Q, Morris L, Quirk J, Stanley M, Tavarnesi ML, Parente P, Cavicchiolo T, Hopkins W, Jackson H, Dimopoulos N, Tai TY, MacGregor D, Browning J, Svobodova S, Caron D, Maraskovsky E, Old LJ, Chen W, Cebon J (2006) Blood dendritic cells generated with Flt3 ligand and CD40 ligand prime CD8+ T cells efficiently in cancer patients. J Immunother 29:499–511 189. Specht JM, Wang G, Do MT, Lam JS, Royal RE, Reeves ME, Rosenberg SA, Hwu P (1997) Dendritic cells retrovirally transduced with a model antigen gene are therapeutically effective against established pulmonary metastases. J Exp Med 186:1213–1221 190. Wan Y, Bramson J, Carter R, Graham F, Gauldie J (1997) Dendritic cells transduced with an adenoviral vector encoding a model tumor-associated antigen for tumor vaccination. Hum Gene Ther 8:1355–1363 191. Fisher KJ, Jooss K, Alston J, Yang Y, Haecker SE, High K, Pathak R, Raper SE, Wilson JM (1997) Recombinant adeno-associated virus for muscle directed gene therapy. Nat Med 3:306–312 192. Yang Y, Li Q, Ertl HC, Wilson JM (1995) Cellular and humoral immune responses to viral antigens create barriers to lung-directed gene therapy with recombinant adenoviruses. J Virol 69:2004–2015 193. Arthur JF, Butterfield LH, Roth MD, Bui LA, Kiertscher SM, Lau R, Dubinett S, Glaspy J, McBride WH, Economou JS (1997) A comparison of gene transfer methods in human dendritic cells. Cancer Gene Ther 4: 17–25 194. Bronte V, Carroll MW, Goletz TJ, Wang M, Overwijk WW, Marincola F, Rosenberg SA, Moss B, Restifo NP (1997) Antigen expression by dendritic cells correlates with the therapeutic effectiveness of a model recombinant poxvirus tumor vaccine. Proc Natl Acad Sci USA 94:3183–3188

282 195. Tuting T, Zorina T, Ma DI, Wilson CC, De Cesare CM, De Leo AB, Lotze MT, Storkus WJ (1997) Development of dendritic cell-based genetic vaccines for cancer. Adv Exp Med Biol 417:511–518 196. Grunebach F, Muller MR, Brossart P (2005) New developments in dendritic cell-based vaccinations: RNA translated into clinics. Cancer Immunol Immunother 54: 517–525 197. Zeis M, Siegel S, Wagner A, Schmitz M, Marget M, KuhlBurmeister R, Adamzik I, Kabelitz D, Dreger P, Schmitz N, Heiser A (2003) Generation of cytotoxic responses in mice and human individuals against hematological malignancies using survivin-RNA-transfected dendritic cells. J Immunol 170:5391–5397 198. Andre F, Escudier B, Angevin E, Tursz T, Zitvogel L (2004) Exosomes for cancer immunotherapy. Ann Oncol 15(Suppl 4):iv141–144 199. Hsu DH, Paz P, Villaflor G, Rivas A, Mehta-Damani A, Angevin E, Zitvogel L, Le Pecq JB (2003) Exosomes as a tumor vaccine: enhancing potency through direct loading of antigenic peptides. J Immunother 26:440–450 200. Kang TH, Lee JH, Bae HC, Noh KH, Kim JH, Song CK, Shin BC, Hung CF, Wu TC, Park JS, Kim TW (2006) Enhancement of dendritic cell-based vaccine potency by targeting antigen to endosomal/lysosomal compartments. Immunol Lett 106:126–134 201. Yasuda T, Kamigaki T, Nakamura T, Imanishi T, Hayashi S, Kawasaki K, Takase S, Ajiki T, Kuroda Y (2006) Dendritic cell-tumor cell hybrids enhance the induction of cytotoxic T lymphocytes against murine colon cancer: a comparative analysis of antigen loading methods for the vaccination of immunotherapeutic dendritic cells. Oncol Rep 16:1317–1324 202. Enomoto Y, Bharti A, Khaleque AA, Song B, Liu C, Apostolopoulos V, Xing PX, Calderwood SK, Gong J (2006) Enhanced immunogenicity of heat shock protein 70 peptide complexes from dendritic cell-tumor fusion cells. J Immunol 177:5946–5955 203. Adams S, O’Neill D, Bhardwaj N (2004) Maturation matters: importance of maturation for antitumor immunity of dendritic cell vaccines. J Clin Oncol 22:3834–3835; author reply 3835 204. Akiyama K, Ebihara S, Yada A, Matsumura K, Aiba S, Nukiwa T, Takai T (2003) Targeting apoptotic tumor cells to Fc gamma R provides efficient and versatile vaccination against tumors by dendritic cells. J Immunol 170: 1641–1648 205. Zhang W, Chen Z, Li F, Kamencic H, Juurlink B, Gordon JR, Xiang J (2003) Tumour necrosis factor-alpha (TNFalpha) transgene-expressing dendritic cells (DCs) undergo augmented cellular maturation and induce more robust T-cell activation and anti-tumour immunity than DCs generated in recombinant TNF-alpha. Immunology 108: 177–188 206. Renneson J, Salio M, Mazouz N, Goldman M, Marchant A, Cerundolo V (2005) Mature dendritic cells differentiated in the presence of interferon-beta and interleukin-3 prime functional antigen-specific CD8 T cells. Clin Exp Immunol 139:468–475 207. Suzuki T, Fukuhara T, Tanaka M, Nakamura A, Akiyama K, Sakakibara T, Koinuma D, Kikuchi T, Tazawa R,

S. Schroter et al.

208.

209.

210.

211.

212.

213.

214.

215.

216.

217.

218.

Maemondo M, Hagiwara K, Saijo Y, Nukiwa T (2005) Vaccination of dendritic cells loaded with interleukin12-secreting cancer cells augments in vivo antitumor immunity: characteristics of syngeneic and allogeneic antigen-presenting cell cancer hybrid cells. Clin Cancer Res 11:58–66 Okada N, Iiyama S, Okada Y, Mizuguchi H, Hayakawa T, Nakagawa S, Mayumi T, Fujita T, Yamamoto A (2005) Immunological properties and vaccine efficacy of murine dendritic cells simultaneously expressing melanomaassociated antigen and interleukin-12. Cancer Gene Ther 12:72–83 Onaitis MW, Kalady MF, Emani S, Abdel-Wahab Z, Tyler DS, Pruitt SK (2003) CD40 ligand is essential for generation of specific cytotoxic T cell responses in RNA-pulsed dendritic cell immunotherapy. Surgery 134:300–305 Vujanovic L, Ranieri E, Gambotto A, Olson WC, Kirkwood JM, Storkus WJ (2006) IL-12p70 and IL18 gene-modified dendritic cells loaded with tumor antigen-derived peptides or recombinant protein effectively stimulate specific Type-1 CD4+ T-cell responses from normal donors and melanoma patients in vitro. Cancer Gene Ther 13:798–805 Takamizawa M, Fagnoni F, Mehta-Damani A, Rivas A, Engleman EG (1995) Cellular and molecular basis of human gamma delta T cell activation. Role of accessory molecules in alloactivation. J Clin Invest 95:296–303 Mehta-Damani A, Markowicz S, Engleman EG (1994) Generation of antigen-specific CD8+ CTLs from naive precursors. J Immunol 153:996–1003 Hsu FJ, Benike C, Fagnoni F, Liles TM, Czerwinski D, Taidi B, Engleman EG, Levy R (1996) Vaccination of patients with B-cell lymphoma using autologous antigenpulsed dendritic cells. Nat Med 2:52–58 Kwak LW, Campbell MJ, Czerwinski DK, Hart S, Miller RA, Levy R (1992) Induction of immune responses in patients with B-cell lymphoma against the surfaceimmunoglobulin idiotype expressed by their tumors [see comments]. N Engl J Med 327:1209–1215 Reichardt V, Okada C, Benike C, Long G, Engleman E, Blume K, Levy R (1996) Idiotypic vaccination using dendritic cells for multiple myeloma patients after autologous peripheral blood stem cell transplantation. Blood 88:481 Kim CJ, Prevette T, Cormier J, Overwijk W, Roden M, Restifo NP, Rosenberg SA, Marincola FM (1997) Dendritic cells infected with poxviruses encoding MART1/Melan A sensitize T lymphocytes in vitro. J Immunother 20:276–286 Osada T, Clay T, Hobeika A, Lyerly HK, Morse MA (2006) NK cell activation by dendritic cell vaccine: a mechanism of action for clinical activity. Cancer Immunol Immunother 55:1122–1131 Mortarini R, Anichini A, Di Nicola M, Siena S, Bregni M, Belli F, Molla A, Gianni AM, Parmiani G (1997) Autologous dendritic cells derived from CD34+ progenitors and from monocytes are not functionally equivalent antigen-presenting cells in the induction of melan-A/Mart-1(27–35)-specific CTLs from peripheral blood lymphocytes of melanoma patients with low frequency of CTL precursors. Cancer Res 57: 5534–5541

14 Cancer Vaccines 219. Bakker AB, Marland G, de Boer AJ, Huijbens RJ, Danen EH, Adema GJ, Figdor CG (1995) Generation of antimelanoma cytotoxic T lymphocytes from healthy donors after presentation of melanoma-associated antigenderived epitopes by dendritic cells in vitro. Cancer Res 55:5330–5334 220. Storkus WJ, Mayordomo JI, Deleo A, Zitvogel L, Tjandrawan T, Lotze MT (1995) Dendritic cells pulsed with tumor epitopes elicit potent anti-tumor CTL in vitro and in vivo. In: The 9th international congress of immunology; Meeting sponsored by the American association of immunologists and the international union of immunological societies, San Francisco, CA, USA, July 23–29, 1995, p 589 221. Nestle FO, Alijagic S, Gilliet M, Sun Y, Grabbe S, Dummer R, Burg G, Schadendorf D (1998) Vaccination of melanoma patients with peptide- or tumor lysate-pulsed dendritic cells. Nat Med 4:328–332 222. Palucka AK, Dhodapkar MV, Paczesny S, Burkeholder S, Wittkowski KM, Steinman RM, Fay J, Banchereau J (2003) Single injection of CD34+ progenitor-derived dendritic cell vaccine can lead to induction of T-cell immunity in patients with stage IV melanoma. J Immunother 26:432–439 223. Palucka AK, Dhodapkar MV, Paczesny S, Ueno H, Fay J, Banchereau J (2005) Boosting vaccinations with peptide-pulsed CD34+ progenitor-derived dendritic cells can expand long-lived melanoma peptide-specific CD8+ T cells in patients with metastatic melanoma. J Immunother 28:158–168 224. Barbuto JA, Ensina LF, Neves AR, Bergami-Santos P, Leite KR, Marques R, Costa F, Martins SC, CamaraLopes LH, Buzaid AC (2004) Dendritic cell-tumor cell hybrid vaccination for metastatic cancer. Cancer Immunol Immunother 53:1111–1118 225. Barrou B, Benoit G, Ouldkaci M, Cussenot O, Salcedo M, Agrawal S, Massicard S, Bercovici N, Ericson ML, Thiounn N (2004) Vaccination of prostatectomized prostate cancer patients in biochemical relapse, with autologous dendritic cells pulsed with recombinant human PSA. Cancer Immunol Immunother 53:453–460 226. Su Z, Dannull J, Yang BK, Dahm P, Coleman D, Yancey D, Sichi S, Niedzwiecki D, Boczkowski D, Gilboa E, Vieweg J (2005) Telomerase mRNA-transfected dendritic cells stimulate antigen-specific CD8+ and CD4+ T cell responses in patients with metastatic prostate cancer. J Immunol 174:3798–3807 227. Chang GC, Lan HC, Juang SH, Wu YC, Lee HC, Hung YM, Yang HY, Whang-Peng J, Liu KJ (2005) A pilot clinical trial of vaccination with dendritic cells pulsed with autologous tumor cells derived from malignant pleural effusion in patients with late-stage lung carcinoma. Cancer 103:763–771 228. Hirschowitz EA, Foody T, Kryscio R, Dickson L, Sturgill J, Yannelli J (2004) Autologous dendritic cell vaccines for non-small-cell lung cancer. J Clin Oncol 22:2808–2815 229. Dees EC, McKinnon KP, Kuhns JJ, Chwastiak KA, Sparks S, Myers M, Collins EJ, Frelinger JA, Van Deventer H, Collichio F, Carey LA, Brecher ME, Graham M, Earp HS, Serody JS (2004) Dendritic cells can be rapidly expanded ex vivo and safely administered in patients with metastatic

283

230.

231.

232.

233.

234.

235.

236. 237.

238.

239.

240.

241.

242.

breast cancer. Cancer Immunol Immunother 53: 777–785 Vanchieri C (2004) Excitement tempered by long road ahead for dendritic cell vaccines. J Natl Cancer. Inst 96:1350–1351 Liu KJ, Wang CC, Chen LT, Cheng AL, Lin DT, Wu YC, Yu WL, Hung YM, Yang HY, Juang SH, WhangPeng J (2004) Generation of carcinoembryonic antigen (CEA)-specific T-cell responses in HLA-A∗ 0201 and HLA-A∗ 2402 late-stage colorectal cancer patients after vaccination with dendritic cells loaded with CEA peptides. Clin Cancer Res 10:2645–2651 Caruso DA, Orme LM, Amor GM, Neale AM, Radcliff FJ, Downie P, Tang ML, Ashley DM (2005) Results of a Phase I study utilizing monocyte-derived dendritic cells pulsed with tumor RNA in children with Stage 4 neuroblastoma. Cancer 103:1280–1291 Fecci PE, Mitchell DA, Archer GE, Morse MA, Lyerly HK, Bigner DD, Sampson JH (2003) The history, evolution, and clinical use of dendritic cell-based immunization strategies in the therapy of brain tumors. J Neurooncol 64:161–176 Zhang JG, Eguchi J, Kruse CA, Gomez GG, Fakhrai H, Schroter S, Ma W, Hoa N, Minev B, Delgado C, Wepsic HT, Okada H, Jadus MR (2007) Antigenic profiling of glioma cells to generate allogeneic vaccines or dendritic cell-based therapeutics. Clin Cancer Res 13:566–575 Prins RM, Odesa SK, Liau LM (2003) Immunotherapeutic targeting of shared melanoma-associated antigens in a murine glioma model. Cancer Res 63:8487–8491 Pellegatta S, Finocchiaro G (2005) Cell therapies in neuro-oncology. Neurol Sci 26(Suppl 1):S43–S45 Driessens G, Hamdane M, Cool V, Velu T, Bruyns C (2004) Highly successful therapeutic vaccinations combining dendritic cells and tumor cells secreting granulocyte macrophage colony-stimulating factor. Cancer Res 64:8435–8442 Kim CH, Hong MJ, Park SD, Kim CK, Park MY, Sohn HJ, Cho HI, Kim TG, Hong YK (2006) Enhancement of antitumor immunity specific to murine glioma by vaccination with tumor cell lysate-pulsed dendritic cells engineered to produce interleukin-12. Cancer Immunol Immunother 55:1309–1319 Kikuchi T, Akasaki Y, Abe T, Fukuda T, Saotome H, Ryan JL, Kufe DW, Ohno T (2004) Vaccination of glioma patients with fusions of dendritic and glioma cells and recombinant human interleukin 12. J Immunother 27: 452–459 Yu JS, Liu G, Ying H, Yong WH, Black KL, Wheeler CJ (2004) Vaccination with tumor lysate-pulsed dendritic cells elicits antigen-specific, cytotoxic T-cells in patients with malignant glioma. Cancer Res 64:4973–4979 Ribas A, Glaspy JA, Lee Y, Dissette VB, Seja E, Vu HT, Tchekmedyian NS, Oseguera D, Comin-Anduix B, Wargo JA, Amarnani SN, McBride WH, Economou JS, Butterfield LH (2004) Role of dendritic cell phenotype, determinant spreading, and negative costimulatory blockade in dendritic cell-based melanoma immunotherapy. J Immunother 27:354–367 Brostjan C, Bayer A, Zommer A, Gornikiewicz A, Roka S, Benko T, Yaghubian R, Jakesz R, Steger G, Gnant M,

284

243.

244.

245.

246.

247. 248.

249.

250. 251.

S. Schroter et al. Friedl J, Stift A (2003) Monitoring of circulating angiogenic factors in dendritic cell-based cancer immunotherapy. Cancer 98:2291–2301 Kao JY, Gong Y, Chen CM, Zheng QD, Chen JJ (2003) Tumor-derived TGF-beta reduces the efficacy of dendritic cell/tumor fusion vaccine. J Immunol 170:3806–3811 Neves AR, Ensina LF, Anselmo LB, Leite KR, Buzaid AC, Camara-Lopes LH, Barbuto JA (2005) Dendritic cells derived from metastatic cancer patients vaccinated with allogeneic dendritic cell-autologous tumor cell hybrids express more CD86 and induce higher levels of interferongamma in mixed lymphocyte reactions. Cancer Immunol Immunother 54:61–66 Banchereau J, Palucka AK (2005) Dendritic cells as therapeutic vaccines against cancer. Nat Rev Immunol 5:296–306 Richwine L (April 29, 2010) U.S. FDA OKs Dendreon’s prostate cancer vaccine. Reuters Retrieved September 14, 2010 Food and Drug Administration (April 29, 2010) Approval letter – Provenge. Kantoff PW, Higano CS, Shore ND, Berger ER, Small EJ, Penson DF, Redfern CH, Ferrari AC, Dreicer R, Sims RB, Xu Y, Frohlich MW, Schellhammer PF (2010) SipuleucelT immunotherapy for castration-resistant prostate cancer. N Engl J Med 363:411–422 Small EJ, Schellhammer PF, Higano CS (2006) Placebocontrolled phase III trial of immunologic therapy with Sipuleucel-T (APC8015) in patients with metastatic, asymptomatic hormone refractory prostate cancer. J Clin Oncol 24:3089–3094 Longo DL (2010) New therapies for castration-resistant prostate cancer. N Engl J Med 363:479–481 Higano CS, Schellhammer PF, Small EJ, Burch PA, Nemunaitis J, Yuh L, Provost N, Frohlich MW (2009) Integrated data from 2 randomized, double-blind,

252.

253.

254.

255.

256.

257.

258.

259.

placebo-controlled, phase 3 trials of active cellular immunotherapy with Sipuleucel-T in advanced prostate cancer. Cancer 115:3670–3679 Nordlund JJ, Kirkwood JM, Forget BM, Milton G, Albert DM, Lerner AB (1983) Vitiligo in patients with metastatic melanoma: a good prognostic sign. J Am Acad Dermatol 9:689–696 Nowak MA, May RM, Phillips RE, Rowland-Jones S, Lalloo DG, McAdam S, Klenerman P, Koppe B, Sigmund K, Bangham CR (1995) Antigenic oscillations and shifting immunodominance in HIV-1 infections [see comments]. Nature 375:606–611 Toes RE, Offringa R, Blom RJ, Melief CJ, Kast WM (1996) Peptide vaccination can lead to enhanced tumor growth through specific T-cell tolerance induction. Proc Natl Acad Sci USA 93:7855–7860 Webb S, Morris C, Sprent J (1990) Extrathymic tolerance of mature T cells: clonal elimination as a consequence of immunity. Cell 63:1249–1256 Aichele P, Brduscha-Riem K, Zinkernagel RM, Hengartner H, Pircher H (1995) T cell priming versus T cell tolerance induced by synthetic peptides. J Exp Med 182:261–266 Benichou G, Fedoseyeva E, Olson CA, Geysen HM, McMillan M, Sercarz EE (1994) Disruption of the determinant hierarchy on a self-MHC peptide: concomitant tolerance induction to the dominant determinant and priming to the cryptic self-determinant. Int Immunol 6:131–138 Sercarz EE, Lehmann PV, Ametani A, Benichou G, Miller A, Moudgil K (1993) Dominance and crypticity of T cell antigenic determinants. Annu Rev Immunol 11: 729–766 Hoon DS, Yuzuki D, Hayashida M, Morton DL (1995) Melanoma patients immunized with melanoma cell vaccine induce antibody responses to recombinant MAGE-1 antigen. J Immunol 154:730–737

Chapter 15

Adoptive Immunotherapy of Cancer Using Autologous Lymphocytes Yoshiyuki Yamaguchi, Riki Okita, Akiko Emi, Katsuji Hironaka, Makoto Okawaki, Takuhiro Ikeda, Masahiro Ohara, Ichiro Nagamine, and Jun Hihara

15.1 Introduction Immunotherapy of cancer can be divided into two categories, one is active immunotherapy and another one is passive immunotherapy. Adoptive immunotherapy (AIT) of cancer belongs to the latter, which includes (1) the administration of antibodies specific for targets including tumor antigens, molecules involved in antigen presentation and recognition, and growth factor-related molecules, and (2) the administration of immune effector lymphocytes reactive with tumor antigens and tumor tissues including neovasculature. In this review, we will summarize the history of the effector cell transfer therapy of cancer, and discuss its future direction.

15.2 History and Big Events for Developing AIT Big discoveries and events for developing AIT are shown in Table 15.1. AIT of cancer using autologous lymphocytes would not be realized without the gene cloning of a crucial T-cell growth factor, interleukin-2 (IL-2) [1]. IL-2 has permitted to manipulate and to propagate natural killer (NK) cells and T lymphocytes to be effector cells with highly cytotoxic activity

Y. Yamaguchi () Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima 734-8553, Japan e-mail: [email protected]

Table 15.1 Big discoveries for AIT of cancer 1982 Lymphokine-activated killer phenomenon 1983 Cloning of IL-2 1985 AIT of cancer using LAK cells 1986 Use of TILs 1991 Discovery of a gene coding a melanoma antigen MAGE 1994 Professional antigen presenting cells, DCs 1995 Regulatory T cells 1997 NKT cells 1999 γδT cells 2002 AIT on lymphodepleting chemotherapy

against wide spectrum tumor cell types. These effector cells have been identified lymphokine-activated killer (LAK) cells [2]. Clinical trials using LAK cells [3], however, have shown limited efficacy, which has been explained by the fact that tumor recognition of LAK cells is not specific for tumor cells. Considering tumor specificity of effector cells, tumor-infiltrating lymphocytes (TILs) were next highlighted to use for clinical application [4]. Clinical trials using TILs have shown positive responses, to some extents, compared with LAK therapy, and still been investigated, now. TIL therapy, however, has a limitation problem in manipulating lymphocytes, so that researchers have introduced the in vitro tumor-sensitization technique to generate tumor specificity in effector lymphocytes [5]. Identification of tumor antigen gene [6] and professional antigen presenting cells, dendritic cells [7], enabled a precise understanding of antigen presentation and recognition machinery [8], which has made researchers more active toward the vaccine strategy apart from the T cell transfer therapy. The understanding of antigen presentation and recognition machinery, however, also permits an efficient generation of effector lymphocytes ex vivo, so that a part of researchers

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_15, © Springer Science+Business Media B.V. 2011

285

286

have still been addressing the development of AIT of cancer using autologous lymphocytes activated with antigens and dendritic cells. In parallel, effector lymphocytes that do not have an HLA-restriction fashion have also been investigated [9, 10]. One of the most practical aspect of AIT of cancer using T cells is those ex vivo expansion enough for clinical use with ease compared with vaccine strategy using DCs where expansion of DCs are relatively difficult and laborious.

15.3 Rationale of AIT The AIT strategy is less dependently of cancerassociated immune dysfunction, which exists in tumorbearing host [11], compared with that of active immunotherapy like a tumor vaccine. There is no doubt that, as a host defense mechanism, the immune system surveys and fights to eradicate not only pathogens but also malignant tumor cells. Insufficiency of this host defense mechanism permits establishment of the initial tumor cells and its further progression to make a tumor tissue, which, in turn, makes the host immune system dysfunctional. The cancer-associated dysfunction of the immune defense mechanism consists of humoral and cellular suppressive factors and populations, which will be a higher hurdle to be overcome for active immunotherapy protocol, which tries to stimulate this dysfunctional immune system of tumor-bearing host for working on the right way. In an AIT strategy, however, effector cell manipulation is accomplished ex vivo where immunosuppressive mechanisms may affect the effector cell generation in a lesser extent compared with the active immunotherapy protocol. This is the theoretical advantage of AIT, which has been emphasized, I also believe, by Prof. Rosenberg [12]. Of course, effector cells transferred in vivo must reach tumor sites and recognize target cells for positive clinical responses.

15.4 Progress of the Generation of Effector Lymphocytes As mentioned in the history of AIT of cancer, many effector lymphocytes have established and used in a clinical setting of treatment. Lymphokine-activated

Y. Yamaguchi et al.

killer (LAK) cells and tumor-infiltrating lymphocytes (TILs) are the first generation and the representatives of effector cells in AIT.

15.4.1 First Generation 15.4.1.1 LAK Cells In 1983, Grim et al. [2] reported the LAK phenomenon that lymphocytes could be propagated with stimulation of IL-2 and could express cytotoxic activity against a wide spectrum of target tumor cells. Rosenberg et al. [3] first introduced AIT using LAK cells in the treatment of human cancer. The clinical results of LAK cell transfer, however, showed the limited efficacy against renal cell carcinoma, malignant melanoma and non-Hodgkin lymphoma. Response rate of LAK cell transfer for metastatic renal cell carcinomas has been reported approximately 16% for metastatic renal cell cancer, 12% for colorectal cancer, and 19% for melanoma [13]. Studies of AIT using LAK cells have also showed significant adverse effects, including vascular leak syndrome [13, 14]. Nevertheless, there are still several research activities demonstrating efficacies of LAK cell transfer in adjuvant setting for treatment of lung cancer [15] and hepatocellular carcinoma [16], which are depending on the fact that LAK cell manipulation is easy when an immobilized antiCD3 antibody/IL-2 (CD3/IL-2) culture system [17] is employed. 15.4.1.2 TILs Tumor-infiltrating lymphocyte (TIL) therapy [4] was next highlighted in a direction focusing on lymphocytes’ specificity for tumor cells and their homing capacity. It has been reported in a murine model that TILs are 50–100-fold more effective than LAK cells for tumor eradication because of their superior specificity for tumors [4]. Clinical study using TILs has shown a response rate of 40–60% for malignant melanoma [18]. However, the TIL therapy has several clinical problems. The number of patients with solid tumors from which we can obtain TILs is limited, as is the amount of TILs that can be obtained from them. The therapy therefore requires much effort, special equipment and a laborious technique for the expansion of TILs. These problems have limited the clinical

15 Adoptive Immunotherapy of Cancer Using Autologous Lymphocytes

application of TILs for treating cancer, although TIL therapy is still in use in Kono’s study for patients with gastric cancer [19], Freedman’s study of ovarian cancer [20], Ravaud’s study of melanoma [21] and Ratto’s study of lung cancer [22]. We have conducted the TIL therapy for patients with malignant effusion [23]. Malignant effusion contains a large amount of tumor cells and lymphocytes, from which we can easily obtain enough numbers of tumorassociated lymphocytes, highly identical with TILs, for AIT of cancer. In our AIT series using LAK cells and TILs, it has been observed that although response rates for organ metastases are not high, locoregional immunotherapy using effusion TILs is beneficial for managing the effusion (Table 15.2). A 48-year-old female patient of malignant mesothelioma with malignant effusion was treated with locoregional administration of effusion TILs (27 × 10ˆ9), the effusion well-controlled with marginal tumor shrinkage, and the patient survived for 4 year and 4 months with tumors but no effusion (Fig. 15.1).

15.4.2 Second Generation: In Vitro Tumor Sensitization Technique The limited applicability of TILs has stimulated researchers to educate lymphocytes ex vivo being specific for tumors, like TILs. I would say this type of effector cells as the second generation, which has been achieved by an in vitro tumor sensitization technique. Pre-treatment

Fig. 15.1 A malignant mesothelioma patient with malignant effusion. A 48-year-old malignant mesothelioma patient with malignant effusion was treated with locoregional administration of effusion lymphocytes activated in vitro with IL-2. The effusion was disappeared and she survived for 4 years and 4 months with tumors but no recurrence of effusion

287

Table 15.2 Efficacy of AIT using LAK cells and TILs Organ metastases Effusion CR+PR NC

PD

Effective No response

LAK 4(8) 22(45) 23(47) 2(67) 1(33) TIL 2(13) 8(50) 6(38) 71(77) 21(23) Total (65) 6(9) 30(46) 29(45) 73(77) 22(23) Patients consisted mainly of gastrointestinal malignancies. Patients with organ metastases, including lung, liver, lymph node, bone and skin metastases, were treated with intravenous administration of effector cells as indicated, and patients with malignant effusion were done with locoregional administration. Responses of organ metastases were evaluated with the Response Evaluation Criteria in Solid Tumors (RECIST), and responses of effusion were determined as effective when effusion was disappeared or decreased lasting for more than 1 month. Numbers in parenthesis indicate percentages

15.4.2.1 Whole Tumor Cells First, whole tumor cells themselves were simply employed in a sensitization culture system for lymphocytes, named as the mixed lymphocyte tumor culture (MLTC). Tumor cells were obtained by surgical resection, purified, then inactivated by radiation or chemotherapeutic drugs before MLTC. Aruga et al. [5] demonstrated the efficacy of AIT for metastatic liver tumors using effector cells generated by MLTC. In general, however, tumor cells themselves fail to stimulate precursor lymphocytes to be cytotoxic to tumor cells because tumor cells are not equipped with molecules required for antigen presentation and recognition and lymphocyte activation, including cytokines, HLA and CD80/86 molecules [24]. Stable generation of effector lymphocytes using tumor cells themselves Post-treatment

288

requires engineering techniques for tumor cells to be immunogenic. 15.4.2.2 Tumor Cell Engineering Advances of gene engineering technology have enabled to introduce genes into tumor cells. Valuable genes involved in antigen presentation and lymphocyte activation machinery have been investigated. Cytokine genes of IFN-gamma, TNF and GM-CSF are representatives. We investigated IL-2 gene introduction into tumor cells and demonstrated a mechanism that bypass the helper arm of the machinery [25]. Adhesion molecules involved in antigen presentation and recognition have also been studied. Soda et al. [24] have reported that the expression of HLA class I and costimulatory CD80 molecules is essentially required on tumor cells for successful CTL induction. Takenoyama et al. [26] have demonstrated that CTL against human lung cancer cells are difficult to induce by a conventional MLTC method using whole tumor cells, although CD80 gene-transduction into tumor cells makes them immunogenic. Schendel et al. [27] have also described the importance of the CD80 expression on allogeneic tumor cells to elucidate tumor antigen-specific CLT responses. AIT of cancer using the effector cells activated by gene-modified tumor cells, however, has not been actively reported, probably because the problem is the difficulty to obtain or to establish autologous tumor cells or cell lines. We [28] and others [29] have demonstrated in the study for adenocarcinomas and melanomas, respectively, that there exist antigens that are shared among tumor cells. The shared antigens have been described to be presented in the context of HLA class I [30] and class II molecules [31]. Thus, research of the AIT of cancer using the effector cells activated by gene-modified tumor cells may be more active when the use of allogeneic tumor cell lines is available for MLTC.

Y. Yamaguchi et al.

DCs lack is tumor antigens. The use of DCs means the modification of DCs with varied forms of tumor antigens, including epitope peptides, tumor cell lysate, tumor cell fusion, and tumor-derived RNA.

15.4.3.1 Peptide/DC System Identification of tumor antigens [6] has been followed by searches of antigenic epitope peptides recognized by CTL using a method of the reverse immunology, and many immunogenic peptides have been proven [32]. Tissue-specific differentiation antigens, cancer-testis antigens, and mutated antigens, including MAGE, MART, gp-100, SART, NY-ESO-1, survivin, CEA, and VEGF-R etc, have been studied. The epitope peptide-pulsed DCs can stimulate CTL precursors, and HLA-restricted antigen-specific effector cells can be efficiently generated [33]. The merit of peptide/DC system is that we can use only the peptides that are proven to be active for CTL generation and negative for unfavorable responses, and the demerit of peptides, on the other hand, is limitation of targets of only one or few molecules, which is not suitable for the heterogeneity of tumor antigens of clinical tumors. Also, HLA status must be measured before treatment in the peptide/DC system. Our phase I clinical study revealed the feasibility of yielding effector lymphocytes and the safety of transferring the cells [34]. Although it is too early to mention the efficacy of AIT using effector cells activated with peptide-pulsed DCs, quality control of the effector cells generated may be highly important for positive clinical responses. Here, an attention should be paid at CTL precursor status of the host, which may be varied among the individuals and among the antigenic protein [35]. We may have to choose the right peptide sequence active for generating CTLs for individual patients. Thus, researchers have to consider host HLA status, antigens expressed in the tumors, and peptides to be used in the peptide/DC system for efficient effector cell generation.

15.4.3 Third Generation: Use of DCs In 1994, dendritic cells (DCs) have been highlighted as a professional antigen presenting cells [7], because DCs have many molecules essentially required for antigen presentation [8]. This has promoted to use DCs for effector cell generation system. The only thing that

15.4.3.2 Tumor Lysate and Tumor Fusion on DC System Considering the heterogeneity of tumor antigens, the uses of tumor lysate and tumor cell fusion systems are also interesting issues to be investigated in

15 Adoptive Immunotherapy of Cancer Using Autologous Lymphocytes

DC-based effector cell generation system. Here, HLA measurement can be omitted in an autologous culture system. Actually, efficient CTL induction has been demonstrated [36, 37]. These strategy, however, are not practical because it is not easy and not usual to obtain a large amount of tumor cells, nor to establish tumor cell lines in vitro for cancer patients. This clinical problem makes the treatment difficult to repeat in clinical setting and limits the uses of tumor lysate and tumor fusion systems for the DC-based effector cell generation.

15.4.3.3 Tumor RNA/DC System It has been reported that tumor-derived RNA allowed DCs to stimulate anti-tumor CTL precursors [38]. In addition, it has been published that RNA can be easily amplified in vitro using T7 promoter system [39]. These investigations have facilitated the use of tumor RNA in the DC-based ex vivo effector cell generation for AIT of cancer. The use of tumor-derived RNA and cultured DCs has several advantages: (1) it requires autologous tumor cells but does only small amount and does not require the establishment of tumor lines; (2) it does not require patients’ HLA measurement; (3) tumor RNA can be amplified and stocked, and therefore the AIT can be repeated; (4) it can meet with heterogenous antigenicity due to immunodominant epitopes processed in DCs. We have demonstrated the superiority of the tumor RNA/DCs culture system compared with the peptide/DC system in effector cells generation [40, 41]. MAGE-3(76) petide-pulased DCactivated killer (MAGE-3(76)-PDAK) cells recognize only MAGE-3(76) peptide-pulsed DCs but not MAGE3(113) peptide-pulsed DCs and MAGE-3(113) PDAK cells recognize only MAGE-3(113) peptide-pulsed DC but not MAGE-3(76) peptide-pulsed DCs, on the other hand, melanoma tumor RNA-introduced DC-activated killer (melanoma-TRiDAK) cells do recognize both target DCs (Table 15.3). Clinical trials of the AIT using the TRiDAK cells may be promising. However, since tumor RNA encodes not only tumor antigen but also normal self antigen protein, the effector cells that are reactive with normal cells as well as tumor cells can be induced. This hazard was wiped up by our investigation [40, 41] and other’s [38]. However, we have to eliminate a possibility that tumor RNA/DC system may induce antigen-specific regulatory T cells [42].

289

Table 15.3 Tumor RNA/DC system is superior to peptide/DC system Specific lysis (%) MAGE-3(76)/DC MAGE-3(113)/DC MNCs 11 15 LAK cells 23 22 MAGE-3(76)-PDAK 28 6 cells MAGE-3(113)-PDAK 4 31 cells Melanoma-TRiDAK 52 53 cells Effector cells were generated either with MAGE-3(76) or MAGE-3(113)-peptide/DC system or malanoma-RNA/DC system, and cytotoxic activity was determined against MAGE3(76)/DCs and MAGE-3(113)/DCs at an effector-to-target ratio of 50 by 51Cr releasing assay. MNCs, mononuclear cells; LAK, lymphokine-activated killer; PDAK peptide-pulsed DCactivated killer; TRiDAK, tumor RNA-introduced DC-activated killer

15.4.4 Novel Effector Cells that are not Restricted by HLA Expression Effector cells mentioned above require HLA molecules on target cells when they attack to them. Loss of the HLA molecules on clinical tumors has often been reported to be involved in the escape mechanisms of clinical tumors from immune system [43]. This evidence augments the importance of looking for novel effector cells that are not restricted by HLA expression on the target tumor cells. AIT of cancer using HLA-unrestricted effector cells may be effective in combination with CTLs that require the HLA restriction. NKT cells and γδT cells have been investigated for this issue. 15.4.4.1 NKT Cells Taniguchi et al. [9, 44] have reported natural killer T cells (NKT cells), which comprise a unique and relatively rare subset of lymphocytes that have features of both T cells and NK cells. NKT cells express a highly restricted T cell receptor (TCR) repertoire consisting of V24-J18 in humans and are called invariant TCR+ NKT cells [45]. Through this invariant TCR, NKT cells recognize bacterial and endogenous glycolipid antigens presented by the nonpolymorphic HLA class I-like protein, CD1d, and rapidly produce large quantities of cytokines, including IL-4 and IFN-gamma,

290

Y. Yamaguchi et al.

which enhance the function of dendritic cells, NK cells, and B cells, as well as conventional CD4+ and CD8+ T cells. Harada et al. [46] have described the effective method to generate NKT cells in vitro. Valpha24+ NKT cells can be efficiently expanded from G-CSF-mobilized peripheral blood MNCs in non-FBS culture conditions with alpha-GalCer and IL-2. Therefore, AIT of cancer using NKT cells are warranted to be investigated for clinical use [47]. 15.4.4.2 γ δ T Cells γδT cells have been investigated as one of interesting effector cells, and this cell type is again highlighted because of understanding the property of bisphosphonate. Bisphosphonates, widely used to treat bone diseases, have direct antitumor effects via the inactivation of Ras proteins. In addition to the direct antitumor activities, bisphosphonates can expand γδT cells in the presence of DCs [10, 48]. Bisphosphonates accumulate intermediate metabolites which may be tumor antigens in target cells. It has also been demonstrated that pre-treatment of tumor cells with bisphosphonates augment the cytotoxic activity of γδT cells [49]. In Fig. 15.2, aggressive growth of γδT cells stimulated in vitro with bisphosphonate and IL-2 is shown. AIT of cancer usingγδT cells in combination with bisphosphonate may be highly promising for clinical use.

15.5 Problems of AIT Although knowledge accumulated on tumor immunology has permitted us to generate excellent effector

cells in vitro as mentioned above, clinical responses obtained have still been unsatisfactory. There still exist problems to be resolved in order to augment clinical efficacy of AIT of cancer.

15.5.1 How to Expand Cells and Their Persistence In Vivo As mentioned above, the understanding of the mechanism of effector cell generation have certainly enabled us to induce tumor-specific lymphocytes in ex vivo culture system. The problem to be resolved is, however, the development of how to expand the induced effector cells. An immobilized anti-CD3 antibody system in combination with IL-2 (CD3/IL-2 system) is widely used and permits T cell growth more than 1,000 fold expansion with minimal reduction of the cytotoxic activity [33]. The culture system using anti-CD28 antibody, and lymphocyte-activating cytokines IL-7, IL-15, and IL-12 is also promising [50]. However, these culture systems may simultaneously propagate lymphocytes irrelevant to tumor antigens. Although lesser labor of expanding large amount of cells for AIT of cancer seems to be a merit of this strategy compared with difficulty of those in the vaccine strategy using DCs, the unexpected expansion of lymphocytes irrelevant to antigens by the culture system can be a demerit. In addition, the most important point is that expanded T cells must persist and work in vivo [51]. Researchers involved in this field should ask themselves and try to answer to this question by conducting scientific research programs to explore the question.

c) flowcytometry b) Day 7

CD3

a) Pre-stimulation

TCRγ δ

Fig. 15.2 γ δ T cell growth by bisphosphonate plus IL-2 and phenotype analysis. Peripheral blood lymphocytes were stimulated with bisphosphonate in the presence of IL-2 for 48 hours

and further cultured with IL-2 for 14 days. Microscopic views and surface analysis are presented

15 Adoptive Immunotherapy of Cancer Using Autologous Lymphocytes

15.5.2 Conditioning of the Host Immune Environment

291

CD25+cells (%)

Another problems to be considered for developing the effective AIT of cancer may be an issue of conditioning the host immune environment. Recently, Pre-treatment Sakaguchi et al. [42] have indicated the involvement of the CD4+CD25+ regulatory T (T-reg) cells in negative regulation of immune responses against tumor cells in tumor-baring host. They have shown in animal models the augmenting antitumor effect of the administration of anti-CD25 antibody [52]. Dudley et al. [53] have demonstrated in the clinical trials that obvious tumor response was obtained in patients with metastatic melanoma in combination Post-treatment with lymphodepleting chemotherapy using fludarabine and cyclophosphamide, indicating the considerable importance of conditioning the host immune status. Alternatively, blockade of cytotoxic T lymphocyteassociated antigen (CTLA)-4 has also been investigated to modulate T-reg cell activity, and objec- Fig. 15.3 In vivo depletion of regulatory T cells using antitive tumor responses have been demonstrated [54]. CD25 antibody. Anti-CD25 antibody was intravenously adminProblem of anti-CTLA-4 strategy, however, is an istered and CD4+CD25++ regulatory T cells were monitored by flowcytometry. CD4+CD25+ cells decreased from 24 to 5% and occurrence of autoimmune diseases, which is depen- CD4+CD25++ cells did from 2 to 0% by the treatment dently of increased T cell activation rather than inhibition or depletion of T-reg cells [55]. We are investigating to down-modulate T-reg cells by using an require Fc-receptors to exert antibody-dependent celanti-CD25 antibody, and observed a selective disap- lular cytotoxicity (ADCC) [56]. In this point of view, pearance of CD4+CD25++ cells in the circulation and LAK cells, NKT cells or γδT cells may be suitable in the tumor site of malignant effusion (Fig. 15.3). for the combination. Another direction is the comLymphocytes that were obtained from patients who bined use of HLA-restricted T cells, like CTLs, in had treated in vivo with anti-CD25 antibody adminis- tandem with HLA-non-restricted T cells, like NKT tration could be expanded well, unless otherwise they cells and γδT cells. This strategy may avoid the escape grew even in the CD3/IL-2 culture system. Clinical of tumor cells from effector cell attacks. Finally, the study of the AIT combined with the host condition- most attractive issue for the AIT of cancer may be ing using anti-CD25 antibody is going on now to the cloning of T cell receptor responsible for antiensure the clinical benefits, in the scientific program gen recognition. This possibility will allow us to use for clinical phase studies. TCR molecules similar with antibodies and to make LAK cells specific for antigens [57]. AIT of cancer requires ex vivo cell manipulation, process of which can be influenced in individual by individual and lab 15.6 Future Perspective by lab. This is the highest hurdle to be overcome for AIT of cancer when AIT wants to be accepted in cliniThe success of antibody engineering has permitted the cal treatment marketing application. The cloning T-cell use of several humanized antibodies for clinical use of receptor responsible for antigen recognition may mincancer treatment. One of the promising future direc- imize the cell manipulation-dependent differences of tion of AIT of cancer is the use of cell transfer therapy effector cells generated, making the AIT nearer to drug in combination with antibodies. Here, effector cells marketing applications.

292

15.7 Clinical Trials and Translational Research It must be of importance to conduct scientific clinical trials for establishing effective AIT applications, where processes of phase I, II, and III trials are a golden standard program under the lessons from the development of toxic anti-cancer drug application. We still do not know even what number of cells nor how to transfer the cells is optimal for AIT of cancer. In this process, comparative phase II randomized controlled trials, in which time to progression (TTP), progression free survival (PFS), and relief of cancer-related symptoms, are especially recommended to be designed as end points of AIT of cancer [58]. Recently, a randomized discontinuation study design has been demonstrated to be beneficial for trials such as immunotherapy [59]. Attempting scientific programs that are translational to ensure experimental results and, in turn, to resolve clinical problems, step-by-step, will be only the nearest way to a goal for establishing the effective and practical AIT of cancer.

Y. Yamaguchi et al.

3.

4.

5.

6.

7.

8.

9.

10.

15.8 Conclusion

11.

AIT using T cells is highly promising modality for eradicating cancer because we have a methodology to activate and expand lymphocytes ex vivo with IL-2 plus adequate stimulations without otherwise immunosuppressive factors or cells in vivo. This is a point we have been interested in. Therefore, it is the most important to define and establish a suitable culture system that can permit adequate expansion of effector lymphocytes with sufficient activities that can persist in vivo. I believe, the time is coming soon when T cell transfer therapy can provide clinical benefits for patients with advanced cancer in the world.

12.

References

16.

1. Taniguchi T, Matsui H, Fujita T et al (1983) Structure and expression of a cloned cDNA for human interleukin-2. Nature 302:305–310 2. Grimm EA, Mazumder A, Zhang HZ et al (1982) Lymphokine-activated killer cell phenomenon. Lysis of natural killer-resistant fresh solid tumor cells by interleukin

13.

14.

15.

17.

2-activated autologous human peripheral blood lymphocytes. J Exp Med 155:1823–1841 Rosenberg SA, Lotze MT, Muul LM et al (1985) Observation on the systemic administration of autologous lymphokine-activated killer cells and recombinant interleukin-2 to patients with metastatic cancer. N Engl J Med 313:1485–1492 Rosenberg SA, Spiess P, Lafreniere R (1986) A new approach to the adoptive immunotherapy of cancer with tumor-infiltrating lymphocytes. Science 233:1318–1321 Aruga A, Yamauchi K, Takasaki K et al (1991) Induction of autologous tumor-specific cytotoxic T cells in patients with liver cancer. Int J Cancer 49:19–24 Van der Bruggen P, Traversari C, Chomez P, Lurquin C, De Plaen E, Van den Eynde B, Knuth A, Boon T (1991) A gene encoding an antigen recognized by cytolytic T lymphocytes on a human melanoma. Science 254:1643–1647 Romani N, Gruner S, Brang D, Kampgen E, Lenz A, Trockenbacher B, Konwalinka G, Fritsch PO, Steinman RM, Schuler G (1994) Proliferating dendritic cell progenitors in human blood. J Exp Med 180:83–93 Mescher MF (1995) Molecular interactions in the activation of effector and precursor cytotoxic T lymphocytes. Immunol Rev 146:177–210 Kawano T, Cui J, Koezuka Y, Toura I, Kaneko Y, Motoki K, Ueno H, Nakagawa R, Sato H, Kondo E, Koseki H, Taniguchi M (1997) CD1d-restricted and TCR-mediated activation of valpha14 NKT cells by glycosylceramides. Science 278(5343):1626–1629 Kunzmann V, Bauer E, Wilhelm M (1999) Gamma/delta T-cell stimulation by pamidronate. N Engl J Med 340(9): 737–738 Kiessling R, Wasserman K, Horiguchi S, Kono K, Sjoberg J, Pisa P, Petersson M (1999) Tumor-induced immune dysfunction. Cancer Immunol Immunother 48:353–362 Rosenberg SA (2004) Shedding light on immunotherapy for cancer. N Engl J Med 350(14):1461–1463 Margolin KA, Rayner AA, Hawkins MJ, Atkins MB, Dutcher JP, Fisher RI, Weiss GR, Doroshow JH, Jaffe HS, Roper M (1989) Interleukin-2 and lymphokine-activated killer cell therapy of solid tumors: analysis of toxicity and management guidelines. J Clin Oncol 7(4):486–498 Parkinson DR, Fisher RI, Rayner AA et al (1990) Therapy of renal cell carcinoma with interleukin-2 and lymphokineactivated killer cells: phase II experience with a hybrid bolus and continuous infusion interleukin-2 regimen. J Clin Oncol 8:1630–1636 Kimura H, Yamaguchi Y (1997) A phase III randomized study of interleukin-2 lymphokine-activated killer cell immunotherapy combined with chemotherapy or radiotherapy after curative or noncurative resection of primary lung carcinoma. Cancer 80:42–49 Takayama T, Sekine T, Makuuchi M, Yamasaki S, Kosuge T, Yamamoto J, Shimada K, Sakamoto M, Hirohashi S, Ohashi Y, Kakizoe T (2000) Adoptive immunotherapy to lower postsurgical recurrence rates of hepatocellular carcinoma: a randomised trial. Lancet 356:802–807 Sekine T, Shiraiwa H, Yamazaki T, Tobisu K, Kakizoe T (1993) A feasible method for expansion of peripheral blood lymphocytes by culture with immobilized anti-CD3 monoclonal antibody and interleukin-2 for use in adoptive

15 Adoptive Immunotherapy of Cancer Using Autologous Lymphocytes

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

immunotherapy of cancer patients. Biomed Pharmacother 47:73–78 Rosenberg SA, Packard BS, Aebersold PM et al (1988) Use of tumor infiltrating lymphocytes and interleukin-2 in the immunotherapy of patients with metastatic melanoma. A preliminary report. N Engl J Med 319:1676–1680 Kono K, Takahashi A, Ichihara F et al (2002) Prognostic significance of adoptive immunotherapy with tumorassociated lymphocytes in patients with advanced gastric cancer: a randomized trial. Clin Cancer Res 8:1767–1771 Freedman RS, Edwards CL, Kavanagh JJ et al (1994) Intraperitoneal adoptive immunotherapy of ovarian carcinoma with tumor-infiltrating lymphocytes and low-dose recombinant interleukin-2: a pilot trial. J Immunother 16:198–210 Ravaud A, Legrand E, Delaunay MM et al (1995) A phase I trial of repeated tumor-infiltrating lymphocyte (TIL) infusion in metastatic melanoma. Br J Cancer 71:331–336 Ratto GB, Zino P, Mirabelli S et al (1996) A randomized trial of adoptive immunotherapy with tumor infiltrating lymphocytes and interleukin-2 versus standard therapy in the postoperative treatment of resected nonsmall cell lung carcinoma. Cancer 78:244–251 Yamaguchi Y, Ohshita A, Kawabuchi Y, Ohta K, Shimizu K, Minami K, Hihara J, Miyahara E, Toge T (2003) Adoptive immunotherapy of cancer using activated autologous lymphocytes – current status and new strategies. Hum Cell 16(4):183–189 Soda H, Koda K, Yasutomi J, Oda K, Takiguchi N, Saito N, Nakajima N (1999) Adoptive immunotherapy for advanced cancer patients using in vitro activated cytotoxic T lymphocytes. J Surg Oncol 72:211–217 Yamaguchi Y, Ohta K, Shimizu K et al (2001) Generation of cytotoxic effector lymphocytes by MLTC using tumor cells genetically modified to secrete interleukin-2. Anticancer Res 21:669–677 Takenoyama M, Yoshino I, Eifuku R, So T, Imahayashi S, Sugaya M, Yasuda M, Inoue M, Ichiyoshi Y, Osaki T, Nagashima A, Nomoto K, Yasumoto K (2001) Successful induction of tumor-specific cytotoxic T lymphocytes from patients with non-small cell lung cancer using CD80transfected autologous tumor cells. Jpn J Cancer Res 92:309–315 Schendel DJ, Frankenberger B, Jantzer P, Cayeux S, Nobetaner E, Willimsky G, Maget B, Pohla H and Blankenstein T (2000) Expression of B7.1 (CD80) in a renal cell carcinoma line allows expansion of tumorassociated cytotoxic T lymphocytes in the presence of an alloresponse. Gene Ther 7:2007–2014 Yamaguchi Y, Ohshita A, Hironaka K, Okita R, Okawaki M, Matsuura K, Nagamine I, Ikeda T, Ohara M, Hihara J (2006) Adoptive immunotherapy using autologous lymphocytes sensitized with HLA class I-matched allogeneic tumor cells. Oncol Rep 16:165–169 Huang LQ, Brasseur F, Serrano A, De Plaen E, Van der Bruggen P, Boon T, Van Pel A (1999) Cytolytic T lymphocytes recognize an antigen encoded by MAGE-A10 on a human melanoma. J Immunol 162:6849–6854 Kawakami Y, Dang N, Wang X, Tupesis J, Robbins PF, Wang RF, Wunderlich JR, Yannelli JR, Rosenberg SA (2000) Recognition of shared melanoma antigens in

31.

32. 33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

293

association with major HLA-A alleles by tumor infiltrating T lymphocytes from 123 patients with melanoma. J Immunother 23:17–27 Chiari R, Hames G, Stroobant V, Texier C, Maillere B, Boon T, Coulie PG (2000) Identification of a tumor-specific shared antigen derived from an Eph receptor and presented to CD4 T cells on HLA class II molecules. Cancer Res 60:4855–4863 Van den Eynde BJ, Boon T (1997) Tumor antigens recognized by T lymphocytes. Int J Clin Lab Res 27:81–86 Ohta K, Yamaguchi Y, Shimizu K et al (2002) Novel system for generating cytotoxic effector lymphocytes using carcinoembryonic antigen (CEA) peptide and cultured dendritic cells. Anticancer Res 22:2597–2606 Yamaguchi Y, Ohta K, Kawabuchi Y, Ohshita A, Okita R, Okawaki M, Hironaka K, Matsuura K, Toge T (2005) Feasibility study of adoptive immunotherapy for metastatic lung tumors using peptide-pulsed dendritic cell-activated killer (PDAK) cells. Anticancer Res 25:2407–2415 Kawabuchi Y, Yamaguchi Y, Ohshita A, Minami K, Toge T (2004) Host-oriented peptide evaluation using whole blood assay for generating antigen-specific cytotoxic T lymphocytes. Anticancer Res 24:1193–1200 Suresh K, Fraser G, Scheid E, Leber B, Gauldie J, Foley R (2006) Generation of in vitro B-CLL specific HLA class I restricted CTL responses using autologous dendritic cells pulsed with necrotic tumor lysate. Leuk Lymphoma 47:297–306 Guo G, Chen S, Zhang J, Luo L, Yu J, Dong H, Xu H, Su Z, Wu L (2005) Antitumor activity of a fusion of esophageal carcinoma cells with dendritic cells derived from cord blood. Vaccine 23:5225–5230 Nair SK, Morse M, Boczkowski D et al (2002) Induction of tumor-specific cytotoxic T lymphocytes in cancer patients by autologous tumor RNA-transfected dendritic cells. Ann Surg 235:540–549 Heil SG, Kluijtmans LA, Spiegelstein O et al (2003) Gene-specific monitoring of T7-based RNA amplification by real-time quantitative PCR. Biotechniques 35:502–504, 506–508 Minami K, Yamaguchi Y, Ohshita A, Kawabuchi Y, Ohta K, Hihara J, Toge T (2005) Generation of antigen presenting cells using cultured dendritic cells and amplified autologous tumor-mRNA. Oncology 69(5):399–407 Ohshita A, Yamaguchi Y, Minami K, Hihara J, Toge T (2006) Generation of Tumor-reactive effector lymphocytes using tumor RNA-introduced dendritic cells in gastric cancer patients. Int’l J Onol 28:1163–1171 Sakaguchi S, Sakaguchi N, Asano M et al (1995) Immunologic self-tolerance maintained by activated T cells expressing IL-2 receptor alpha-chains (CD25). Breakdown of single mechanism of self-tolerance causes various autoimmune disease. J Immunol 155:1151–1164 So T, Takenoyama M, Mizukami M, Ichiki Y, Sugaya M, Hanagiri T, Sugio K, Yasumoto K (2005) Haplotype loss of HLA class I antigen as an escape mechanism from immune attack in lung cancer. Cancer Res 65(13):5945–5952 Cui JQ, Shin T, Kawano T, Sato H, Kondo E, Toura I, Kaneko Y, Koseki H, Kanno M, Taniguchi M (1997) Requirement for Valpha14 NKT cells in IL-12-mediated rejection of tumors Science 278, 1623–1626

294 45. Kawano T, Tanaka Y, Shimizu E, Kaneko Y, Kamata N, Sato H, Osada H, Sekiya S, Nakayama T, Taniguchi M (1999) A novel recognition motif of human NKT antigen receptor for a glycolipid ligand. Int Immunol 11(6): 881–887 46. Harada Y, Imataki O, Heike Y, Kawai H, Shimosaka A, Mori S, Kami M, Tanosaki R, Ikarashi Y, Iizuka A, Yoshida M, Wakasugi H, Saito S, Takaue Y, Takei M, Kakizoe T (2005) Expansion of alpha-galactosylceramide-stimulated Valpha24+ NKT cells cultured in the absence of animal materials. J Immunother 28(4):314–321 47. Ishikawa A, Motohashi S, Ishikawa E, Fuchida H, Higashino K, Otsuji M, Iizasa T, Nakayama T, Taniguchi M, Fujisawa T (2005) A phase I study of alphagalactosylceramide (KRN7000)-pulsed dendritic cells in patients with advanced and recurrent non-small cell lung cancer. Clin Cancer Res 11(5):1910–1917 48. Miyagawa F, Tanaka Y, Yamashita S, Minato N (2001) Essential requirement of antigen presentation by monocyte lineage cells for the activation of primary human gamma delta T cells by aminobisphosphonate antigen. J Immunol 166(9):5508–5514 49. Sato K, Kimura S, Segawa H, Yokota A, Matsumoto S, Kuroda J, Nogawa M, Yuasa T, Kiyono Y, Wada H, Maekawa T (2005) Cytotoxic effects of gammadelta T cells expanded ex vivo by a third generation bisphosphonate for cancer immunotherapy. Int J Cancer 116(1):94–99 50. Vonderheide RH, June CH (2003) A translational bridge to cancer immunotherapy:exploiting costimulation and target antigens for active and passive T cell immunotherapy. Immunol Res 27:341–356 51. Knutson KL, Wagner W, Disis ML (2006) Adoptive T cell therapy of solid cancers. Cancer Immunol Immunother 55:96–103 52. Onizuka S, Tawara I, Shimizu J et al (1999) Tumor rejection by in vivo administration of anti-CD25 (interleukin2 receptor alpha) monoclonal antibody. Cancer Res 59: 3128–3133

Y. Yamaguchi et al. 53. Dudley ME, Wunderlich JR, Yang JC, Sherry RM, Topalian SL, Restifo NP, Royal RE, Kammula U, White DE, Mavroukakis SA, Rogers LJ, Gracia GJ, Jones SA, Mangiameli DP, Pelletier MM, Gea-Banacloche J, Robinson MR, Berman DM, Filie AC, Abati A, Rosenberg SA (2005) Adoptive cell transfer therapy following nonmyeloablative but lymphodepleting chemotherapy for the treatment of patients with refractory metastatic melanoma. J Clin Oncol 23:2346–2357 54. Maker AV, Phan GQ, Attia P, Yang JC, Sherry RM, Topalian SL, Kammula US, Royal RE, Haworth LR, Levy C, Kleiner D, Mavroukakis SA, Yellin M, Rosenberg SA (2005) Tumor regression and autoimmunity in patients treated with cytotoxic T lymphocyte-associated antigen 4 blockade and interleukin 2: a phase I/II study. Ann Surg Oncol 12(12):1005–1016. Epub 2005 Oct 21 55. Maker AV, Attia P, Rosenberg SA (2005) Analysis of the cellular mechanism of antitumor responses and autoimmunity in patients treated with CTLA-4 blockade. J Immunol 175(11):7746–7754 56. Yamaguchi Y, Hironaka K, Okawaki M, Okita R, Matsuura K, Ohshita A, Toge T (2005) HER2-Specific cytotoxic activity of lymphokine-activated killer cells in the presence of trastuzumab. Anticancer Res 25(2A):827–832 57. Xue S, Gillmore R, Downs A, Tsallios A, Holler A, Gao L, Wong V, Morris E, Stauss HJ (2005) Exploiting T cell receptor genes for cancer immunotherapy. Clin Exp Immunol 139:167–172 58. Johnson JR, Williams G, Pazdur R (2003) End points and United States food and drug administration approval of oncology drugs. J Clin Oncol 21:1404–1411 59. Stadler WM, Rosner G, Small E, Hollis D, Rini B, Zaentz SD, Mahoney J, Ratain MJ (2005) Successful implementation of the randomized discontinuation trial design: an application to the study of the putative antiangiogenic agent carboxyaminoimidazole in renal cell carcinoma – CALGB 69901. J Clin Oncol 23:3726–3732

Chapter 16

Oncolytic Virotherapy of Cancer Nanhai G. Chen and Aladar A. Szalay

16.1 Introduction Oncolytic virotherapy of cancer is a treatment modality for cancer using viruses that inherently or have been genetically engineered to selectively infect, replicate within, and ultimately destroy cancer cells while sparing normal cells. The idea of using viruses to eradicate tumors was spurred by the observations that were made more than a century ago. In 1893, the Hungarian physician F. Kovàcs reported remissions in patients with leukaemia after contracting natural infections that were probably caused by viruses [1]. In 1904, G. Dock observed that a 42-year old housewife with “myelogenous leukaemia” went into remission for more than 6 months after a presumed “influenza” infection [2]. A few years later, in 1912, N. G. De Pace reported that a woman experienced regression of her large uterine cervical carcinoma after she was vaccinated with the live attenuated rabies vaccine because she was bitten by a rabid dog. Her remission lasted for 8 years [3]. On account of these early intriguing observations, a great number of viruses were tested for their oncolytic activities against a large number of tumors in laboratory animals such as mice, rat, and rabbits in the 1920s and thereafter [4, 5]. Vaccinia virus (VACV) was the first virus tested in transplantable animal tumor

A.A. Szalay () Genelux Corporation, San Diego Science Center, San Diego, CA 92109, USA; Rudolf Virchow Center for Experimental Biomedicine, Institute for Biochemistry and Institute for Molecular Infection Biology, University of Würzburg, Würzburg, Germany; Department of Radiation Oncology, Rebecca and John Moores Comprehensive Cancer Center, University of California, San Diego, CA, USA e-mail: [email protected]

models. Its oncolytic activity against various types of mouse and rat tumors was demonstrated [4]. In 1951, A. E. Moore showed that Russian Far East encephalitis virus was able to completely destroy five histologically different types of mouse tumors [6]. These exciting results prompted more intensive studies into oncolytic viruses both in laboratories and in the clinic in the 1950s and 1960s [7, 8]. While laboratory studies indicated that naturally oncolytic viruses were able to replicate in and destroy tumor cells in vitro and cause tumors to shrink in vivo [9, 10], the clinical efficacy of oncolytic viruses, however, was not very impressive although the localization of virus in tumors in some patients was demonstrated and transient responses were seen sometimes [11–14]. Due to the lack of clinical efficacy, serious toxicity seen in some patients, and the enthusiasm for chemotherapy, the interest in oncolytic virotherapy was dramatically decreased in the 1970s and 1980s. With the advent of genetic engineering, molecular virology, and molecular cancer biology and immunology, it became possible that oncolytic viruses can be genetically modified so as to enhance their tumor selectivity and antitumoral potency while their toxicity is minimized. Thus, the interest in viruses as a treatment for cancer was resurged in the 1990s. The first genetically engineered oncolytic virus, the thymidine kinase (tk)-negative mutant of herpes simplex virus-1 (HSV-1) dlsptk was reported to successfully inhibit the growth of human glioma xenografts in mice and prolong survival in 1991 [15]. Five years later, an adenovirus mutant that lacks E1B-55kD gene, dl1520 (ONYX-015), was shown to be more tumor-specific than a wild-type adenovirus [16]. ONYX-015 was the first genetically engineered oncolytic virus that went on to the phase I clinical trial at the University of

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_16, © Springer Science+Business Media B.V. 2011

295

296

Texas, San Antonio in 1996 [17]. Its cousin, the adenovirus mutant H101 (similar to ONYX-015 except for a slightly larger deletion in the E3 region) was approved by the China’s state food and drug administration (SFDA) for the treatment of nasopharyngeal carcinoma in combination with cisplatin-based chemotherapy in November, 2005 [18]. The approval of the world’s first oncolytic virotherapy for cancer treatment was hailed by the experts in the field as “a good first start” [18] or “the end of the beginning” [19].

16.2 Mechenisms of Tumor Selectivity Tumor selectivity is one of the most important factors that determine the clinical safety of any cancer therapeutics. High selectivity means high therapeutic index, and thus, low side effects. Oncolytic viruses are capable of specifically infect and destroy cancer cells while leaving normal cells unharmed. Conversely, conventional cancer therapies such as chemotherapy and radiotherapy are well known to cause serious adverse effects due to their lack of tumor selectivity. Several mechanisms have been employed to achieve tumor-selective viral replication.

16.2.1 Inherent Tumor Selectivity During carcinogenesis, genetic mutations have accrued in cancer cells, resulting in several essential alterations in cell physiology in order for cancer cells to gain growth advantages and evade host immune surveillances [20]. These alterations such as induction of mitosis and evasion of apoptosis and innate immune responses are strikingly similar to the cellular changes induced by viral infection. Owing to this genetic convergence, many wild-type oncolytic viruses have been shown to preferentially infect and replicate in cancer cells to a certain extent. While the tumor selectivity of many oncolytic viruses have been further improved through genetic engineering, some oncotropic viruses like myxoma virus (MYXV), vesicular stomatitis virus (VSV), reovirus, Newcastle disease virus (NDV), and measles virus are used for oncolytic virotherapy without genetic modifications through genetic engineering.

N. Chen and A.A. Szalay

MYXV is a rabbit-specific poxvirus that causes a benign infection in American rabbits (Sylvilagus sp.), but lethal infection in European rabbits (Oryctolagus cuniculus). MYXV is non-pathogenic in other vertebrates including man. In spite of its narrow host range in nature, MYXV can productively infect many nonrabbit cells in vitro, including the majority (15/21) of cancer cell lines tested. MYXV host range gene, M-T5, was shown to be necessary for infection of certain cancer cell lines [21]. Importantly, the permissiveness of MYXV in all cancer cell lines tested was demonstrated to be directly related to the basal level of endogenous phosphorylated Akt [22]. The Akt pathway is either mutated or constitutively activated in the majority of human cancer cells [23]. Recently, it has been shown that tumor necrosis factor and interferon-β (IFN-β) completely restrict MYXV infection in primary human fibroblasts, but fails to synergistically inhibit MYXV in transformed human cancer cells [24–26]. VSV is an enveloped, negative-strand RNA virus belonging to the Rhabdoviridae family. VSV infects horses, cattle, and pigs, resulting in vesicular lesions in their mucous membranes of the mouth and nose while not causing any significant diseases in humans [27]. In vitro, VSV replicates in almost all tissue cultured cell lines tested so far, many of which are transformed or malignant [28]. VSV is well known to be exquisitely sensitive to treatment with IFNs [29, 30]. When a panel of cell lines consisting of primary normal human cells (fibroblast and epithelium) and various types of carcinoma cells was screened for VSV infection it was found that VSV replicated more efficiently in cancer cells than in normal cells. More importantly, while pre-treatment with IFN protected normal cells from VSV infection, VSV rapidly replicated in and selectively killed a variety of human tumor cells even in the presence of IFN [31]. IFNs not only play key roles in mediating anti-virus responses and in modulating immune responses, but also induce growth inhibitory and/or apoptotic signals in normal and tumor cells [32]. It is not surprising that most of the common solid tumors are refractory to IFN treatment [33]. Tumor cells with defects in the IFN-pathway may have a growth and/or survival advantage over their normal counterparts, but are simultaneously more susceptible to viral infections such as VSV. Moreover, cancer cells with defects in Ras, p53, or Myc signalling pathways are also susceptible to VSV infection [34]. VSV

16 Oncolytic Virotherapy of Cancer

has been shown to be effective against human tumor xenografts in nude mice [31], orthotopic rat hepatocellular carcinoma [35], and orthotopoc murine bladder cancer [36]. Reovirus is a non-enveloped double-stranded RNA virus, the prototype member of the Reoviridae family. Reovirus infections in humans are usually asymptomatic, or sometimes are associated with mild respiratory and gastrointestinal illnesses although reoviral exposure is quite common in humans [37–40]. In vitro, reoviruses were shown to preferably kill transformed cells [41, 42]. Later, it was demonstrated that reovirus oncolysis was associated with the activated Ras signalling pathway in transformed cells [43]. The Ras signalling pathway can be activated through mutations in the Ras proto-oncogene or over-expression and genetic alterations of upstream pathway elements such as the epidermal growth factor receptor and plateletderived growth factor receptor [43–46]. Activated Ras signalling pathway promotes cell proliferation, transformation, angiogenesis, and metastasis [47]. Ras gene mutations have been found in a variety of tumor types including 90% of pancreatic adenocarcinomas, 50% of colon and thyroid tumors, and 30% of lung cancers [48]. The molecular mechanisms by which Ras transformation mediates selective viral oncolysis have not been fully elucidated. This effect, however, was believed to be caused by the inhibition of the doublestranded RNA-dependent protein kinase (PKR) activation in cells with an activated Ras pathway upon infection. This inhibition increases synthesis of viral proteins. Conversely, the activation of PKR in normal cells after reovirus infection leads to an inhibition of viral protein synthesis, thus, prevents virus replication [49]. Recent studies indicated that Ras transformation could also enhance virus uncoating, virus infectivity, and apoptosis-dependent release [50, 51]. How ever, Smakman et al has recently showed that viral replication and cell lysis do not correlate with Ras activation status in a panel of human colorectal tumor cell lines [52]. Obviously, the importance of Ras activation for reovirus oncolysis and its mode of action need to be further examined. The safety and efficacy of reovirus have been demonstrated in extensive preclinical studies in both immune-compromised and immune-competent mice [49, 53–58]. The results from multiple phase I clinical trials indicate that reovirus is safe in patients and hints of antitumoral activity were observed [59, 60].

297

NDV is an enveloped negative single-stranded RNA virus belonging to the Paramyxoviridae family, which infects a variety of birds and causes the Newcastle disease in birds, especially in chicken. NDV is not pathogenic to humans, but may cause laryngitis and conjunctivitis in people who work with poultry. NDV was first observed to replicate in tumor cells in vitro and in vivo in 1955 [61] and was first tested in a patient with cervical cancer in 1965 [10]. The preferential replication of NDV in tumor cells were demonstrated in several studies [62–65]. Although the mechanisms that render NDV tumor-specific are not fully understood, some studies indicate that the tumor-selective replication behaviour of NDV may be associated with an activated Ras pathway or defects in antiviral defence, especially the IFN pathway in tumor cells [63–65]. The safety and efficacy of NDV demonstrated in preclinical studies has led to multiple phase I clinical trials of NDV in patients as an oncolytic agent [62, 63, 66, 67]. Measles virus is another member of the family Paramyxoviridae that has been extensively studied as an oncolytic agent. Wild-type measles virus is a well-known human pathogen causing the acute, exanthemous, and highly contagious measles disease. However, the vaccine strains of measles virus are apathogenic to man and has been administered into millions of people in over 40 years of use with an excellent safety record [68]. Two receptors have been identified: CD46 [69, 70] and the signalling lymphocyte-activation molecule (SLAM) [71]. SLAM is primarily expressed on cells of the immune system such as B- and T-lymphocytes [71], whereas CD46 is a human complement regulatory protein expressed ubiquitously on all nucleated cells but is frequently over-expressed in tumors [72]. Both vaccine and wildtype strains of measles virus can use SLAM as a receptor, however, vaccine strains enters cells via the CD46 receptor efficiently while wild type strains of measles virus often do not [73, 74]. Therefore, vaccine strains, especially Edmonston vaccine strain of measles virus preferentially infect and kill tumor cells without significant cytopathic effect against non-transformed cells expressing low CD46 receptor levels [75]. The preclinical efficacy and safety and the clinical trials of measles virus were recently reviewed by the Russell group [76, 77]. Other genetically non-engineered viruses used for oncolytic virotherapy include mumps virus

298

(Paramyxoviridae family) [78, 79], Semliki Forest virus (Togaviridae family) [80–83], Sindbis virus (Togaviridae family) [84–88], coxsackievirus (Picornaviridae family) [89–91], echovirus type 1 (Picornaviridae family) [92, 93], Seneca Valley virus (Picornaviridae family) [94, 95], and autonomous parvoviruses (Parvoviridae family) [96–101].

16.2.2 Viral Gene Inactivation In order to successfully and productively infect cells, viruses have evolved many strategies to promote cell growth and subvert antiviral defence mechanisms (such as apoptosis, antiviral cytokine responses) mounted by infected cells [102, 103]. However, viral genes involved in promoting cell growth and evasion of cellular antiviral responses are not required for their growth in cancer cells since cancer cells are actively proliferating cells and many of cancer cells have defects in induction of antiviral responses. Thus, inactivation of such viral genes that are critical for efficient viral replication in normal cells but are dispensable upon infection of tumour cells has become a common strategy to improve tumor selectivity. VACV is a prototype member of the family Poxviridae with a doubles-stranded DNA genome, which has a natural tumour tropism [104–106]. Owing to safety concerns about using VACV in immunecompromised patients, several oncolytic VACV deletion mutants have been constructed to further improve its tumor selectivity. VACV J2R gene encoding a thymidine kinase (TK) is required to synthesize deoxythymidine monophosphate and deoxyuridine monophosphate for DNA and RNA synthesis. Deletion of the J2R gene leads to viral dependence on the expression of cellular TK that is higher in transformed cells than in normal cells during all phases of the cell cycle [107]. VACV with an inactivated TK was shown to be much less pathogenic for mice and more tumour-selective in several tumour models than wild type virus [108, 109]. Furthermore, a recombinant vaccinia virus lacking both the TK and vaccinia growth factor (VGF) genes was constructed and has been extensively tested in different tumour models. VGF is a homologue of cellular growth factors – epidermal growth factor (EGF) and transforming growth factor alpha (TGF-α), which is secreted from infected

N. Chen and A.A. Szalay

cells and was shown to stimulate surrounding resting cells to proliferate in order to prime them for vaccinia infection [110]. Deletion of the VGF gene reduces virus virulence and leads to viral growing preferably in proliferating cells [111]. The double-deleted virus, vvDD-GFP was shown to replicate much less efficiently in resting cells and to be more tumor specific in vivo than wild-type and TK, or VGF single-deleted viruses [112]. VACV encodes many proteins with antiapoptotic or immunomodulatory functions. Deletion of these genes is another strategy to increase tumour selectivity. For example, deletion of vaccinia-encoded serine protease inhibitors (serpin) SPI-1 and SPI-2, both of which are implicated in the inhibition of apoptosis, leads to enhanced tumor selectivity [113, 114]. VACV B18R encodes a secreted type I IFN binding protein that blocks IFN-α transmembrane signalling. A vaccinia virus mutant lacking the B18R gene was demonstrated to have IFN-dependent cancer selectivity [115]. A recently extensively tested vaccinia virus mutant, GLV-1h68, has demonstrated tumour selectivity and efficacy in several tumour models (see the figure included for an example), including human breast cancer [116], anaplastic thyroid carcinoma [117, 118], malignant pleural meothelioma [119], pancreatic tumor [120], squamous cell carcinoma [121], and canine breast cancer [122]. GLV-1h68 was derived from VACV LIVP strain that contains a naturally inactivated TK gene and is inherently more tumor-targeting than VACV WR strain [116, 123]. GLV-1h68 was constructed by inserting Renilla luciferase-Aequorea green fluorescent protein fusion, β-galactosidase, and β-glucuronidase expression cassettes into the F14.5L, J2R, and A56R (encoding hemagglutinin) loci of the LIVP genome, respectively, resulting in inactivation of both F14.5L and A56R genes. GLV-1h68 demonstrates an enhanced tumor targeting specificity and much reduced toxicity in comparison with its parental stains [116]. VACV F14.5L gene encodes a small transmembrane protein that is incorporated into vaccinia intracellular mature virus and the cell surface of infected cells. The F14.5 protein mediates calciumindependent cell adhesion. Deletion of the F14.5L gene results in decreased virulence in mice [123, 124]. VACV A56R gene encodes a hemagglutinin that inhibits cell-to-cell fusion during infection and is a virulence factor in mice [125, 126]. The combination of inactivation of the F14.5L, J2R, and A56R genes and

16 Oncolytic Virotherapy of Cancer

Tumor therapy with vaccinia virus. Mice were i.v. injected with a single dose (1 × 107 pfu per mice) of the light-emitting oncolytic vaccinia virus GLV-1h68 (row 2–4) or PBS control (row 1) 30 d after breast tumor cell implantation. Bright field photographs (left column), GFP fluorescence images (middle column), and immunohistochemical analyses of expression of GLV-1h68-encoded β-galactosidase (right column) in tumors were done 14 (row 2), 28 (row 1 and 3), and 56 d (row 4)

299

after virus or PBS injection. Two weeks after virus injection, strong fluorescence of GFP was seen in tumors with a volume of ∼1400 mm3 . An additional 2 wk later, a much reduced GFP fluorescence was observed at tumor size of ∼480 mm3 in the same mouse. After 56 d, no GFP fluorescence was seen in the tumor which was ∼180 mm3 in size. β-galactosidase activity was detected concomitant with light emission and was completely eliminated as light emission was extinguished.

300

over-expression of foreign gene expression cassettes that puts extra transcriptional and translational burden on the virus might contribute to the enhanced tumor selectivity of GLV-1h68. Several GLV-1h68 derivatives that have the same gene inactivation but a different foreign gene expression cassette at F14.5L or J2R locus showed a similar tumor targeting specificity compared to GLV-1h68 [127–129]. HSV-1 is an enveloped, double-stranded DNA virus belonging to the family Herpesviridae. HSV-1 is a neutotropic human pathogen that can cause destructive encephalitis. The HSV-1 TK-deletion mutant, dlsptk, is a first genetically engineered virus used for oncolytic virotherapy [15]. TK is needed for nucleic acid metabolism. Deletion of the TK decreases neurovirulence and leads to viral growing preferably in proliferating cells such as cancer cells that have high levels of endogenous TK. The TK-deleted mutants were shown to induce tumor regression in several tumor models in both immuno-compromised and immuno-competent mice [15, 130]. However, it was found that these mutants can establish a persistent infection in severe combined immunodeficiency (SCID) mice and infect both tumor cells and adjacent normal neurons as well as astrocytes [131, 132]. In addition, these mutants are insensitive to the most potent anti-herpetic drugs, acyclovir (ACV) and ganciclovir (GCV) due to their disrupted TK gene. Hence, investigators turned their attention to mutations in other genes affecting virulence. The protein ICP34.5 encoded by the γ1 34.5 gene, the major viral determinant of neuropathogenicity, enables HSV-1 to replicate in neurons and blocks the shut-off of protein synthesis in infected cells by interaction with cellular phosphatase 1α to dephosphorylate eIF2α. Several γ1 34.5-deleted mutants have been constructed, including HSV 1716, R3616. These mutants were replication-defective in neurons and have been shown to induce tumor regression and significantly prolong animal survival in a variety of animal tumor models [133]. However, it should be pointed out that these γ1 34.5-deleted mutants replicate less efficiently than wild-type HSV-1 [134]. The HSV-1 UL 39 gene encodes ICP6, the large subunit of ribonucleotide reductase, which is required for efficient viral DNA replication. The UL 39-deleted mutant, hrR3, exhibits decreased neurovirulence and are hypersensitive to ACV and GCV [135]. This virus replicates efficiently in cancer cells but is significantly attenuated for replication in normal cells. In many animal models, this

N. Chen and A.A. Szalay

virus has demonstrated significant inhibition of tumor growth and survival benefit [133]. In order to maximize safety and decrease the likelihood of reversion to wild-type, HSV mutants often referred to as the second-generation viruses have been constructed, which contain mutations in more than one genes. G207, an important representative of the second generation oncolytic herpes viruses, contains deletions in both copies of the γ1 34.5 gene and an inactivating insertion of E. coli lacZ gene in the UL 39 locus [136]. G207 demonstrates tumor-specific replication and has shown potent anti-tumor efficacy in many different tumor models in both immuno-deficient and immuno-competent animals [133]. G207 is sensitive to antitherpetics. G47, a derivative of G207, was constructed by deleting the α47 gene (encoding ICP 47) and the overlapping US 11 promoter region resulting in placing the late US 11 gene under the control of the immediate-early α47 promoter [137]. ICP47 inhibits transporter associated with antigen presentation (TAP), the absence of which results in increased MHC class I expression in infected human cells. G47 replicates better and exhibits greater cytopathic effect and efficacy against a variety of tumors than its parent virus, G207 [138]. For information about more HSV-1 deletion mutants, please refer to references [8, 133, 139]. Adenovirus is a non-enveloped, double-stranded DNA virus belonging to the family Adenoviridae. Most adenoviral vectors are derived from serotypes 2 and 5. Adenovirus is endemic in the human population with more than 50% of the population showing antibodies to adenovirus serotype 5. However, adenovirus does not cause serious diseases in humans and is normally associated with mild respiratory infections. The first adenovirus deletion mutant used for oncolytic virotherapy is dl1520 (ONYX-015), which lacks the gene encoding E1B-55kD [16]. The E1B55kD binds and inactivates p53. Thus, it was initially thought that ONYX-015 would selectively replicate in p53-defective tumor cells while sparing normal cells with the intact p53 pathway [16, 140]. However, it was demonstrated later that the loss of E1B-55kD-mediated late viral RNA export rather than p53 degradation is the major determinant of ONYX-015 tumor-selective replication [141]. ONYX-015 has undergone extensive preclinical and clinical testing. Its safety and tumor selectivity have been very well established [142]. Other tumor-selective, replicating adenovirus deletion

16 Oncolytic Virotherapy of Cancer

mutants have been generated by deleting the conserved region 2 (CR-2) of the E1A gene responsible for pRb binding, such as dl922–947 [143] and 24 [144]. These mutants replicate specifically in cancer cells with abnormalities in the pRb pathway. Interestingly, dl922–947 demonstrated greater potency than ONYX015 both in vitro and in vivo [143]. Another adenovirus mutant, CB1, contains a double deletion of the CR-2 of the E1A gene and the gene encoding E1B-55KD. This virus exerted a potent anticancer effect against several human glioma cell lines in vitro and prolonged survival in vivo [145]. Adenovirus type 5 contains two virus-associated RNA genes, VAI and VAII. The small RNAs transcripted from these genes bind to PKR and inactivate it. The adenovirus mutants that lack either VAI [146] or both VAI and VAII [147] have been constructed. The VAI deletion mutant presents a Ras-dependent replication. The VAI and VAII doubledeletion mutant replicates 100-fold less efficiently in normal cells compared with wild-type adenovirus, whereas this virus demonstrated an unaffected ability to replicate and kill different types of tumor cells and active antitumoral activity in vivo. The tumor-selective gene-deletion/inactivation mutants of other viruses include influenza virus NS-1 deletion mutants [148, 149], a poliovirus mutant with its internal ribosomal entry site (IRES) replaced with that of human rhinovirus type 2 [150], and a VSV mutant with a mutated matrix protein [151].

16.2.3 Transcriptional Targeting Transcriptional targeting of oncolytic viruses is another commonly employed and well established strategy to achieve tumor-selective viral replication. This strategy involves use of tissue/tumor-specific promoters to drive viral gene(s) essential to viral replication. The first viruses generated using this strategy are adenovirus CN706 and herpes simplex virus G92A, both of which were reported in 1997 [152, 153]. In the adenovirus CN706, the prostate-specific antigen (PSA) promoter was used to drive the E1A gene that is essential for viral replication to limit virus replication in PSA-expressing prostate tumor cells. In the G92A, the HSV intermediate-early gene ICP4, the main trans-activator of HSV transcription, is under control of the albumin enhancer/promoter to target virus

301

replication to albumin expressing liver cells. Over the last two decades, more than thirty promoters have been exploited for transcriptional targeting of oncolytic viruses. For a comprehensive list of tissue/tumorspecific promoters see the reference [154]. There are two types of tissue/tumor-specific promoters. The first type is a tissue-type/tumor-type-specific promoter that is highly active in a specific type of tissues or tumors, such as PSA promoter, albumin promoter, and chromogranin A promoter [155]. The second type of promoters is a pan-cancer-specific promoter that is very active in many different tumor types but inactive in normal cells. Examples are human telomerase reverse transcriptase (hTERT) promoter [156], E2F-responsive element [157], and survivin promoter [158] that are highly active in most tumor cells but inactive in normal cells. Transcriptional targeting strategy has been most widely applied to oncolytic adenovirus and HSV-1 although autonomous parvoviruses were also reported to transcriptionally target colon cancer cells [159]. Different viral genes or therapeutic genes or combinations have been transcriptionally targeted [154]. Moreover, transcriptional targeting was also combined with other targeting strategies such as entry targeting strategies to further improve tumor selectivity [160].

16.2.4 Regulation of mRNA Stability It has been well known that enhanced expression of some tumor-associated proteins in many tumors is partly due to stabilization of their mRNAs through AU-rich sequences in the 3 -untranslated regions (3 -UTRs) [161]. The mRNAs of these genes are normally destabilized in normal, resting cells, but preferentially stabilized in tumor cells [162, 163]. Cyclooxygenase 2 (COX-2), an inducible prostaglandin G/H synthase, is not detectable in most normal tissues, but over-expressed in many premalignant and malignant tissues [164]. Up-regulation of COX-2 in tumors is at least in part due to enhanced mRNA stability. The 3 -UTR of COX-2 mRNA contains multiple copies of Shaw-Kamen sequences (AUUUA) that confer mRNA instability in normal cells. Activation of the RAS/phosphorylated mitogenactivated protein kinase (P-MAPK) pathway stabilizes COX-2 mRNA in tumors. The differential stability of

302

COX-2 mRNA in normal vs. tumor cells was exploited to generate a tumor-targeting adenovirus. The adenovirus Ad-E1A-COX in which the E1A gene was ligated to the COX-2 3 -UTR, was shown to preferentially lyse human tumor cells with high P-MAPK activity both in vitro and in vivo [165]. Recently, a new strategy has been developed to regulate virus tissue tropism using microRNAs (miRNA) [166, 167]. miRNAs are small (∼22 nucleotides in length), endogenous, noncoding RNAs that exert post-transcriptional regulation through specific recognition of short sequences, often located in the 3 -UTR in target mRNAs. miRNAs have been shown to induce mRNA degradation or translational repression, depending on their degree of complementarity to the target. More than 10% of human genes have been estimated to be regulated by miRNAs [168]. While some of miRNAs are constitutively expressed, others are expressed in a tissue-specific fashion [169, 170]. Most miRNA are down-regulated in cancer cells due to a decrease in post-transcriptional processing of these RNAs [171, 172]. The differences in miRNA expression between normal and cancer cells have been recently exploited to improve tumor-targeting of oncolytic viruses by incorporating multiple tandem copies of artificial miRNA target sequences into 3 -UTRs of essential viral genes [166, 167]. Since these artificial miRNA target sequences are designed to be perfectly complementary to miRNAs, a viral gene contains a specific miRNA target sequence is supposed to be degraded in cells expressing the cognate miRNA. This strategy has been applied to coxsackievirus [173], VSV [174], adenovirus [175, 176], and HSV-1 [177]. Coxsackievirus A21 is a naturally occurring oncolytic virus with an inherent tumor specificity [89]. However, it causes lethal myositis in suckling mice and immunocompromised tumor-bearing mice. After two copies of the target sites for miR-133 and miR206, which are highly expressed in muscle cells, were inserted in its 3 -UTR, the resulting virus was shown to replicate in subcutaneous tumors causing total regression without causing myositis [173]. The let-7a miRNA is a tumor-suppressor miRNA that is often expressed at low levels in cancer cells, but ubiquitously and abundantly expressed in normal cells. A recombinant VSV was created to contain three copies of the let7a target sequence within the 3 -UTR of the viral M gene that has an essential role in viral growth and replication [174]. The new recombinant

N. Chen and A.A. Szalay

VSV replicates preferentially in tumor cells and is less pathogenic in both immuno-compromised and immuno-competent mice while retaining its in vivo antitumoral activity. Hepatotoxicity is a major concern for adenovirusbased oncolytic virotherapy. Recently, two groups reported that incorporation of the hepatocyte-specific miR122 target sequence within the viral gene E1A decreased E1A mRNA and protein expression in normal hepatocytes in vitro and in vivo, and virtually abrogated liver toxicity in mice while retaining full activity within cancer cells [175, 176]. Two miRNA-regulated amplicon HSV-1 viruses have been recently reported [177], which contain multiple copies of miR143 or miR145 target sequence with the 3 -UTR of the HSV-1 essential gene, ICP4. miR143 and miR145 are highly expressed in normal cells, but significantly down-regulated in prostate cancer cells. In vitro, the expression of the ICP4 gene was inhibited by miR143 and miR145 in a dose-dependent manner. In vivo, these miRNA-responsive viruses were shown to inhibit human prostate tumor growth by more than 80% with significantly attenuated virulence to normal tissues. Another way to use miRNA regulation to control virus tissue tropism is to incorporate into a viral genome, an artificial miRNA network directed against essential virus genes that is expressed in a tissuespecific manner. As a proof of principle, an adenovirus that specifically replicates in p53 dysfunctional tumor cells was recently reported [178]. This adenovirus contains an artificial miRNA network directed against essential adenoviral genes, expression of which is dependent on the p53 status in infected cells. This miRNA-controlled virus was shown to efficiently lyses p53 dysfunctional tumor cells in vitro and in vivo, whereas the virus DNA in the liver of treated mice was dramatically reduced.

16.2.5 mRNA Translational Control Dysregulation of cap-dependent translation has been indicated to confer malignant characteristics and induce cancer [179]. Cap-dependent translational control occurs mainly during the initiation step that involves translation eukaryotic initiation factors and accessory proteins. For example, the translation

16 Oncolytic Virotherapy of Cancer

eukaryotic initiation factor eIF4E has been found to be over-expressed in many human cancers [179]. Although an increase in eIF4E expression does not necessarily lead to elevated levels of global translation, it is critical for translation of mRNAs with a long and complex 5 -UTR. eIF4E is a subunit of a translational pre-initiation complex containing a helicase activity that unwinds the secondary structure at the 5 -UTR of mRNA. Elevated eIF4E expression was shown to drastically increase expression of basic fibroblast growth factor (FGF-2) and vascular endothelial growth factor (VEGF), both of which are encoded by mRNAs with a long and complex 5 -UTR [180, 181]. To take advantage of this unique translation control in cancer cells, a novel dual-level targeted adenovirus has been recently constructed, which contains a cancer specific gene transcriptional control using the CXCR4 promoter and a cancer specific mRNA translational control using the 5 -UTR from the EGF-2 mRNA [182]. The dual-level targeted adenovirus replicates similarly in human breast cancer cell lines that express high levels of eIF4E, but displays significantly lower viral copy number in normal human mammary epithelial and dermal fibroblast cells expressing low levels of eIF4E in comparison to the single-level targeted adenovirus that only contains a cancer specific gene transcriptional control using the CXCR4 promoter. In vivo, the dual-level targeted adenovirus shows similar oncolytic potency against human breast cancer xenografts in mice. Importantly, the dual-level targeted adenovirus displays reduced replication in a human liver tissue slice model compared to the single-level targeted counterpart.

303

using adaptors, and genetic incorporation of targeting ligands [183]. Pseudotyping involves use of a viral attachment protein from a different virus strain of family. Adaptors are molecules that bind both the viral attachment protein and target cell receptor to facilitate virus entry. Using adaptors would normally ablate virus native tropism and confer a new tropism towards the desired target. Several types of adaptors have been developed, including receptor-ligand complexes, chemical conjugation, avidin-biotin system, and monoclonal antibodies. Due to the complexities of adaptor system, a preferred transductional targeting strategy is genetic incorporation of targeting ligands. This strategy involves incorporation a polypeptide into the virus through genetic engineering to facilitate virus entry. Although transdutional targeting has been most used to increase tumor specificity of oncolytic adenoviruses [184], this strategy has also been applied to other viruses, such as HSV-1 [133], measles virus [185], and vaccinia virus [186].

16.3 Mechanisms of Antitumoral Potency Antitumoral potency is one of the most important factors that determine the clinical efficacy of any cancer therapeutics, and goes hand in hand with tumor selectivity. Oncolytic viruses mediate tumor destruction by several mechanisms, involving intrinsic antitumoral activity, induction of antitumoral immune responses, expression of therapeutic genes, and sensitization to conventional therapies such as chemotherapy and radiotherapy.

16.2.6 Transductional Targeting Tumor targeting of oncolytic viruses can be manipulated at two levels: either before virus entry (transductional targeting) or after virus entry. The strategies used to control virus tissue tropism after virus entry include viral gene inactivation, transcriptional targeting, regulation of mRNA stability, and mRNA translational control as discussed above. Virus entry is the first step towards a successful viral infection. Modifying a virus to only recognize tumor cells would restrict virus replication to cancer cells without harming normal cells. Many strategies have been developed for transductional targeting, including pseudotyping,

16.3.1 Intrinsic Antitumoral Activity By definition, oncolytic virus must replicate in and destroy cancer cells, normally through apoptosis and/or necrosis, depending on virus and cell types or the combination. Specifically, some naturally occurring, virus-encoded cytotoxic proteins have been identified, such as adenovirus proteins E3–11.6kD (adenovirus death protein, ADP), early region 4 open reading frame 4 (E4orf4), and parvovirus H1 nonstructural protein 1 (NS1). ADP is an adenovirus late protein that is required for efficient cell lysis and

304

release of adenovirus from infected cells [187]. The adenoviruses over-expressing the ADP were shown to lyse tumor cells and spread from cell to cell more rapidly in vitro and regress tumors more efficiently in vivo than the E3-deleted counterparts [188]. The adenovirus E4orf4 can selectively kill tumor cells independent of p53 by triggering alternative cell death processes that might be absent in normal cells, resulting in tumor growth inhibition [189]. The NS1 protein derived from parvovirus H1 induces tumor-selective apoptosis [190].

16.3.2 Antitumoral Immune Responses Oncolytic virus therapy can trigger potent antitumoral immune responses by release of tumor-associated antigens (TAAs), induction of cytokines, and/or activation of tumor-infiltrating dendritic cells (DCs) within the tumor microenvironment [191]. Both preclinical and clinical data indicate that the immune response may play an important role in the eradication of tumors [192, 193]. A recent study investigating the role that innate immunity plays in the eradication of tumors with the VACV GLV-1h68 indicated that tumor rejection was associated with in vivo activation of interferon-stimulated genes (ISGs) and innate immune host’s effector functions [194]. Interestingly, these signatures are in parallel with what is observed in humans during immune-mediated tissue-specific destruction. The innate natural killer (NK) cell activity was shown to be required for antitumoral efficacy using reovirus, VSV, and HSV [191]. The ability of oncolytic viruses to generate adaptive anti-tumor immunity is well documented. A variety of oncolytic viruses have been reported to facilitate the generation of adaptive antitumoral immunity, including HSV, VSV, NDV, VACV, reovirus, measles virus, and parvovirus H-1 [191]. For example, oncolytic HSV-2, FusOn-H2, was shown to induce strong anti-tumor T-cell responses in both syngeneic murine neuroblastomal and mammary tumor models, and this antitumoral immunity could be adoptively transferred [195, 196]. In a phase I dose escalation clinical trial, patients with cutaneous T-cell lymphoma were treated intratumorally with measles virus Edmonston-Zargreb vaccine strain. Evaluation of biopsies revealed an increase of IFN-γ expression in infiltrating CD4 and CD8 T-lymphocytes and an overall expansion of the CD8 T-cell population [197].

N. Chen and A.A. Szalay

16.3.3 Expression of Therapeutic Genes Although it is easily achievable to infect and lyse 100% of tumor cells in vitro, it proves hard to treat the entire tumor mass effectively in vivo using oncolytic viruses alone due to limited virus replication and spread in the tumor microenvironment. Clinical experiences indicate that oncolytic viruses are generally safe, but have fallen short of their expected efficacy. Thus, oncolytic viruses are often “armed” with therapeutic genes to potentiate their therapeutic potency [198]. This strategy takes advantage of the tumor-specific replication of oncolytic viruses to achieve high-levels of therapeutic gene expression within the tumor. However, it is crucial to carefully choose therapeutic genes in order to gain synergistic effects between oncolytic viruses and therapeutic genes. It is preferable to select a therapeutic gene that can produce potent bystander effects capable of eliminating surrounding non-infected cells since oncolytic viruses themselves can destroy infected tumor cells. In addition, the gene product of a selected therapeutic gene should not interfere with virus replication and spread, and/or result in clearance of the virus prematurely. A variety of therapeutic genes have been exploited to arm oncolytic viruses. These genes can be broadly grouped into six categories: (1) prodrug converting enzymes to convert non-cytotoxic prodrugs to cytotoxic drugs [199]; (2) immuno-stimulatory molecules to enhance ant-tumor immunity [198]; (3) antiangiogenic agents to specifically target the tumor vasculature [129]; (4) agents that break down the tumor extracellular matrix to improve viral spread within the tumor [200]; (5) fusogenic glycoproteins to induce formation of multi-cellular syncytia, resulting in enhanced virus replication and spread [201]; (6) tumor suppressors and anti-oncogenes to enhance cell killing [198]. Imaging genes have also been inserted into oncolytic viruses. Although these genes do not generally contribute to therapeutic efficacy, they enable non-invasive detection of tumors and metastasis and monitoring of oncolytic viral infection and replication in vivo [105, 127, 128, 202]. Imaging genes include genes for optical imaging, such as fluorescent proteins, and luciferases [105], and genes for deep tissue imaging, for example, sodium iodide symporter [203], and human norepinephrine transporter [127, 203].

16 Oncolytic Virotherapy of Cancer

16.3.4 Sensitization to Chemotherapy and Radiotherapy Chemotherapy and radiotherapy together with surgery are conventional therapies currently used to treat a wide range of cancers. However, due to lack of selectivity, chemotherapy and radiotherapy are well known to cause serious side effects and are often ineffective in treating patients with advanced cancer. One of intriguing features of oncolytic viruses is that they can kill cancer cells that are high in ribonucleotide reductase, high in DNA-repair enzymes, and resistant to apoptosis, all of which would make tumor cells resistant to chemotherapy and radiotherapy. Preclinical and clinical data indicate that oncolytic virotherapy can effectively complement these therapeutic modalities [204, 205]. Adenovirus ONYX-015 was extensively evaluated in the clinic either as a single agent therapy or in combination with different chemotherapeutics. As a single agent therapy, only 14% of patients showed objective responses in injected head and neck tumors. However, in combination with chemotherapy, about 65% of patients with head and neck tumors showed tumor regression when treated with ONYX-015 and cisplatin and 5-fluorouracil (5-FU) [206]. A very similar adenovirus, H101, was evaluated in patients with head and neck cancers in a randomized phase III clinical trial in combination with cisplatin and 5-FU, a 79% response rate in combination-treated patients was reported, whereas a response rate of 40% was observed for chemotherapy alone [207]. The mechanism underlying this enhanced therapeutic effect is not totally understood. The adenovirus E1A protein was shown to sensitize hepatocellular carcinoma cells to gemcitabine [208]. Some drugs, such as MEK inhibitors, can promoter the coxsackie-adenovirus receptor (CAR) expression [209]. Some investigators proposed that in vivo virus-induced cytokines may enhance the effects of chemotherapy [204]. The improved therapeutic efficacy was also seen when other viruses, such as HSV-1, VACV were tested in combination with chemotherapy [120, 204]. The treatment with oncolytic viruses armed with prodrug converting enzymes can be considered as a special form of the combination with chemotherapy in which the oncolytic virus converts a non-toxic drug into a toxic drug within the tumor to limit chemotherapeutic toxicity.

305

Several oncolytic viruses have been shown to enhance the radiation response [205]. In a study in which ONYX-015 was combined with radiotherapy, the combination therapy produced an significantly enhanced antitumoral effect when compared with either monotherapy [140]. This enhanced antitumoral effect was also observed with other oncolytic adenovirus mutants in combination with radiotherapy, which was sometimes associated with increased apoptosis and reduced tumor vascularization [205]. A study with a HSV mutant, R7020, demonstrated that ionizing radiation enhanced the virus replication in hepatomas Hep3b xenografts and caused a greater regression when combined with R7020 in comparison with either R7020 or radiation alone [210]. A similar phenomenon was observed in a human U-87 glioma xenograft model treated with HSV-1 mutant R3616 in combination with radiotherapy [211]. Later, it was found that ionizing radiation can activate HSV-1 late promoters via the p38 pathway in tumors infected with the virus [212]. Other viruses like reovirus and measles virus have also been combined synergistically with radiotherapy [205]. Some transgenes carried by oncolytic viruses can facilitate radiotherapy. These transgenes include prodrug converting enzymes, cytokines, and transport proteins [205].

16.4 Targeting Cancer Stem Cells A growing body of evidence indicates that a subpopulation of cells with stem cell-like characteristics, including self-renewal and pluripotency, exists within the cancer, which is responsible for tumorigenesis. These cells have been generally referred to as cancer stem cells (CSCs) or cancer-initiating cells (CICs) [213]. The existence of CSCs was first documented in acute myelogenous leukemia [214, 215]. Later, CSCs were also isolated from solid tumors, including those arising in the brain, breast, bone, colon, head and neck, liver, lung, ovary, pancreas, prostate, and skin [216]. CSCs are resistant to radiation and chemotherapy due to high-level expression of anti-apoptotic proteins and multi-drug transporter molecules, and their ability to efficiently repair radiation-induced DNA damage [217]. Thus, CSCs is believed to account for tumor relapses following successful initial induction of remission upon conventional treatments (radiation and

306

chemotherapy). Oncolytic viruses infect and destroy tumor cells using mechanisms different from conventional therapies as described above and therefore might not be sensitive to CSC resistance mechanisms. Indeed, recent studies suggest that oncolytic viruses are able to target and efficiently kill CSCs [218]. Several oncolytic adenovirus mutants have been shown to effectively kill CSCs in vitro and in vivo [216]. For example, capsid-modified adenoviruses Ad5/3-24 and Ad5.pk7-24 that contain a 24-bp deletion in the E1A gene and use the adenovirus serotype 3 receptor and heparin sulfate proteoglycans for cellular entry, respectively, were able to effectively kill breast CSCs (CD44+ /CD24−/low cells) in vitro. The infected CD44+ /CD24−/low cells did not form tumors in vivo. In addition, treatment of established CD44+ /CD24−/low derived tumors with Ad5/3-24 or Ad5.pk7-24 stopped tumor growth and prolonged animal survival. Furthermore, CSCspecific promoter-controlled oncolytic adenoviruses have been recently generated [219]. Among these viruses, Ad5/3-cox2L-d24 and Ad5/3-mdr-d24 were able to completely eradicate CD44+ /CD24−/low cells in vitro and show significant antitumoral efficacy against CD44+ /CD24−/low derived tumors in vivo. In addition to breast CSCs, adenoviruses are also capable of effectively target brain CSCs in vitro and prolong survival of tumor-bearing mice [216, 220]. rQnestin34.5, an oncolytic HSV-1 mutant expressing ICP34.5 under the control of a nestin promoter, was showed to be able to infect tumorspheres derived from a neuroblastoma cell line, LA-N-5. These tumorspheres showed multi-lineage potential and were enriched for CD133 and ABCG2 expression and more resistant to doxorubicin. rQnestin34.5 infection caused significant cell death of both bulk and tumorsphere-derived LA-N-5 cells. Moreover, rQnestin34.5-infected LA-N-5 cells were not able to form tumors in mice whereas control virus and saline treated tumor cells did form tumors, suggesting that the virus was capable of killing the neuroblastoma CSCs in the culture [218]. Recent studies indicate that oncolytic HSV-1 is also capable of infect and destroy glioblastoma-derived CSCs in vitro and prolong mouse survival in vivo [218, 221]. Other oncolytic viruses including reovirus and MYXV have also been shown to effectively target and kill CSCs derived from breast cancer and neuroblastoma, respectively [218].

N. Chen and A.A. Szalay

16.5 The Host Immune Response: A Double-Edged Sword Oncolytic viruses are natural danger agents that would induce strong innate and adaptive host immune responses against the virus, and probably against the tumor as well in an immune competent host. While antitumoral immune responses are beneficial to virotherapy as discussed in the Section 16.3.2, antiviral immune responses would play a detrimental role in limiting virus replication, spread and restricting subsequent dosing with the same virus, thus limiting the efficacy of virotherapy [222]. Several strategies have been developed to circumvent the host antiviral immune response. These include: (1) use of immunomodulatory agents; (2) serotype switching; (3) viral shielding by biological or chemical methods; (4) expression of genes with immunosuppressive functions. A classical way to suppress the immune response to oncolytic viruses is the use of immunomodulatory agents. For example, cyclophosphamide, an alkylating agent used in cancer treatment, which has a nonspecific activity on reducing systemic host responses, has been successfully used in combination with HSV1, reovirus, measles virus, and adenovirus to enhance their oncolytic effect [222]. Other immunomodulatory agents that have been tested so far include cyclosporine A [223], cyclooxygenase-2 inhibitors [224], rapamycin [225], cobra venom factor [226], histone deacetylase inhibitors [191], and antiangiogenic agents [227]. Serotype switching is a strategy for viruses to evade neutralizing antibodies against the capsid by using alternate viral serotype. This strategy has been widely applied to adenovirus, but also to VSV. There are more than 50 human adenovirus serotypes and the neutralizing antibody to adenovirus is serotype-specific. Thus, the adenovirus mutants based on the adenoviruses with low seroprevalence such as adenovirus serotype 11 should be very useful for in vivo application due to lack of cross-reactivity of anti-adenovirus serotype 5 antibodies with adenovirus serotype 11 [228]. Another approach to escape neutralization by prexisting or therapy-elicited antiviral antibodies is to chemically shield viruses with polymers such as polyethylene glycol or poly-(N-(2-hydroxypropyl) methacrylamide) that crosslinks with capsid proteins, or by encapsulation into alginate microspheres or cationic liposomes [192]. More recently, ex vivo

16 Oncolytic Virotherapy of Cancer

infected cells have been used as carriers for oncolytic viruses [229, 230]. This approach not only shields the virus from the immune system, but also provides additional benefits: reduction in liver uptake, local amplification within carrier cells, and enhanced trafficking to metastatic sites. Various cell types have been successfully used to deliver oncolytic viruses, which includes tumor cells, mesenchymal progenitor cells, neuronal precursor cells, T-lymphocytes, monocytic cells, and endothelial progenitor cells [229]. Many viruses have evolved to produce immunomodulatory proteins that can modulate the host antiviral immune response. Incorporation of the genes encoding these immunomodulatory proteins into viruses that naturally do not have such genes would allow for enhanced viral replication and spread with tumors in vivo. For example, an oncolytic VSV expressing a chemokine binding protein from equine herpes virus was shown to have enhanced replication and efficacy in a rat hepatoma model [231]. Other examples include a NDV expressing influenza NS1 protein and a measles virus containing the P gene from wild-type measles virus IC-B. In both cases the inhibition of the innate antiviral mechanisms resulted in enhanced antitumoral activity in vivo [232, 233].

16.6 Clinical Trials The adenovirus mutant ONYX-015 is the first genetically engineered oncolytic virus to enter clinical trials in 1996 [17]. Since then, oncolytic viruses from at least seven different species have been tested in a wide range of clinical trials [185, 234]. These oncolytic viruses include adenovirus [235], HSV [236], VACV [237], NDV [67], reovirus [60], measles virus [72], and coxsackievirus [185]. The viruses were administered into patients with different types of cancer through a variety of routes including intratumoral, intracavitary, and intravascular administration, or hepatic artery infusion. A great deal of safety data have been accumulated from the numerous completed phase I or II clinical trials. Oncolytic viruses have proven generally safe in patients, with most common adverse events being flulike symptoms. In fact, the maximum tolerated dose (MTD) has not been achieved for most of oncolytic virus constructs tested so far with exceptions of NDV PV701 [67] and VACV JX-594 [238]. The MTD for

307

PV701 was reported to be 1.2 x 1010 plaque-forming units (pfu)/m2 or 1.2 × 1011 pfu/m2 when patients were desensitized with a lower initial dose. JX-594 is an armed VACV with inactivation of TK and transgenic expression of GM-CSF, which was recently tested in a phase I-II dose-escalation trial in patients with refractory primary or metastatic liver cancer [238]. The MTD for JX-594 was determined to be 1 × 109 pfu in this trial. Only one treatment-related death from all oncolytic virus clinical trials conducted to date has been reported. The patient with renal carcinoma metastatic to the lungs died of respiratory failure 5 days after his initial intravenous dose of PV701. The death might be associated with rapid tumor lysis [239]. Virus replication and efficacy have been demonstrated in many clinical trials. For example, analysis of three phase I trials of intravenous administration of PV701 indicated that there were 11 objective responses in 95 evaluable patients [67], which compares favorably to the 7–14% local response rate for intratumorally injected ONXY-015 [234], considering that the intravenous route is a preferred route for the delivery of oncolytic viruses. PV701 replication was demonstrated in the tumor tissue from a patient treated for 11 months [239]. In a phase I trial, JX-594 was intratumorally injected into superficial melanomas in seven patients. A 71% local response rate (five out of seven patients) in melanomas, including two complete responses, was achieved, more importantly, distant uninjected skin metastases also responded to the treatment [240]. Reolyisin, a reovirus, has been tested in several phase I and II clinical trials [60]. In one phase I trial of intravenously administered Reolysin, 6 out of 33 patients showed stable diseases and varying degrees of tumor regression. Moreover, evidence of virus replication within the tumor was observed [241]. Other clinically tested oncolytic viruses include measles virus and HSV, for which varies of response rates have been seen in different clinical trials and virus replication was demonstrated in some of the trials [72, 236]. As discussed in the Section 16.3.4, virotherapy in combination with conventional cancer therapies such as chemotherapy and radiotherapy holds great promise. The available preclinical and clinical data indicate that combination therapy is safe and feasible. More importantly, a lack of cross-resistance between virotherapy and chemotherapy, or radiotherapy, and enhanced efficacy have been demonstrated.

308

16.7 Conclusions Tumor selectivity and anti-tumor potency are the two most important factors that would eventually determine the clinical safety and efficacy of any cancer therapeutics. Oncolytic viruses selectively infect and destroy cancer cells while leaving normal cells unaffected. Many strategies have been developed to further enhance tumor selectivity of oncolytic viruses. An oncolytic virus with combined tumor-selective mechanisms (such as combined transcriptional and transductional targeting mechanisms) would be expected to be safer than a virus with single tumor-selective mechanism. Intriguingly, some oncolytic viruses have been recently shown to specifically target CSCs that are resistant to chemotherapy and radiotherapy and are presumably responsible for tumor metastases and relapse. It will be interesting to know if other oncolytic viruses are also CSC targeting. New strategies will need to be developed to improve CSC selectivity since CSCs represent a distinct subpopulation with the tumor. Numerous clinical trials with many oncolytic virus constructs from seven different species indicate that oncolytic viruses are generally safe and well tolerated in patients with advanced tumors. Certain degrees of antitumoral activity have also been demonstrated in many clinical trials. However, the response rate is relatively low and definitive clinical benefits are mostly unknown. Thus, efforts must now be aimed at improving efficacy. With many oncolytic viral constructs currently being tested in varied phases of clinical trials and intense efforts dedicated to improve efficacy, more sophisticated oncolytic viruses than H101, the world’s first oncolytic virus approved for cancer treatment in China, will soon become available either as monotherapies or in combination with existing treatments for human malignancies.

References 1. Sinkovics JG, Horvath JC (2005) Viral therapy of human cancers. Marcel Dekker, New York 2. Dock G (1904) The influence of complicating diseases upon leukemia. Am J Med Sci 127:563–592 3. De Pace NG (1912) Sulla scomparsa di un enorme cancro vegetante del collo dell’utero senza cura chirurgica. Ginecologia 9:82–88 4. Moore AE (1954) Effects of viruses on tumors. Annu Rev Microbiol 8:393–410

N. Chen and A.A. Szalay 5. Southam CM (1960) Present status of oncolytic virus studies. Trans NY Acad Sci 22:657–673 6. Moore AE (1951) Inhibition of growth of five transplantable mouse tumors by the virus of Russian Far East encephalitis. Cancer 4:375–382 7. Kelly E, Russell SJ (2007) History of oncolytic viruses: genesis to genetic engineering. Mol Ther 15:651–659 8. Sinkovics JG, Horvath JC (2008) Natural and genetically engineered viral agents for oncolysis and gene therapy of human cancers. Arch Immunol Ther Exp (Warsz) 56(Suppl 1):3s–59s 9. Krulwich TA, Jacobs CF, Weisman JH, Southam CM (1962) Studies of six new viruses in tumor-bearing mice. Cancer Res 22:322–328 10. Cassel WA, Garrett RE (1965) Newcastle disease virus as an antineoplastic agent. Cancer 18:863–868 11. Southam CM, Moore AE (1951) West Nile, Ilheus, and Bunyamwera virus infections in man. Am J Trop Med Hyg 31:724–741 12. Southam CM, Moore AE (1952) Clinical studies of viruses as antineoplastic agents with particular reference to Egypt 101 virus. Cancer 5:1025–1034 13. Newman W, Southam CM (1954) Virus treatment in advanced cancer; a pathological study of fifty-seven cases. Cancer 7:106–118 14. Huebner RJ, Rowe WP, Schatten WE, Smith RR, Thomas LB (1956) Studies on the use of viruses in the treatment of carcinoma of the cervix. Cancer 9:1211–1218 15. Martuza RL, Malick A, Markert JM, Ruffner KL, Coen DM (1991) Experimental therapy of human glioma by means of a genetically engineered virus mutant. Science 252:854–856 16. Bischoff JR, Kirn DH, Williams A, Heise C, Horn S, Muna M, Ng L, Nye JA, Sampson-Johannes A, Fattaey A, McCormick F (1996) An adenovirus mutant that replicates selectively in p53-deficient human tumor cells. Science 274:373–376 17. Ganly I, Kirn D, Eckhardt G, Rodriguez GI, Soutar DS, Otto R, Robertson AG, Park O, Gulley ML, Heise C, Von Hoff DD, Kaye SB (2000) A phase I study of ONYX-015, an E1B attenuated adenovirus, administered intratumorally to patients with recurrent head and neck cancer. Clin Cancer Res 6:798–806 18. Garber K (2006) China approves world’s first oncolytic virus therapy for cancer treatment. J Natl Cancer Inst 98:298–300 19. Kirn DH (2006) The end of the beginning: oncolytic virotherapy achieves clinical proof-of-concept. Mol Ther 13:237–238 20. Hanahan D, Weinberg RA (2000) The hallmarks of cancer. Cell 100:57–70 21. Sypula J, Wang F, Ma Y, Bell J, McFadden G (2004) Myxoma virus tropism in human tumor cells. Gene Ther Mol Biol 8:103–114 22. Wang G, Barrett JW, Stanford M, Werden SJ, Johnston JB, Gao X, Sun M, Cheng JQ, McFadden G (2006) Infection of human cancer cells with myxoma virus requires Akt activation via interaction with a viral ankyrin-repeat host range factor. Proc Natl Acad Sci USA 103:4640–4645 23. Testa JR, Bellacosa A (2001) AKT plays a central role in tumorigenesis. Proc Natl Acad Sci USA 98:10983–10985

16 Oncolytic Virotherapy of Cancer 24. Wang F, Gao X, Barrett JW, Shao Q, Bartee E, Mohamed MR, Rahman M, Werden S, Irvine T, Cao J, Dekaban GA, McFadden G (2008) RIG-I mediates the co-induction of tumor necrosis factor and type I interferon elicited by myxoma virus in primary human macrophages. PLoS Pathog 4:e1000099 25. Bartee E, McFadden G (2009) Human cancer cells have specifically lost the ability to induce the synergistic state caused by tumor necrosis factor plus interferon-beta. Cytokine 47:199–205 26. Bartee E, Mohamed MR, Lopez MC, Baker HV, McFadden G (2009) The addition of tumor necrosis factor plus beta interferon induces a novel synergistic antiviral state against poxviruses in primary human fibroblasts. J Virol 83:498–511 27. Letchworth GJ, Rodriguez LL, Del cbarrera J (1999) Vesicular stomatitis. Vet J 157:239–260 28. Barber GN (2005) VSV-tumor selective replication and protein translation. Oncogene 24:7710–7719 29. Baxt B, Sonnabend JA, Bablanian R (1977) Effects of interferon on vesicular stomatitis virus transcription and translation. J Gen Virol 35:325–334 30. Belkowski LS, Sen GC (1987) Inhibition of vesicular stomatitis viral mRNA synthesis by interferons. J Virol 61:653–660 31. Stojdl DF, Lichty B, Knowles S, Marius R, Atkins H, Sonenberg N, Bell JC (2000) Exploiting tumor-specific defects in the interferon pathway with a previously unknown oncolytic virus. Nat Med 6:821–825 32. Stark GR, Kerr IM, Williams BR, Silverman RH, Schreiber RD (1998) How cells respond to interferons. Annu Rev Biochem 67:227–264 33. Kloke O, Niederle N (1990) Development and mechanisms of interferon resistance. Cancer Treat Rev 17 (Suppl A):81–88 34. Balachandran S, Porosnicu M, Barber GN (2001) Oncolytic activity of vesicular stomatitis virus is effective against tumors exhibiting aberrant p53, Ras, or myc function and involves the induction of apoptosis. J Virol 75:3474–3479 35. Shinozaki K, Ebert O, Kournioti C, Tai YS, Woo SL(2004) Oncolysis of multifocal hepatocellular carcinoma in the rat liver by hepatic artery infusion of vesicular stomatitis virus. Mol Ther 9:368–376 36. Hadaschik BA, Zhang K, So AI, Fazli L, Jia W, Bell JC, Gleave ME, Rennie PS (2008) Oncolytic vesicular stomatitis viruses are potent agents for intravesical treatment of high-risk bladder cancer. Cancer Res 68: 4506–4510 37. Jackson GG, Muldoon RL (1973) Viruses causing common respiratory infection in man. IV. Reoviruses and adenoviruses. J Infect Dis 128:811–866 38. Minuk GY, Paul RW, Lee PW (1985) The prevalence of antibodies to reovirus type 3 in adults with idiopathic cholestatic liver disease, J Med Virol 16:55–60 39. Minuk GY, Rascanin N, Paul RW, Lee PW, Buchan K, Kelly JK (1987) Reovirus type 3 infection in patients with primary biliary cirrhosis and primary sclerosing cholangitis. J Hepatol 5:8–13 40. Tai JH, Williams JV, Edwards KM, Wright PF, Crowe JE Jr, Dermody TS (2005) Prevalence of reovirus-specific

309

41.

42.

43.

44.

45.

46.

47. 48. 49.

50.

51.

52.

53.

54. 55.

56.

57.

antibodies in young children in Nashville, Tennessee. J Infect Dis 191:1221–1224 Hashiro G, Loh PC, Yau JT (1977) The preferential cytotoxicity of reovirus for certain transformed cell lines. Arch Virol 54:307–315 Duncan MR, Stanish SM, Cox DC (1978) Differential sensitivity of normal and transformed human cells to reovirus infection. J Virol 28:444–449 Strong JE, Coffey MC, Tang D, Sabinin P, Lee PW (1998) The molecular basis of viral oncolysis: usurpation of the Ras signaling pathway by reovirus. EMBO J 17:3351–3362 Strong JE, Tang D, Lee PW (1993) Evidence that the epidermal growth factor receptor on host cells confers reovirus infection efficiency. Virology 197:405–411 Strong JE, Lee PW (1996) The v-erbB oncogene confers enhanced cellular susceptibility to reovirus infection. J Virol 70:612–616 Norman KL, Hirasawa K, Yang AD, Shields MA, Lee PW (2004) Reovirus oncolysis: the Ras/RalGEF/p38 pathway dictates host cell permissiveness to reovirus infection. Proc Natl Acad Sci USA 101:11099–11104 Malumbres M, Barbacid M (2003) RAS oncogenes: the first 30 years. Nat Rev Cancer 3:459–465 Bos JL (1989) Ras oncogenes in human cancer: a review. Cancer Res 49:4682–4689 Shmulevitz M, Marcato P, Lee PW (2005) Unshackling the links between reovirus oncolysis, Ras signaling, translational control and cancer. Oncogene 24:7720–7728 Marcato P, Shmulevitz M, Pan D, Stoltz D, Lee PW (2007) Ras transformation mediates reovirus oncolysis by enhancing virus uncoating, particle infectivity, and apoptosis-dependent release. Mol Ther 15:1522–1530 Alain T, Kim TS, Lun X, Liacini A, Schiff LA, Senger DL, Forsyth PA (2007) Proteolytic disassembly is a critical determinant for reovirus oncolysis. Mol Ther 15: 1512–1521 Smakman N, van den Wollenberg DJ, Elias SG, Sasazuki T, Shirasawa S, Hoeben RC, Borel Rinkes IH, Kranenburg O (2006) KRAS(D13) Promotes apoptosis of human colorectal tumor cells by ReovirusT3D and oxaliplatin but not by tumor necrosis factor-related apoptosis-inducing ligand. Cancer Res 66:5403–5408 Coffey MC, Strong JE, Forsyth PA, Lee PW (1998) Reovirus therapy of tumors with activated Ras pathway. Science 282:1332–1334 Norman KL, Lee PW (2000) Reovirus as a novel oncolytic agent. J Clin Invest 105:1035–1038 Hirasawa K, Nishikawa SG, Norman KL, Alain T, Kossakowska A, Lee PW (2002) Oncolytic reovirus against ovarian and colon cancer. Cancer Res 62: 1696–1701 Hirasawa K, Nishikawa SG, Norman KL, Coffey MC, Thompson BG, Yoon CS, Waisman DM, Lee PW (2003) Systemic reovirus therapy of metastatic cancer in immune-competent mice. Cancer Res 63:348–353 Prestwich RJ, Errington F, Ilett EJ, Morgan RS, Scott KJ, Kottke T, Thompson J, Morrison EE, Harrington KJ, Pandha HS, Selby PJ, Vile RG, Melcher AA (2008) Tumor infection by oncolytic reovirus primes adaptive antitumoral immunity. Clin Cancer Res 14:7358–7366

310 58. Marcato P, Dean CA, Giacomantonio CA, Lee PW (2009) Oncolytic reovirus effectively targets breast cancer stem cells. Mol Ther 17:972–979 59. Yap TA, Brunetto A, Pandha H, Harrington K, Debono JS (2008) Reovirus therapy in cancer: has the orphan virus found a home? Expert Opin Investig Drugs 17: 1925–1935 60. Lal R, Harris D, Postel-Vinay S, de Bono J (2009) Reovirus: rationale and clinical trial update. Curr Opin Mol Ther 11:532–539 61. Flanagan AD, Love R, Tesar W (1955) Propagation of Newcastle disease virus in Ehrlich ascites cells in vitro and in vivo. Proc Soc Exp Biol Med 90:82–86 62. Reichard KW, Lorence RM, Cascino CJ, Peeples ME, Walter RJ, Fernando MB, Reyes HM, Greager JA (1992) Newcastle disease virus selectively kills human tumor cells. J Surg Res 52:448–453 63. Lorence RM, Katubig BB, Reichard KW, Reyes HM, Phuangsab A, Sassetti MD, Walter RJ, Peeples ME (1994) Complete regression of human fibrosarcoma xenografts after local Newcastle disease virus therapy. Cancer Res 54:6017–6021 64. Krishnamurthy S, Takimoto T, Scroggs RA, Portner A (2006) Differentially regulated interferon response determines the outcome of Newcastle disease virus infection in normal and tumor cell lines, J Virol 80:5145–5155 65. Fiola C, Peeters B, Fournier P, Arnold A, Bucur M, Schirrmacher V (2006) Tumor selective replication of Newcastle disease virus: association with defects of tumor cells in antiviral defence. Int J Cancer 119: 328–338 66. Laurie SA, Bell JC, Atkins HL, Roach J, Bamat MK, O’Neil JD, Roberts MS, Groene WS, Lorence RM (2006) A phase 1 clinical study of intravenous administration of PV701, an oncolytic virus, using two-step desensitization. Clin Cancer Res 12:2555–2562 67. Lorence RM, Roberts MS, O’Neil JD, Groene WS, Miller JA, Mueller SN, Bamat MK (2007) Phase 1 clinical experience using intravenous administration of PV701, an oncolytic Newcastle disease virus. Curr Cancer Drug Targets 7:157–167 68. Griffin DE, Pan CH, Moss WJ (2008) Measles vaccines. Front Biosci 13:1352–1370 69. Dorig RE, Marcil A, Chopra A, Richardson CD (1993) The human CD46 molecule is a receptor for measles virus (Edmonston strain). Cell 75:295–305 70. Naniche D, Varior-Krishnan G, Cervoni F, Wild TF, Rossi B, Rabourdin-Combe C, Gerlier D (1993) Human membrane cofactor protein (CD46) acts as a cellular receptor for measles virus. J Virol 67:6025–6032 71. Tatsuo H, Ono N, Tanaka K, Yanagi Y (2000) SLAM (CDw150) is a cellular receptor for measles virus. Nature 406:893–897 72. Msaouel P, Dispenzieri A, Galanis E (2009) Clinical testing of engineered oncolytic measles virus strains in the treatment of cancer: an overview, Curr Opin Mol Ther 11:43–53 73. Erlenhofer C, Duprex WP, Rima BK, ter Meulen V, Schneider-Schaulies J (2002) Analysis of receptor (CD46, CD150) usage by measles virus. J Gen Virol 83: 1431–1436

N. Chen and A.A. Szalay 74. Yanagi Y, Ono N, Tatsuo H, Hashimoto K, Minagawa H (2002) Measles virus receptor SLAM (CD150). Virology 299:155–161 75. Anderson BD, Nakamura T, Russell SJ, Peng KW (2004) High CD46 receptor density determines preferential killing of tumor cells by oncolytic measles virus, Cancer Res 64:4919–4926 76. Blechacz B, Russell SJ (2008) Measles virus as an oncolytic vector platform. Curr Gene Ther 8:162–175 77. Russell SJ, Peng KW (2009) Measles virus for cancer therapy. Curr Top Microbiol Immunol 330:213–241 78. Russell SJ (2002) RNA viruses as virotherapy agents. Cancer Gene Ther 9:961–966 79. Vaha-Koskela MJ, Heikkila JE, Hinkkanen AE (2007) Oncolytic viruses in cancer therapy. Cancer Lett 254: 178–216 80. Vaha-Koskela MJ, Kallio JP, Jansson LC, Heikkila JE, Zakhartchenko VA, Kallajoki MA, Kahari VM, Hinkkanen AE (2006) Oncolytic capacity of attenuated replicative semliki forest virus in human melanoma xenografts in severe combined immunodeficient mice. Cancer Res 66:7185–7194 81. Maatta AM, Liimatainen T, Wahlfors T, Wirth T, VahaKoskela M, Jansson L, Valonen P, Hakkinen K, Rautsi O, Pellinen R, Makinen K, Hakumaki J, Hinkkanen A, Wahlfors J (2007) Evaluation of cancer virotherapy with attenuated replicative Semliki forest virus in different rodent tumor models. Int J Cancer 121: 2863–870 82. Ketola A, Hinkkanen A, Yongabi F, Furu P, Maatta AM, Liimatainen T, Pirinen R, Bjorn M, Hakkarainen T, Makinen K, Wahlfors J, Pellinen R (2008) Oncolytic Semliki forest virus vector as a novel candidate against unresectable osteosarcoma. Cancer Res 68:8342–8350 83. Maatta AM, Makinen K, Ketola A, Liimatainen T, Yongabi FN, Vaha-Koskela M, Pirinen R, Rautsi O, Pellinen R, Hinkkanen A, Wahlfors J (2008) Replication competent Semliki Forest virus prolongs survival in experimental lung cancer. Int J Cancer 123:1704–1711 84. Tseng JC, Levin B, Hirano T, Yee H, Pampeno C, Meruelo D (2002) In vivo antitumoral activity of Sindbis viral vectors. J Natl Cancer Inst 94:1790–1802 85. Tseng JC, Hurtado A, Yee H, Levin B, Boivin C, Benet M, Blank SV, Pellicer A, Meruelo D (2004) Using sindbis viral vectors for specific detection and suppression of advanced ovarian cancer in animal models. Cancer Res 64:6684–6692 86. Tseng JC, Levin B, Hurtado A, Yee H, Perez de Castro I, Jimenez M, Shamamian P, Jin R, Novick RP, Pellicer A, Meruelo D (2004) Systemic tumor targeting and killing by Sindbis viral vectors, Nat Biotechnol 22:70–77 87. Wollmann G, Tattersall P, van den Pol AN (2005) Targeting human glioblastoma cells: comparison of nine viruses with oncolytic potential. J Virol 79:6005–6022 88. Tseng JC, Granot T, Digiacomo V, Levin B, Meruelo D (2010) Enhanced specific delivery and targeting of oncolytic Sindbis viral vectors by modulating vascular leakiness in tumor. Cancer Gene Ther 17:244–255 89. Au GG, Lincz LF, Enno A, Shafren DR (2007) Oncolytic Coxsackievirus A21 as a novel therapy for multiple myeloma. Br J Haematol 137:133–141

16 Oncolytic Virotherapy of Cancer 90. Shafren DR, Au GG, Nguyen T, Newcombe NG, Haley ES, Beagley L, Johansson ES, Hersey P, Barry RD (2004) Systemic therapy of malignant human melanoma tumors by a common cold-producing enterovirus, coxsackievirus a21. Clin Cancer Res 10:53–60 91. Au GG, Lindberg AM, Barry RD, Shafren DR (2005) Oncolysis of vascular malignant human melanoma tumors by Coxsackievirus A21. Int J Oncol 26:1471–1476 92. Shafren DR, Sylvester D, Johansson ES, Campbell IG, Barry RD (2005) Oncolysis of human ovarian cancers by echovirus type 1. Int J Cancer 115:320–328 93. Haley ES, Au GG, Carlton BR, Barry RD, Shafren DR (2009) Regional administration of oncolytic Echovirus 1 as a novel therapy for the peritoneal dissemination of gastric cancer. J Mol Med 87:385–399 94. Reddy PS, Burroughs KD, Hales LM, Ganesh S, Jones BH, Idamakanti N, Hay C, Li SS, Skele KL, Vasko AJ, Yang J, Watkins DN, Rudin CM, Hallenbeck PL (2007) Seneca Valley virus, a systemically deliverable oncolytic picornavirus, and the treatment of neuroendocrine cancers. J Natl Cancer Inst 99:1623–1633 95. Wadhwa L, Hurwitz MY, Chevez-Barrios P, Hurwitz RL (2007) Treatment of invasive retinoblastoma in a murine model using an oncolytic picornavirus. Cancer Res 67:10653–10656 96. Geletneky K, Herrero YCM, Rommelaere J, Schlehofer JR (2005) Oncolytic potential of rodent parvoviruses for cancer therapy in humans: a brief review. J Vet Med B Infect Dis Vet Public Health 52:327–330 97. Abschuetz A, Kehl T, Geibig R, Leuchs B, Rommelaere J, Regnier-Vigouroux A (2006) Oncolytic murine autonomous parvovirus, a candidate vector for glioma gene therapy, is innocuous to normal and immunocompetent mouse glial cells. Cell Tissue Res 325:423–436 98. Raykov Z, Grekova S, Galabov AS, Balboni G, Koch U, Aprahamian M, Rommelaere J (2007) Combined oncolytic and vaccination activities of parvovirus H-1 in a metastatic tumor model. Oncol Rep 17:1493–1499 99. Angelova AL, Aprahamian M, Balboni G, Delecluse HJ, Feederle R, Kiprianova I, Grekova SP, Galabov AS, Witzens-Harig M, Ho AD, Rommelaere J, Raykov Z (2009) Oncolytic rat parvovirus H-1PV, a candidate for the treatment of human lymphoma: in vitro and in vivo studies. Mol Ther 17:1164–1172 100. Raykov Z, Georgieva PB, Angelova A, Galabov AS, Rommelaere J (2009) Anticancer effects of an oncolytic parvovirus combined with non-conventional therapeutics on pancreatic carcinoma cell lines, Acta Virol 53:57–60 101. Angelova AL, Aprahamian M, Grekova SP, Hajri A, Leuchs B, Giese NA, Dinsart C, Herrmann A, Balboni G, Rommelaere J, Raykov Z (2009) Improvement of gemcitabine-based therapy of pancreatic carcinoma by means of oncolytic parvovirus H-1PV. Clin Cancer Res 15:511–519 102. Best SM (2008) Viral subversion of apoptotic enzymes: escape from death row. Annu Rev Microbiol 62: 171–192 103. McFadden G, Mohamed MR, Rahman MM, Bartee E (2009) Cytokine determinants of viral tropism. Nat Rev Immunol 9:645–655

311 104. Whitman ED, Tsung K, Paxson J, Norton JA (1994) In vitro and in vivo kinetics of recombinant vaccinia virus cancer-gene therapy. Surgery 116:183–188 105. Yu YA, Shabahang S, Timiryasova TM, Zhang Q, Beltz R, Gentschev I, Goebel W, Szalay AA (2004) Visualization of tumors and metastases in live animals with bacteria and vaccinia virus encoding light-emitting proteins. Nat Biotechnol 22:313–320 106. Thorne SH, Hwang TH, O’Gorman WE, Bartlett DL, Sei S, Kanji F, Brown C, Werier J, Cho JH, Lee DE, Wang Y, Bell J, Kirn DH (2007) Rational strain selection and engineering creates a broad-spectrum, systemically effective oncolytic poxvirus, JX-963. J Clin Invest 117: 3350–3358 107. Hengstschlager M, Knofler M, Mullner EW, Ogris E, Wintersberger E, Wawra E (1994) Different regulation of thymidine kinase during the cell cycle of normal versus DNA tumor virus-transformed cells. J Biol Chem 269:13836–13842 108. Buller RM, Smith GL, Cremer K, Notkins AL, Moss B (1985) Decreased virulence of recombinant vaccinia virus expression vectors is associated with a thymidine kinasenegative phenotype. Nature 317:813–815 109. Puhlmann M, Brown CK, Gnant M, Huang J, Libutti SK, Alexander HR, Bartlett DL (2000) Vaccinia as a vector for tumor-directed gene therapy: biodistribution of a thymidine kinase-deleted mutant. Cancer Gene Ther 7:66–73 110. Buller RM, Chakrabarti S, Moss B, Fredrickson T (1988) Cell proliferative response to vaccinia virus is mediated by VGF. Virology 164:182–192 111. Buller RM, Chakrabarti S, Cooper JA, Twardzik DR, Moss B (1988) Deletion of the vaccinia virus growth factor gene reduces virus virulence. J Virol 62:866–874 112. McCart JA, Ward JM, Lee J, Hu Y, Alexander HR, Libutti SK, Moss B, Bartlett DL (2001) Systemic cancer therapy with a tumor-selective vaccinia virus mutant lacking thymidine kinase and vaccinia growth factor genes. Cancer Res 61:8751–8757 113. Guo ZS, Naik A, O’Malley ME, Popovic P, Demarco R, Hu Y, Yin X, Yang S, Zeh HJ, Moss B, Lotze MT, Bartlett DL (2005) The enhanced tumor selectivity of an oncolytic vaccinia lacking the host range and antiapoptosis genes SPI-1 and SPI-2. Cancer Res 65:9991–9998 114. Yang S, Guo ZS, O’Malley ME, Yin X, Zeh HJ, Bartlett DL (2007) A new recombinant vaccinia with targeted deletion of three viral genes: its safety and efficacy as an oncolytic virus. Gene Ther 14:638–647 115. Kirn DH, Wang Y, Le Boeuf F, Bell J, Thorne SH (2007) Targeting of interferon-beta to produce a specific, multimechanistic oncolytic vaccinia virus, PLoS Med 4:e353 116. Zhang Q, Yu YA, Wang E, Chen N, Danner RL, Munson PJ, Marincola FM, Szalay AA (2007) Eradication of solid human breast tumors in nude mice with an intravenously injected light-emitting oncolytic vaccinia virus. Cancer Res 67:10038–10046 117. Lin SF, Yu Z, Riedl C, Woo Y, Zhang Q, Yu YA, Timiryasova T, Chen N, Shah JP, Szalay AA, Fong Y, Wong RJ (2007) Treatment of anaplastic thyroid carcinoma in vitro with a mutant vaccinia virus. Surgery 142:976–983; discussion 976–983

312 118. Lin SF, Price DL, Chen CH, Brader P, Li S, Gonzalez L, Zhang Q, Yu YA, Chen N, Szalay AA, Fong Y, Wong RJ (2008) Oncolytic vaccinia virotherapy of anaplastic thyroid cancer in vivo. J Clin Endocrinol Metab 93: 4403–4407 119. Kelly KJ, Woo Y, Brader P, Yu Z, Riedl C, Lin SF, Chen N, Yu YA, Rusch VW, Szalay AA, Fong Y (2008) Novel oncolytic agent GLV-1h68 is effective against malignant pleural mesothelioma. Hum Gene Ther 19:774–782 120. Yu YA, Galanis C, Woo Y, Chen N, Zhang Q, Fong Y, Szalay AA (2009) Regression of human pancreatic tumor xenografts in mice after a single systemic injection of recombinant vaccinia virus GLV-1h68. Mol Cancer Ther 8:141–151 121. Yu Z, Li S, Brader P, Chen N, Yu YA, Zhang Q, Szalay AA, Fong Y, Wong RJ (2009) Oncolytic vaccinia therapy of squamous cell carcinoma. Mol Cancer 8:45 122. Gentschev I, Stritzker J, Hofmann E, Weibel S, Yu YA, Chen N, Zhang Q, Bullerdiek J, Nolte I, Szalay AA (2009) Use of an oncolytic vaccinia virus for the treatment of canine breast cancer in nude mice: preclinical development of a therapeutic agent. Cancer Gene Ther 16:320–328 123. Zhang Q, Liang C, Yu YA, Chen N, Dandekar T, Szalay AA (2009) The highly attenuated oncolytic recombinant vaccinia virus GLV-1h68: comparative genomic features and the contribution of F14.5L inactivation. Mol Genet Genomics 282:417–435 124. Izmailyan R, Chang W (2008) Vaccinia virus WR53.5/F14.5 protein is a new component of intracellular mature virus and is important for calcium-independent cell adhesion and vaccinia virus virulence in mice. J Virol 82:10079–10087 125. Shida H, Hinuma Y, Hatanaka M, Morita M, Kidokoro M, Suzuki K, Maruyama T, Takahashi-Nishimaki F, Sugimoto M, Kitamura R et al (1988) Effects and virulences of recombinant vaccinia viruses derived from attenuated strains that express the human T-cell leukemia virus type I envelope gene. J Virol 62:4474–4480 126. Mackett M, Smith GL, Moss B (1982) Vaccinia virus: a selectable eukaryotic cloning and expression vector, Proc Natl Acad Sci USA 79:7415–7419 127. Chen N, Zhang Q, Yu YA, Stritzker J, Brader P, Schirbel A, Samnick S, Serganova I, Blasberg R, Fong Y, Szalay AA (2009) A novel recombinant vaccinia virus expressing the human norepinephrine transporter retains oncolytic potential and facilitates deep tissue imaging. Mol Med 15:144–151 128. Brader P, Kelly KJ, Chen N, Yu YA, Zhang Q, Zanzonico P, Burnazi EM, Ghani RE, Serganova I, Hricak H, Szalay AA, Fong Y, Blasberg RG (2009) Imaging a genetically engineered oncolytic vaccinia virus (GLV-1h99) using a human norepinephrine transporter reporter gene. Clin Cancer Res 15:3791–3801 129. Frentzen A, Yu YA, Chen N, Zhang Q, Weibel S, Raab V, Szalay AA (2009) Anti-VEGF single-chain antibody GLAF-1 encoded by oncolytic vaccinia virus significantly enhances antitumoral therapy. Proc Natl Acad Sci USA 106:12915–12920 130. Jia WW, McDermott M, Goldie J, Cynader M, Tan J, Tufaro F (1994) Selective destruction of gliomas in

N. Chen and A.A. Szalay

131.

132.

133.

134.

135. 136.

137.

138.

139.

140.

141.

142.

143.

144.

145.

immunocompetent rats by thymidine kinase-defective herpes simplex virus type 1. J Natl Cancer Inst 86:1209–1215 Boviatsis EJ, Scharf JM, Chase M, Harrington K, Kowall NW, Breakefield XO, Chiocca EA (1994) Antitumoral activity and reporter gene transfer into rat brain neoplasms inoculated with herpes simplex virus vectors defective in thymidine kinase or ribonucleotide reductase. Gene Ther 1:323–331 T. Valyi-Nagy, Gesser RM, Raengsakulrach B, Deshmane SL, Randazzo BP, Dillner AJ, Fraser NW (1994) A thymidine kinase-negative HSV-1 strain establishes a persistent infection in SCID mice that features uncontrolled peripheral replication but only marginal nervous system involvement. Virology 199:484–490 Shen Y, Nemunaitis J (2006) Herpes simplex virus 1 (HSV-1) for cancer treatment. Cancer Gene Ther 13: 975–992 Varghese S, Rabkin SD (2002) Oncolytic herpes simplex virus vectors for cancer virotherapy. Cancer Gene Ther 9:967–978 Martuza RL (2000) Conditionally replicating herpes vectors for cancer therapy. J Clin Invest 105:841–846 Mineta T, Rabkin SD, Yazaki T, Hunter WD, Martuza RL (1995) Attenuated multi-mutated herpes simplex virus1 for the treatment of malignant gliomas. Nat Med 1: 938–943 Todo T, Martuza RL, Rabkin SD, Johnson PA (2001) Oncolytic herpes simplex virus vector with enhanced MHC class I presentation and tumor cell killing. Proc Natl Acad Sci USA 98:6396–6401 Todo T (2008) Oncolytic virus therapy using genetically engineered herpes simplex viruses. Front Biosci 13: 2060–2064 Friedman GK, Pressey JG, Reddy AT, Markert JM, Gillespie GY (2009) Herpes simplex virus oncolytic therapy for pediatric malignancies. Mol Ther 17:1125–1135 Rogulski KR, Freytag SO, Zhang K, Gilbert JD, Paielli DL, Kim JH, Heise CC, Kirn DH (2000) In vivo antitumoral activity of ONYX-015 is influenced by p53 status and is augmented by radiotherapy. Cancer Res 60: 1193–1196 C.C. O’Shea, Johnson L, Bagus B, Choi S, Nicholas C, Shen A, Boyle L, Pandey K, Soria C, Kunich J, Shen Y, Habets G, Ginzinger D, McCormick F (2004) Late viral RNA export, rather than p53 inactivation, determines ONYX-015 tumor selectivity. Cancer Cell 6:611–623 Reid T, Warren R, Kirn D (2002) Intravascular adenoviral agents in cancer patients: lessons from clinical trials. Cancer Gene Ther 9:979–986 Heise C, Hermiston T, Johnson L, Brooks G, SampsonJohannes A, Williams A, Hawkins L, Kirn D (2000) An adenovirus E1A mutant that demonstrates potent and selective systemic anti-tumoral efficacy. Nat Med 6: 1134–1139 Fueyo J, Gomez-Manzano C, Alemany R, Lee PS, McDonnell TJ, Mitlianga P, Shi YX, Levin VA, Yung WK, Kyritsis AP (2000) A mutant oncolytic adenovirus targeting the Rb pathway produces anti-glioma effect in vivo. Oncogene 19:2–12 C. Gomez-Manzano, Balague C, Alemany R, Lemoine MG, Mitlianga P, Jiang H, Khan A, Alonso M, Lang

16 Oncolytic Virotherapy of Cancer

146.

147.

148.

149.

150.

151.

152.

153.

154.

155.

156.

157.

158.

159.

FF, Conrad CA, Liu TJ, Bekele BN, Yung WK, Fueyo J (2004) A novel E1A-E1B mutant adenovirus induces glioma regression in vivo. Oncogene 23:1821–1828 Cascallo M, Capella G, Mazo A, Alemany R (2003) Ras-dependent oncolysis with an adenovirus VAI mutant. Cancer Res 63:5544–5550 Cascallo M, Gros A, Bayo N, Serrano T, Capella G, Alemany R (2006) Deletion of VAI and VAII RNA genes in the design of oncolytic adenoviruses. Hum Gene Ther 17:929–940 Muster T, Rajtarova J, Sachet M, Unger H, Fleischhacker R, Romirer I, Grassauer A, Url A, Garcia-Sastre A, Wolff K, Pehamberger H, Bergmann M (2004) Interferon resistance promotes oncolysis by influenza virus NS1-deletion mutants. Int J Cancer 110:15–21 Bergmann M, Romirer I, Sachet M, Fleischhacker R, A. Garcia-Sastre, Palese P, Wolff K, Pehamberger H, Jakesz R, Muster T (2001) A genetically engineered influenza A virus with ras-dependent oncolytic properties. Cancer Res 61:8188–8193 Gromeier M, Lachmann S, Rosenfeld MR, Gutin PH, Wimmer E (2000) Intergeneric poliovirus recombinants for the treatment of malignant glioma. Proc Natl Acad Sci USA 97:6803–6808 Stojdl DF, Lichty BD, tenOever BR, Paterson JM, Power AT, Knowles S, Marius R, Reynard J, Poliquin L, Atkins H, Brown EG, Durbin RK, Durbin JE, Hiscott J, Bell JC (2003) VSV strains with defects in their ability to shutdown innate immunity are potent systemic anti-cancer agents. Cancer Cell 4:263–275 Rodriguez R, Schuur ER, Lim HY, Henderson GA, Simons JW, Henderson DR (1997) Prostate attenuated replication competent adenovirus (ARCA) CN706: a selective cytotoxic for prostate-specific antigen-positive prostate cancer cells. Cancer Res 57:2559–2563 Miyatake S, Iyer A, Martuza RL, Rabkin SD (1997) Transcriptional targeting of herpes simplex virus for cellspecific replication. J Virol 71:5124–5132 Dorer DE, Nettelbeck DM (2009) Targeting cancer by transcriptional control in cancer gene therapy and viral oncolysis, Adv Drug Deliv Rev 61:554–571 Leja J, Dzojic H, Gustafson E, Oberg K, Giandomenico V, Essand M (2007) A novel chromogranin-A promoterdriven oncolytic adenovirus for midgut carcinoid therapy. Clin Cancer Res 13:2455–2462 Huang TG, Savontaus MJ, Shinozaki K, Sauter BV, Woo SL (2003) Telomerase-dependent oncolytic adenovirus for cancer treatment. Gene Ther 10:1241–1247 Johnson L, Shen A, Boyle L, Kunich J, Pandey K, Lemmon M, Hermiston T, Giedlin M, McCormick F, Fattaey A (2002) Selectively replicating adenoviruses targeting deregulated E2F activity are potent, systemic antitumoral agents. Cancer Cell 1:325–337 Kamizono J, Nagano S, Murofushi Y, Komiya S, Fujiwara H, Matsuishi T, Kosai K (2005) Survivin-responsive conditionally replicating adenovirus exhibits cancerspecific and efficient viral replication. Cancer Res 65: 5284–5291 Malerba M, Daeffler L, Rommelaere J, Iggo RD (2003) Replicating parvoviruses that target colon cancer cells. J Virol 77:6683–6691

313 160. Rocconi RP, Zhu ZB, Stoff-Khalili M, Rivera AA, Lu B, Wang M, Alvarez RD, Curiel DT, Makhija SK (2007) Treatment of ovarian cancer with a novel dual targeted conditionally replicative adenovirus (CRAd). Gynecol Oncol 105:113–121 161. Guhaniyogi J, Brewer G (2001) Regulation of mRNA stability in mammalian cells. Gene 265:11–23 162. Ross J (1995) mRNA stability in mammalian cells. Microbiol Rev 59:423–450 163. Lee CH, Bradley G, Ling V (1998) Increased P-glycoprotein messenger RNA stability in rat liver tumors in vivo. J Cell Physiol 177:1–12 164. Subbaramaiah K, Dannenberg AJ (2003) Cyclooxygenase 2: a molecular target for cancer prevention and treatment. Trends Pharmacol Sci 24:96–102 165. Ahmed A, Thompson J, Emiliusen L, Murphy S, Beauchamp RD, Suzuki K, Alemany R, Harrington K, Vile RG (2003) A conditionally replicating adenovirus targeted to tumor cells through activated RAS/P-MAPKselective mRNA stabilization. Nat Biotechnol 21:771–777 166. Brown BD, Naldini L (2009) Exploiting and antagonizing microRNA regulation for therapeutic and experimental applications. Nat Rev Genet 10:578–585 167. Kelly EJ, Russell SJ (2009) MicroRNAs and the regulation of vector tropism. Mol Ther 17:409–416 168. John B, Enright AJ, Aravin A, Tuschl T, Sander C, Marks DS (2004) Human MicroRNA targets. PLoS Biol 2:e363 169. Xu S, Witmer PD, Lumayag S, Kovacs B, Valle D (2007) MicroRNA (miRNA) transcriptome of mouse retina and identification of a sensory organ-specific miRNA cluster. J Biol Chem 282:25053–25066 170. Landgraf P, Rusu M, Sheridan R, Sewer A, Iovino N, Aravin A, Pfeffer S, Rice A, Kamphorst AO, Landthaler M, Lin C, Socci ND, Hermida L, Fulci V, Chiaretti S, Foa R, Schliwka J, Fuchs U, Novosel A, Muller RU, Schermer B, Bissels U, Inman J, Phan Q, Chien M, Weir DB, Choksi R, De Vita G, Frezzetti D, Trompeter HI, Hornung V, Teng G, Hartmann G, Palkovits M, Di Lauro R, Wernet P, Macino G, Rogler CE, Nagle JW, Ju J, Papavasiliou FN, Benzing T, Lichter P, Tam W, Brownstein MJ, Bosio A, Borkhardt A, Russo JJ, Sander C, Zavolan M, Tuschl T (2007) A mammalian microRNA expression atlas based on small RNA library sequencing. Cell 129:1401–1414 171. Jay C, Nemunaitis J, Chen P, Fulgham P, Tong AW (2007) miRNA profiling for diagnosis and prognosis of human cancer, DNA Cell Biol 26:293–300 172. Kumar MS, Lu J, Mercer KL, Golub TR, Jacks T (2007) Impaired microRNA processing enhances cellular transformation and tumorigenesis. Nat Genet 39:673–677 173. Kelly EJ, Hadac EM, Greiner S, Russell SJ (2008) Engineering microRNA responsiveness to decrease virus pathogenicity. Nat Med 14:1278–1283 174. Edge RE, Falls TJ, Brown CW, Lichty BD, Atkins H, Bell JC (2008) A let-7 MicroRNA-sensitive vesicular stomatitis virus demonstrates tumor-specific replication. Mol Ther 16:1437–1443 175. Ylosmaki E, Hakkarainen T, Hemminki A, Visakorpi T, Andino R, Saksela K (2008) Generation of a conditionally replicating adenovirus based on targeted destruction of E1A mRNA by a cell type-specific MicroRNA. J Virol 82:11009–11015

314 176. Cawood R, Chen HH, Carroll F, Bazan-Peregrino M, van Rooijen N, Seymour LW (2009) Use of tissue-specific microRNA to control pathology of wild-type adenovirus without attenuation of its ability to kill cancer cells. PLoS Pathog 5:e1000440 177. Lee CY, Rennie PS, Jia WW (2009) MicroRNA regulation of oncolytic herpes simplex virus-1 for selective killing of prostate cancer cells. Clin Cancer Res 15:5126–5135 178. Gurlevik E, Woller N, Schache P, Malek NP, Wirth TC, Zender L, Manns MP, Kubicka S, Kuhnel F (2009) p53dependent antiviral RNA-interference facilitates tumorselective viral replication. Nucleic Acids Res 37:e84 179. Bjornsti MA, Houghton PJ (2004) Lost in translation: dysregulation of cap-dependent translation and cancer. Cancer Cell 5:519–523 180. Kevil C, Carter P, Hu B, DeBenedetti A (1995) Translational enhancement of FGF-2 by eIF-4 factors, and alternate utilization of CUG and AUG codons for translation initiation. Oncogene 11:2339–2348 181. Kevil CG, De Benedetti A, Payne DK, Coe LL, Laroux FS, Alexander JS (1996) Translational regulation of vascular permeability factor by eukaryotic initiation factor 4E: implications for tumor angiogenesis. Int J Cancer 65:785–790 182. Stoff-Khalili MA, Rivera AA, Nedeljkovic-Kurepa A, DeBenedetti A, Li XL, Odaka Y, Podduturi J, Sibley DA, Siegal GP, Stoff A, Young S, Zhu ZB, Curiel DT, Mathis JM (2008) Cancer-specific targeting of a conditionally replicative adenovirus using mRNA translational control. Breast Cancer Res Treat 108:43–55 183. Waehler R, Russell SJ, Curiel DT (2007) Engineering targeted viral vectors for gene therapy. Nat Rev Genet 8:573–587 184. Everts M, Curiel DT (2004) Transductional targeting of adenoviral cancer gene therapy. Curr Gene Ther 4: 337–346 185. Parato KA, Senger D, Forsyth PA, Bell JC (2005) Recent progress in the battle between oncolytic viruses and tumours. Nat Rev Cancer 5:965–976 186. Purow B, Staveley-O’Carroll K (2005) Targeting of vaccinia virus using biotin-avidin viral coating and biotinylated antibodies. J Surg Res 123:49–54 187. Tollefson AE, Ryerse JS, Scaria A, Hermiston TW, Wold WS (1996) The E3–11.6-kDa adenovirus death protein (ADP) is required for efficient cell death: characterization of cells infected with ADP mutants. Virology 220: 152–162 188. Doronin K, Toth K, Kuppuswamy M, Ward P, Tollefson AE, Wold WS (2000) Tumor-specific, replicationcompetent adenovirus vectors overexpressing the adenovirus death protein. J Virol 74:6147–6155 189. Mitrus I, Missol-Kolka E, Plucienniczak A, Szala S (2005) Tumour therapy with genes encoding apoptin and E4orf4. Anticancer Res 25:1087–1090 190. Di Piazza M, Mader C, Geletneky K, Herrero YCM, Weber E, Schlehofer J, Deleu L, Rommelaere J (2007) Cytosolic activation of cathepsins mediates parvovirus H-1-induced killing of cisplatin and TRAIL-resistant glioma cells. J Virol 81:4186–4198 191. Prestwich RJ, Errington F, Diaz RM, Pandha HS, Harrington KJ, Melcher AA, Vile RG (2009) The case of

N. Chen and A.A. Szalay

192.

193.

194.

195.

196.

197.

198.

199.

200.

201.

202.

203.

204.

205.

206.

oncolytic viruses versus the immune system: waiting on the judgment of Solomon. Hum Gene Ther 20:1119–1132 Parato KA, Lichty BD, Bell JC (2009) Diplomatic immunity: turning a foe into an ally. Curr Opin Mol Ther 11:13–21 Worschech A, Haddad D, Stroncek DF, Wang E, Marincola FM, Szalay AA (2009) The immunologic aspects of poxvirus oncolytic therapy. Cancer Immunol Immunother 58:1355–1362 Worschech A, Chen N, Yu YA, Zhang Q, Pos Z, Weibel S, Raab V, Sabatino M, Monaco A, Liu H, Monsurro V, Buller RM, Stroncek DF, Wang E, Szalay AA, Marincola FM (2009) Systemic treatment of xenografts with vaccinia virus GLV-1h68 reveals the immunologic facet of oncolytic therapy. BMC Genomics 10:301 Li H, Dutuor A, Tao L, Fu X, Zhang X (2007) Virotherapy with a type 2 herpes simplex virus-derived oncolytic virus induces potent antitumoral immunity against neuroblastoma. Clin Cancer Res 13:316–322 Li H, Dutuor A, Fu X, Zhang X (2007) Induction of strong antitumoral immunity by an HSV-2-based oncolytic virus in a murine mammary tumor model. J Gene Med 9: 161–169 Heinzerling L, Kunzi V, Oberholzer PA, Kundig T, Naim H, Dummer R (2005) Oncolytic measles virus in cutaneous T-cell lymphomas mounts antitumoral immune responses in vivo and targets interferon-resistant tumor cells. Blood 106:2287–2294 Hermiston TW, Kuhn I (2002) Armed therapeutic viruses: strategies and challenges to arming oncolytic viruses with therapeutic genes. Cancer Gene Ther 9:1022–1035 Schepelmann S, Springer CJ (2006) Viral vectors for gene-directed enzyme prodrug therapy. Curr Gene Ther 6:647–670 Kim JH, Lee YS, Kim H, Huang JH, Yoon AR, Yun CO (2006) Relaxin expression from tumor-targeting adenoviruses and its intratumoral spread, apoptosis induction, and efficacy. J Natl Cancer Inst 98:1482–1493 Nakamori M, Fu X, Meng F, Jin A, Tao L, Bast RC Jr, Zhang X (2003) Effective therapy of metastatic ovarian cancer with an oncolytic herpes simplex virus incorporating two membrane fusion mechanisms. Clin Cancer Res 9:2727–2733 Kelly KJ, Brader P, Woo Y, Li S, Chen N, Yu YA, Szalay AA, Fong Y (2009) Real-time intraoperative detection of melanoma lymph node metastases using recombinant vaccinia virus GLV-1h68 in an immunocompetent animal model. Int J Cancer 124:911–918 Msaouel P, Iankov ID, Allen C, Aderca I, Federspiel MJ, Tindall DJ, Morris JC, Koutsilieris M, Russell SJ, Galanis E (2009) Noninvasive imaging and radiovirotherapy of prostate cancer using an oncolytic measles virus expressing the sodium iodide symporter. Mol Ther 17:2041–2048 Kumar S, Gao L, Yeagy B, Reid T (2008) Virus combinations and chemotherapy for the treatment of human cancers. Curr Opin Mol Ther 10:371–379 Harrington KJ, Melcher A, Vassaux G, Pandha HS, Vile RG (2008) Exploiting synergies between radiation and oncolytic viruses. Curr Opin Mol Ther 10:362–370 Crompton AM, Kirn DH (2007) From ONYX-015 to armed vaccinia viruses: the education and evolution of

16 Oncolytic Virotherapy of Cancer

207. 208.

209.

210.

211.

212.

213.

214.

215.

216.

217.

218.

219.

220.

oncolytic virus development. Curr Cancer Drug Targets 7:133–139 Yu W, Fang H (2007) Clinical trials with oncolytic adenovirus in China. Curr Cancer Drug Targets 7:141–148 Lee WP, Tai DI, Tsai SL, Yeh CT, Chao Y, Lee SD, Hung MC (2003) Adenovirus type 5 E1A sensitizes hepatocellular carcinoma cells to gemcitabine. Cancer Res 63:6229–6236 Zurakowski R, Wodarz D (2007) Model-driven approaches for in vitro combination therapy using ONYX-015 replicating oncolytic adenovirus. J Theor Biol 245:1–8 Chung SM, Advani SJ, Bradley JD, Kataoka Y, Vashistha K, Yan SY, Markert JM, Gillespie GY, Whitley RJ, Roizman B, Weichselbaum RR (2002) The use of a genetically engineered herpes simplex virus (R7020) with ionizing radiation for experimental hepatoma. Gene Ther 9:75–80 Advani SJ, Sibley GS, Song PY, Hallahan DE, Kataoka Y, Roizman B, Weichselbaum RR (1998) Enhancement of replication of genetically engineered herpes simplex viruses by ionizing radiation: a new paradigm for destruction of therapeutically intractable tumors. Gene Ther 5:160–165 Mezhir JJ, Advani SJ, Smith KD, Darga TE, Poon AP, Schmidt H, Posner MC, Roizman B, Weichselbaum RR (2005) Ionizing radiation activates late herpes simplex virus 1 promoters via the p38 pathway in tumors treated with oncolytic viruses. Cancer Res 65:9479–9484 Zhou BB, Zhang H, Damelin M, Geles KG, Grindley JC, Dirks PB (2009) Tumour-initiating cells: challenges and opportunities for anticancer drug discovery. Nat Rev Drug Discov 8:806–823 Lapidot T, Sirard C, Vormoor J, Murdoch B, Hoang T, Caceres-Cortes J, Minden M, Paterson B, Caligiuri MA, Dick JE (1994) A cell initiating human acute myeloid leukaemia after transplantation into SCID mice. Nature 367:645–648 Bonnet D, Dick JE (1997) Human acute myeloid leukemia is organized as a hierarchy that originates from a primitive hematopoietic cell. Nat Med 3:730–737 Ribacka C, Hemminki A (2008) Virotherapy as an approach against cancer stem cells. Curr Gene Ther 8: 88–96 Ishii H, Iwatsuki M, Ieta K, Ohta D, Haraguchi N, Mimori K, Mori M (2008) Cancer stem cells and chemoradiation resistance. Cancer Sci 99:1871–1877 Cripe TP, Wang PY, Marcato P, Mahller YY, Lee PW (2009) Targeting cancer-initiating cells with oncolytic viruses. Mol Ther 17:1677–1682 Bauerschmitz GJ, Ranki T, Kangasniemi L, Ribacka C, Eriksson M, Porten M, Herrmann I, Ristimaki A, Virkkunen P, Tarkkanen M, Hakkarainen T, Kanerva A, Rein D, Pesonen S, Hemminki A (2008) Tissue-specific promoters active in CD44+CD24-/low breast cancer cells. Cancer Res 68:5533–5539 Nandi S, Ulasov IV, Tyler MA, Sugihara AQ, Molinero L, Han Y, Zhu ZB, Lesniak MS (2008) Lowdose radiation enhances survivin-mediated virotherapy against malignant glioma stem cells. Cancer Res 68: 5778–5784

315 221. Friedman GK, Langford CP, Coleman JM, Cassady KA, Parker JN, Markert JM, Yancey Gillespie G (2009) Engineered herpes simplex viruses efficiently infect and kill CD133+ human glioma xenograft cells that express CD111. J Neurooncol 95:199–209 222. Alemany R, Cascallo M (2009) Oncolytic viruses from the perspective of the immune system. Future Microbiol 4:527–536 223. Smakman N, van der Bilt JD, van den Wollenberg DJ, Hoeben RC, Borel Rinkes IH, Kranenburg O (2006) Immunosuppression promotes reovirus therapy of colorectal liver metastases. Cancer Gene Ther 13:815–818 224. Chang CL, Ma B, Pang X, Wu TC, Hung CF (2009) Treatment with cyclooxygenase-2 inhibitors enables repeated administration of vaccinia virus for control of ovarian cancer. Mol Ther 17:1365–1372 225. Lun XQ, Zhou H, Alain T, Sun B, Wang L, Barrett JW, Stanford MM, McFadden G, Bell J, Senger DL, Forsyth PA (2007) Targeting human medulloblastoma: oncolytic virotherapy with myxoma virus is enhanced by rapamycin. Cancer Res 67:8818–8827 226. Stanford MM, Breitbach CJ, Bell JC, McFadden G (2008) Innate immunity, tumor microenvironment and oncolytic virus therapy: friends or foes? Curr Opin Mol Ther 10: 32–37 227. Kurozumi K, Hardcastle J, Thakur R, Yang M, Christoforidis G, Fulci G, Hochberg FH, Weissleder R, Carson W, Chiocca EA, Kaur B (2007) Effect of tumor microenvironment modulation on the efficacy of oncolytic virus therapy. J Natl Cancer Inst 99:1768–1781 228. Bangari DS, Mittal SK (2006) Current strategies and future directions for eluding adenoviral vector immunity. Curr Gene Ther 6:215–226 229. Russell SJ, Peng KW (2008) The utility of cells as vehicles for oncolytic virus therapies, Curr Opin Mol Ther 10: 380–386 230. Willmon C, Harrington K, Kottke T, Prestwich R, Melcher A, Vile R (2009) Cell carriers for oncolytic viruses: Fed Ex for cancer therapy. Mol Ther 17:1667–1676 231. Altomonte J, Wu L, Chen L, Meseck M, Ebert O, GarciaSastre A, Fallon J, Woo SL (2008) Exponential enhancement of oncolytic vesicular stomatitis virus potency by vector-mediated suppression of inflammatory responses in vivo. Mol Ther 16:146–153 232. Zamarin D, Martinez-Sobrido L, Kelly K, Mansour M, Sheng G, Vigil A, Garcia-Sastre A, Palese P, Fong Y (2009) Enhancement of oncolytic properties of recombinant newcastle disease virus through antagonism of cellular innate immune responses. Mol Ther 17:697–706 233. Haralambieva I, Iankov I, Hasegawa K, Harvey M, Russell SJ, Peng KW (2007) Engineering oncolytic measles virus to circumvent the intracellular innate immune response. Mol Ther 15:588–597 234. Liu TC, Galanis E, Kirn D (2007) Clinical trial results with oncolytic virotherapy: a century of promise, a decade of progress. Nat Clin Pract Oncol 4:101–117 235. Shirakawa T (2009) Clinical trial design for adenoviral gene therapy products. Drug News Perspect 22:140–145 236. Jeyaretna DS, Kuroda T (2007) Recent advances in the development of oncolytic HSV-1 vectors: ‘arming’ of HSV-1 vectors and application of bacterial artificial

316 chromosome technology for their construction. Curr Opin Mol Ther 9:447–466 237. Kirn DH, Thorne SH (2009) Targeted and armed oncolytic poxviruses: a novel multi-mechanistic therapeutic class for cancer. Nat Rev Cancer 9:64–71 238. Park BH, Hwang T, Liu TC, Sze DY, Kim JS, Kwon HC, Oh SY, Han SY, Yoon JH, Hong SH, Moon A, Speth K, Park C, Ahn YJ, Daneshmand M, Rhee BG, Pinedo HM, Bell JC, Kirn DH (2008) Use of a targeted oncolytic poxvirus, JX-594, in patients with refractory primary or metastatic liver cancer: a phase I trial, Lancet Oncol 9:533–542 239. Pecora AL, Rizvi N, Cohen GI, Meropol NJ, Sterman D, Marshall JL, Goldberg S, Gross P, O’Neil JD, Groene WS,

N. Chen and A.A. Szalay Roberts MS, Rabin H, Bamat MK, Lorence RM (2002) Phase I trial of intravenous administration of PV701, an oncolytic virus, in patients with advanced solid cancers. J Clin Oncol 20:2251–2266 240. Mastrangelo MJ, Maguire HC Jr, Eisenlohr LC, Laughlin CE, Monken CE, McCue PA, Kovatich AJ, Lattime EC (1999) Intratumoral recombinant GM-CSF-encoding virus as gene therapy in patients with cutaneous melanoma. Cancer Gene Ther 6:409–422 241. Vidal L, Pandha HS, Yap TA, White CL, Twigger K, Vile RG, Melcher A, Coffey M, Harrington KJ, Debono JS (2008) A phase I study of intravenous oncolytic reovirus type 3 dearing in patients with advanced cancer. Clin Cancer Res 14:7127–7137

Part III

Other

Chapter 17

Protein Kinase Inhibitors Daanish Hoda and Adil Daud

17.1 Introduction In the 1970s investigators discovered that mutant genes referred to as “oncogenes” were responsible for the transformed phenotype in many malignant cells. The transformed phenotype referred to was a distinctive constellation of features that included lack of contact inhibition in cell culture, increased proliferation, reduced sensitivity to apoptotic stimuli and increased invasiveness in soft agar. Working from viruses that were responsible for transformation, several groups of investigators showed that the viral “oncogenes” were actually mutated copes of somatic genes [46]. The first oncogene described, Src, was a cytoplasmic protein tyrosine kinase. Subsequently, it has been shown that many critical signalling functions within the cell are controlled by the tyrosine kinase enzymes [4]. These enzymes play a major role in cellular processes such as metabolism, proliferation, differentiation, survival and angiogenesis. Inappropriate signalling in this pathway causes dysregulation of processes involving angiogenesis, apoptosis, cell migration and cell cycle control. The tyrosine kinases are divided structurally into the receptor tyrosine kinases (RTK) which are anchored into the cell membrane and the cytoplasmic non receptor tyrosine kinases (NRTK) which are cytosolic or nuclear. Intracellular tyrosine kinases are located in the cytoplasm, nucleus, or at the intracellular side of the plasma membrane [52].

A. Daud () Division of Hematology Oncology, Department of Medicine, University of California, 1600 Divisadero Street, San Francisco, CA 94010, USA e-mail: [email protected]; [email protected]

Typically, the activity of these enzymes is tightly regulated, so that nonproliferating cells have low levels of tyrosyl phosphorylated proteins. RTK are activated when a ligand binds to the extracellular domain, resulting in oligomerization and eventual autophosphorylation of a regulatory tyrosine in the activation loop of the kinase. After activation, autophosphorylation generates binding sites for signalling proteins and activates multiple signalling pathways. NRTKs are maintained inactive by intramolecular inhibition by cellular inhibitory proteins and lipids. NRTKs are activated by the dissociation of inhibitors, recruitment of transmembrane receptors and trans-phosphorylation of other kinases [33]. Abnormal activation can occur in numerous ways. It may occur by genomic rearrangements causing a fusion protein such as in BCR-ABL resulting from the Philadelphia chromosome. It can also occur when a point mutation causes a protein kinase to be constitutively active such as c-Kit. Increased or aberrant expression of the protein kinase or ligand for RTK such as Her2 or VEGF can also initiate or promote neoplasia [60]. Targeting the aberrant RTK or NRTK therefore can arrest or reverse the process of neoplasia [3]. A variety of strategies have been used to inhibit these enzymes. Small molecule tyrosine kinase inhibitors (TKI) mimic ATP and are frequently designed to bind to the ATP binding within the intracellular domain of various wild type and/or mutated RTK. Another strategy used is to design monoclonal antibodies to bind the extracellular domains of RTK’s such as EGFR (epidermal growth factor receptor), HER2 (Human Epidermal growth factor Receptor 2) and VEGF (vascular endothelial growth factor) The

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_17, © Springer Science+Business Media B.V. 2011

319

320

D. Hoda and A. Daud

Fig. 17.1 Tyrosine kinase inhibitors organized by chemical structure class

binding of the monoclonal antibodies to the extracellular sites prevents the dimerization and subsequent activation. Both strategies prevents downstream signalling, which subsequently stops the cancer cell from promoting malignant transformation and tumor progression (Fig. 17.1).

17.2 C-Kit and BCR-ABL Tyrosine Kinases Imatinib R Imatinib mesylate (Gleevec ) is a benzamide NRTK inhibitor that was the first commercially available small molecule tyrosine kinase inhibitor on the market.

It targets both forms of the abnormal fusion NRTK formed by the reciprocal 9:22 chromosomal translocation seen in many patients with chronic myeloid leukemia and acute lymphoid leukemia p190 (BCRABL) and p210 (BCR-ABL) [11]. The BCR-ABL fusion protein appears to be abnormally localized and activated in leukemic cells. Imatinib can cause apoptosis in these cells and dramatically impact the clinical outcome in patients [13]. In addition imatinib also binds to the kinase domain of c-Kit and PDGFR-β (platelet derived growth factor β) tyrosine kinase. A phase II study involving 1000 patients with CML was published in 2001. It studied CML patients in chronic phase with 400 mg/day of Imatinib and those in accelerated or blast crisis receiving

17 Protein Kinase Inhibitors

600 mg/day. Astonishing results were seen with a complete hematologic response in 91% of patients in chronic phase CML, 53% of patients with accelerated phase CML and 26% of patients in blast crisis [13]. Imatinib therapy has also been shown to be effective in treatment of relapsed or refractory adult ALL who are BCR-ABL positive. Complete responses were seen in 60–70% of cases, but most relapsed within months of treatment [12]. Imatinib has shown remarkable results in nonhematologic malignancies as well. Gastrointestinal stromal tumors (GIST) exhibit the c-Kit tyrosine kinase. This is constantly activated in 90% of GISTs [50] and is a site of inhibition by imatinib. An initial study was published in 2002 which studied 147 patients with GIST. They were randomized to either 400 mg or 600 mg of imatinib daily. Overall 54% had a partial response and 28% had stable disease [9]. In a subsequent Phase III trial, 946 patients were randomized to either 400 mg daily or 400 mg twice daily. In this trial, at a median of 760 days, there was better progression free survival in the twice daily arm vs. the once daily arm (56% vs. 50%, P = 0.026). However, the group that was treated twice daily had more dose reductions (66% vs. 17%) and treatment interruptions (64% vs. 40%) [61]. Imatinib is generally well tolerated with minimal side effects. Grade 3 or 4 neutropenia occured in 8.1% of patients, grade 3 or 4 thrombocytopenia in 0.9%, and grade 3 or 4 anemia in 1.1% of patients. Grade 3 or 4 non hematologic side effects included nausea (1.5%), skin rash (3.0%), edema (1.1%), muscle cramps (0.9%), and weight gain (4.3%) [29]. GIST patients demonstrated minimal myelosuppression, although anemia did occur. Intratumoral bleeding developed in fewer than 5% of these patients [51]. In patients with CML, imatinib should be started at 400 mg daily. For patients with a complete cytogenetic response, hematologic assessment should be done every 4–6 weeks, BCR-ABL transcript levels should be measured every 3 months, and cytogenetic assessment should be done every 12–18 months because of the risk of resistance to Imatinib [37]. There are several mechanisms that have been proposed for imatinib resistance. These include, but are not limited to, BCR-ABL gene mutations, overexpression of the BCR-ABL gene locus [20] and activation of BCRABL independent pathways such as the Src family of kinases [10].

321

17.3 Dasatinib With the use of imatinib, it was realized that a fraction of patients appear to have or develop resistance to this drug. Several newer generation drugs have been developed that can overcome some types of imatinib resistance. One of these drugs is dasatinib monohydrate (Sprycel). It is a carboxamide NRTK inhibitor which not only inhibits the wild type BCRABL tyrosine kinase, but also several imatinib resistant mutants and also the Src family of kinases which appear to play a role in imatinib resistance. Activated Src tyrosine kinases signal through many downstream signalling intermediates which include the Stat (signal transducers and activator of transcription) [63], focal adhesion kinase, cadherin, βcatenin and others [36]. In addition dasatinib inhibits the ephrin receptor kinases, platelet derived growth factor receptor and c-Kit [53]. Dasatinib has been shown in in-vitro and in-vivo preclinical studies to have inhibitory activities against BCR-ABL in 18 of 19 tested mutations associated with resistance to imatinib [53]. A phase I trial of dasatinib was done in patients with chronic, accelerated, or blast phase CML or Philadelphia chromosome positive ALL who were imatinib resistant or intolerant [58]. In chronic phase CML the complete hematologic response was 93% and major cytogenetic response was 45%. Among the patients with accelerated phase CML, the complete hematologic response was 45% and in the blast phase it was 35%. Dasatinib was well tolerated in this trial. The rate of grade 3 or 4 cytopenias was reported as 45% in chronic phase, 82% in accelerated phase, and 96% in blast phase. 15 of the 84 studied patients developed unexplained pleural effusions [58]. Dasatinib was further studied in a group of phase II trials called the START trials, the most recent of these was the START R trial [32]. In this latest trial, imatinib resistant CML, dasatinib demonstrated higher rates of complete hematologic response (93% vs. 82%; P = 0.034), major cytogenetic response (MCyR) (53% vs. 33%; P = 0.017), and complete cytogenetic response (44% vs. 18%; P = 0.0025) compared to high dose imatinib. At 18 months, the MCyR was maintained in 90% of patients on the dasatinib arm and in 74% of patients on the high-dose

322

imatinib arm. These studies followed and confirmed the phase I study mentioned above. The complete hematologic response was as follows: chronic phase – 90%, accelerated phase – 33%, and blast phase – 24%. Major cytogenetic response in the chronic phase was 45%, accelerated phase was 32% and blast phase was 30% [31]. These response rates are even more impressive considering that many patients had a long pre-treatment course with imatinib and eventually failed it.

17.4 Nilotinib Another new tyrosine kinase inhibitor directed against BCR-ABL, platelet derived growth factor, and c-Kit is R ). Nilotinib is a benzanilotinib (AMN 107, Tasigna mide NRTK inhibitor which has 20–50 times greater potency for BCR-ABL inhibition compared to imatinib [39]. However, it does not inhibit the Src kinase like dasatinib. Initial results of a Phase I trial have been reported in patients intolerant of or resistant to imatinib. One hundred nineteen patients were given the drug with a maximally tolerated dose of 600 mg twice daily. However, responses did not seem to vary significantly in the 400 mg twice daily group vs. the 600 mg twice daily group. The incidence of grade 3 or 4 neutropenia was 22% with 600 mg twice daily and 9% with 400 mg twice daily; the incidence of increased indirect bilirubinemia was 11% with 600 mg twice daily and 3% with 400 mg twice daily. Hematologic responses were noted in 11/12 of patients in chronic phase CML, 33/46 in accelerated phase and 13/33 in blastic phase CML [30]. It is currently being evaluated in phase II studies (Fig. 17.2).

17.5 EGFR and HER2 Tyrosine Kinase Inhibitors The Her family of tyrosine kinases include four members. Her 1 (Human Epidermal Growth Factor Receptor, or EGFR/erbB1) HER2 (erbB2), Her3 (erbB3) and Her4 (erbB4). Upon ligand binding these RTKs undergo hetero- or homo-dimerization. This dimerization causes autophosphorylation of the

D. Hoda and A. Daud

intracellular domain and subsequently deregulates growth, decreases apoptosis and regulates angiogenesis [2]. Thus small molecule inhibitors were developed to block the downstream activation which in turn could help regulate growth, increase apoptosis and disrupt angiogenesis.

17.6 Gefitinib R Gefitinib (Iressa ) is an amine RTK inhibitor which was the first commercially available TKI directed against the epidermal growth factor receptor. Based on the overexpression of EGFR in Non-Small Cell Lung Cancer (NSCLC), it was studied extensively in these patients and was initially approved for patients as second and third line treatment of NSCLC by the FDA in May 2003 under the Agency’s accelerated approval program. Gefitinib monotherapy in patients with stage IIIB and IV NSCLC as second or third line has been investigated in two large, multicenter, randomized Phase II trials, “Iressa” Dose Evaluation in Advanced Lung cancer (IDEAL) 1 and 2. The objective tumor response rate at 250 mg day in IDEAL 1 was 18.4%. In IDEAL 2, which included a more heavily pre-treated population, the objective response rate was 11.8% for the 250 mg day dose. Objective responses were unrelated to the number of prior chemotherapy regimens. In addition, gefitinib was found to improve NSCLCspecific symptoms in the two trials (40.3 and 43.1% of patients in IDEAL 1 and 2, respectively) [34]. This objective response rate was what lead to its initial FDA approval. Overall, 250 mg/day was as effective as 500 mg/day. Adverse events were generally grade 1 and 2 diarrhea, skin rash, pruritus, dry skin, and acne with a low incidence of grade 3 and 4 adverse drug reactions. There have also been reports of interstitial lung disease. Gefitinib was not associated with significant hematologic toxicity. Further analysis of the gefitinib studies suggests that individuals with bronchoalveolar subtype, never smokers, Asians, and females are more likely to benefit [34]. Combining gefitinib with chemotherapy has also been evaluated. In a randomized phase II placebocontrolled double blinded trial, 1037 patients who were chemotherapy naïve with advanced NSCLC received

17 Protein Kinase Inhibitors

323

Fig. 17.2 Downstream signalling pathway and its small molecule inhibitors of the EGFR receptors

gefitinib or placebo plus paclitaxel (225 mg/m2 ) and carboplatin (area under concentration/time curve of 6 mg/min/ml, once every three weeks) [23]. After a maximum of six cycles, daily gefitinib or placebo continued until disease progression. This trial did not show a difference in overall survival (median 8.7, 9.8, and 9.9 months for gefitinib 500 mg/day, 250 mg/day, and placebo, respectively; P = 0.64), time to tumor progression (4.6, 5.3, and 5.0 months, respectively), and overall response rate (30.0, 30.4, and 28.7%). Unfortunately, final data from IDEAL and a Phase III trial, ISEL, did not show any survival benefit to gefitinib monotherapy [59]. The FDA then released a statement on December 17, 2004, after the failure of gefitinib to show an overall survival advantage in treating patients with lung cancer, urging patients to consult with their physicians regarding available alternative therapies to gefitinib. It is now only available for those patients who have achieved a benefit with Gefitinib.

17.7 Erlotinib R Erlotinib (Tarceva ) is another amine EGFR inhibitor recently extensively tested. It has been studied in patients with NSCLC, ovarian cancer, squamous cell cancer of head and neck, primary glioblastoma and pancreatic cancer. In November 2004 the FDA approved Erlotinib as monotherapy for patients with locally advanced or metastatic NSCLC, which had failed previous treatment. Subsequently, the FDA approved it for first line treatment in combination with gemcitabine for locally advanced, inoperable or metastatic pancreatic cancer. Patients with NSCLC, who had previously failed chemotherapy, were tested in a Phase III study with erlotinib [54]. Seven hundred thirty one patients were given 150 mg/day of erlotinib vs. placebo. The response rate was 8.9% in the erlotinib group and <1% in the placebo group; the median duration of the response was 7.9 months and 3.7 months respectively.

324

Progression free survival was 2.2 months and 1.8 months respectively. Overall survival was 6.7 months and 4.7 months, in favor of erlotinib. The response of erlotinib among patients with NSCLC was not significantly altered by performance status, prior treatments, prior response, or age, but it was higher among women, nonsmokers, Asians, and patients with adenocarcinoma. In multiple logistic-regression analyses, never having smoked, the presence of adenocarcinoma, and EGFR expression were associated with responsiveness to erlotinib. The combination of erlotinib with conventional chemotherapy has been studied in TALENT and TRIBUTE. No difference has been found in overall survival in combination with other chemotherapy agents. In a phase III trial, 1059 patients with good performance status and previously untreated advanced (stage IIIB/IV) NSCLC were randomly assigned erlotinib (150 mg/day) or placebo combined with up to six cycles of carboplatin (area under the curve of 6) and paclitaxel (200 mg/m2 ), followed by maintenance monotherapy with erlotinib [24]. Median survival for patients treated with erlotinib was 10.6 vs. 10.5 months for placebo. There was no difference in overall response (21.5% vs. 19.3%), or median time to tumor progression (5.1 month for erlotinib and 4.9 months for placebo, P = 0.36). Patients who reported never smoking (72 erlotinib; 44 placebo) had improved overall median survival (22.5 vs. 10.1 months, P = 0.01). The erlotinib arm had a higher incidence of serious adverse events relative to the placebo arm (8.6% vs. 2.4%). The most common events included diarrhea and rash. There were five severe interstitial lung disease events in the erlotinib arm and one in the placebo arm. Erlotinib was well tolerated in heavily pre-treated head and neck squamous cell carcinoma patients and produced prolonged disease stabilization [55]. One hundred fifteen patients received erlotinib at 150 mg daily. The overall objective response rate was 4.3%. Disease stabilization was maintained in 44 patients (38.3%) for a median duration of 16.1 weeks. The median progression-free survival was 9.6 weeks (95% CI, 8.1–12.1 weeks), and the median overall survival was 6.0 months (95% CI, 4.8–7.0 months). Subgroup analyses revealed a significant difference in overall survival favoring patients who developed at least grade 2 skin rashes vs. those who did not (P =0.045). Rash and diarrhea were the most common

D. Hoda and A. Daud

drug-related toxicities, encountered in 79 and 37% of patients. The addition of erlotinib to gemcitabine significantly improves survival and progression free survival in advanced pancreatic cancer. Five hundred sixty nine patients with advanced pancreatic adenocarcinoma and no prior systemic chemotherapy were randomized to receive gemcitabine 1000 mg/m2 IV weekly × 7 for 8 weeks then weekly × 3 out of 4 weeks plus either erlotinib 100 mg oral daily or a placebo in a double blind fashion [40]. There was a difference in overall survival in favor of erlotinib arm with a hazard ratio of 0.81. The corresponding one-year survival rates were 24% vs. 17%. PFS was also significantly improved in the gemcitabine and erlotinib treatment group with a hazard ratio of 0.76, P = 0.003. The tumor control rates were 57 and 49% for the erlotinib and placebo groups respectively. An increase in grade 1 and 2 rash, diarrhea and hematologic toxicity was seen with erlotinib. Rates of grade 3 or 4 toxicity were comparable in both arms. The development of skin rash, but not the EGFR status was associated with longer survival. Patients with renal cell cancer have also been studied. Erlotinib (150 mg/day) combined with bevacizumab (10 mg/kg IV once every 2 weeks) in a phase II trial demonstrated 25% OR and a further 61% SD in 59 patients after 8 weeks of treatment. The median and 1-year PFS was 11 months and 43%, respectively. The median survival had not been reached at the time of reporting (median follow-up of 15 months), and survival at 18 months was 60% [21]. The additive or synergistic potential of this regimen was further evaluated in a randomized phase II trial of bevacizumab plus placebo vs. bevacizumab plus erlotinib [5]. This trial demonstrated identical response rates and PFS rates for the 2 arms (ORR: 13.7% vs. 14%, respectively, and PFS of 8.5 vs. 9.9 months, respectively; P = 0.58). Based on this trial, it does not seem like erlotinib plus bevacizumab in renal cell cancer has any role. Further studies are underway. Erlotinib in combination with carboplatin is currently being studied in patients with glioblastoma multiforme [8]. Twenty patients had been enrolled at the time of interim analysis at the 2007 Annual ASCO meeting. The median time to progression was 15.2 weeks with a 95% CI of 8.0–28.4 weeks. These results were compared to historical data (median of 9.0 weeks, 95% CI of 8.1–10.1 weeks). Grade 3 and 4 toxicities included fatigue, leukopenia, thrombocytopenia and

17 Protein Kinase Inhibitors

rash requiring dose reductions. These are promising results and further studies are underway.

325

patients with platinum refractory or recurrent ovarian cancer, canertinib did not show significant activity [6]. Studies in breast cancer and NSCLC have also been disappointing (Fig. 17.3) [28, 49].

17.8 Lapatinib R Lapatinib (Tykerb ) is an amine RTK inhibitor that inhibits both EGFR and HER2 [44]. The FDA approved it in March 2007 for use with capecitabine in trastuzumab refractory breast cancer. An international phase III study in HER2 overexpressing patients was stopped early after interim analysis. It studied lapatinib with capecitabine or capecitabine alone of 392 patients. Median time to progression was 8.4 months in the combination arm and 4.4 months in the capecitabine alone arm [18]. Based on the progression data, the FDA approved its use. The most common adverse events were diarrhea, the hand–foot syndrome), nausea, vomiting, fatigue, and rash that was distinct from the hand–foot syndrome. Grade 4 diarrhea occurred in two women in the combination-therapy group (1%). One case each of grade 4 fatigue, headache, and dizziness was reported in the monotherapy group. In phase II studies in patients with metastatic colorectal cancer (mCRC) the effects of lapatinib were small. Of the 86 patients, 1 had partial response, 5 minor responses and 5 patients with stable disease [17]. Reported adverse events were diarrhea and skin rash. An analysis of 2812 patients in trials with lapatinib was done for cardiac function. Left ventricular ejection fraction (LVEF) was done every 8 weeks. Of those patients only 1.3% (n = 37) had any significant decrease in LVEF. In 68% of cases, the decrease in ejection fraction was within 9 weeks and improved in 57% of cases. Only 4 of the 37 patients were symptomatic (0.1% of total) [47].

17.9 Canertinib Canertinib dihydrochloride is a propenamide RTK inhibitor currently under investigation. It irreversibly binds all members of the EGFR family. This may have the advantage of prolonged clinical effect and reduce the need for frequent dosing [48]. In a phase II study in

17.10 Vascular Endothelial Growth Factor Tyrosine Kinase Inhibitors The vascular endothelial growth factor (VEGF) family belongs to the platelet derived growth factor superfamily. It consists of VEGF A, B, C, D, E and placenta growth factor. VEGF-A is the most potent of these growth factors. It contributes to tumor angiogenesis, tumor growth, and presumably hematogenous spread of tumor cells. It also protects endothelial cells from apoptosis [14].

17.11 Sunitinib R Sunitinib malate (Sutent ), a carboxamide, is a broad spectrum, multitargeted TKI against VEGFR, PDGFR, c-Kit and FLT-3. In January 2006, Sunitinib was approved by the FDA for patients with advanced renal cell carcinoma as well as for imatinib resistant GIST. In a phase II study in patients with immunotherapy refractory metastatic renal cell carcinoma, 40% of patients showed a partial response and 27% had stable disease [42]. A second study with an identical patient population was also done, and when combined with the first study objective responses were seen in 42% and stable disease was seen in 24% for at least 3 months. Median progression free survival was 8.2 months [43]. The main adverse events of this study were fatigue, diarrhea, nausea, dyspepsia, stomatitis and bone marrow abnormalities. After it had been tested in immunotherapy refractory patients, it started being evaluated as first line therapy. A phase III study comparing sunitinib to IFN-α as first line therapy for metastatic renal cell carcinoma showed a significant improvement in median progression free survival (47.3 vs. 24.9 weeks) and significantly increased objective response rates (24.8% vs. 4.9%) [41]. Sunitinib has also been shown to be effective in imatinib resistant GIST. A phase III study of sunitinib vs.

326

D. Hoda and A. Daud

Fig. 17.3 The VEGF pathway and its small molecule tyrosine kinase inhibitors

placebo was stopped after an interim analysis showed significant results. Partial response was seen in 6.8% of patients who received sunitinib vs. 0% who did not. There was also significantly longer median time to progression (27.3 vs. 6.4 weeks) for patients who received sunitinib. 17.4% of patients had stable disease for more than 22 weeks compared to 6.4 weeks for the placebo group [7]. Based on these studies, sunitinib has become front line therapy in patients with advanced renal cell carcinoma as well as with imatinib resistant GIST.

17.12 Vandetanib R Vandetanib (Zactima ) is an amine dual VEGFR-2 and EGFR tyrosine TKI. It is currently being investigated in patients with NSCLC as well as hereditary medullary thyroid carcinoma.

A phase II study with 181 previously untreated, stage IIIB/IV, NSCLC patients, vandetanib alone vs. vandetanib + carboplatin/taxol vs. carboplatin/taxol alone was studied. There was a slightly higher progression free survival advantage in the vandetanib plus carboplatin/taxol arm (24 weeks) vs. the carboplatin/taxol arm alone (23 weeks). There was no overall survival advantage [25]. A phase II trial studying vandetanib +/− docetaxel as second line in stage IIIB/IV NSCLC patients who had failed first line platinum based therapy has also been published. Median progression free survival was higher in the combination arm 18.7 weeks vs. 12 weeks. This has led to the initiation of phase III studies with this combination [26]. Another Phase II study of vandetanib was studied as maintenance therapy in both limited and extensive stage small cell lung cancer. One hundred seven patients were given vandetanib or placebo for maintenance following CR or PR after standard

17 Protein Kinase Inhibitors

chemotherapy +/– radiation. Vandetanib patients had increased toxicity (rash and gastrointestinal symptoms) and did not have a difference in progression free survival (2.7 vs. 2.8 months). Overall survival was 10.6 months for those receiving vandetanib and 11.9 months for placebo. However, a planned subgroup analysis showed that patients with limited stage disease had a trend toward longer overall survival in the vandetanib arm vs. the placebo arm. The extensive stage patients had a shorter overall survival [1]. Vandetanib has also been studied in hereditary medullary thyroid carcinoma. Of the 15 evaluable patients, 3 had partial responses and 10 had stable disease at the time of the report [62].

17.13 Raf Kinase Inhibitors The Raf serine/threonine kinases are molecules with the Raf/Mitogen activated protein kinase (MAPK)/extracellular signal related kinase (ERK) pathway. This pathway has also been shown to regulate cellular proliferation and survival. The Raf kinase pathway has been shown to be activated in a variety of solid tumors. Sorafenib, the first of these to be developed, not only inhibits Raf-1, but also wild type B-Raf, PDGF, VEGFR, Flt-3 and c-Kit [19] and is discussed further.

17.14 Sorafenib R Sorafenib (Nexavar ) is a carboxamide that was granted fast track approval by the FDA in December 2005 for metastatic renal cell carcinoma. It is a novel oral Raf-1 kinase, PDGFR and VEGFR kinase inhibitor [56]. In a Phase I study of 69 patients with refractory solid tumors the side effects were mainly diarrhea, fatigue, hypertension, skin rash and hematologic toxicity [57]. An interim analysis of a phase III trial which randomized 769 patients with advanced renal cell carcinoma to sorafenib or placebo showed an improvement of progression free survival from 12 to 24 weeks in patients treated with sorafenib as compared to placebo [16]. Data presented one year later showed a survival benefit of sorafenib over placebo of 19.3 months vs. 15.9 months) [15].

327

A phase II study of sorafenib + dacarbazine vs. dacarbazine + placebo in patients with chemotherapy naïve melanoma has been reported [38]. The dacarbazine + sorafenib arm had a significant longer progression free survival advantage of 21.1 weeks vs. 11.7 weeks in the dacarbazine + placebo arm but no difference was seen in survival. Subsequently, the PRISM trial which randomized temozolomide failed melanoma to either carboplatin paclitaxel or carboplatin paclitaxel combined with sorafenib has been reported [22]. In this trial, the median PFS was 17.9 weeks for carboplatin paclitaxel arm and 17.4 weeks for the sorafenib plus carboplatin paclitaxel arm (hazard ratio, 0.91; 99% CI, 0.63–1.31; two-sided logrank test P = 0.49). Response rate was 11% vs. 12%; no difference was see in overall survival. Sorafenib, based on these trials seems inactive in melanoma. However, newer more selective RAF inhibitors such as the PLX4032 molecule (Plexxicon) are under investigation; these appear to have activity in early phase clinical testing. More results with selective potent RAF inhibitors in melanoma is expected in the coming years. Another phase II trial, also reported at the annual ASCO meeting in 2007, revealed a survival advantage in chemotherapy naïve hepatocellular carcinoma patients. Six hundred two patients were enrolled and at interim analysis, median overall survival improved from 7.9 months to 10.7 months [35]. This essentially establishes sorafenib as first line therapy in patients with advanced hepatocellular carcinoma.

17.15 Mammalian Target of Rapamycin Kinase (mTOR) Inhibitor The mammalian target of rapamycin has emerged as a vital component of tumorigenesis. There is strong evidence that mTOR is required for cell cycle progression and its inhibition arrests cells in the G1 phase of the cell cycle. The inhibition of mTOR activity may also accelerate apoptosis and prevent angiogenesis. There are many upstream regulators of mTOR and downstream targets that effect protein synthesis. Blocking mTOR effectively blocks this protein synthesis and its effect on mRNA translation [45].

328

17.16 Temsirolimus R Temsirolimus (Torisel ) is an mTOR inhibitor that received FDA approval in May 30, 2007 based on a phase III trial of 626 patients with untreated renal cell cancer. Temsirolimus alone, in combination with interferon, or interferon alone was tested. The patients selected had at least 3 out of 6 poor prognostic factors. These factors included time from diagnosis to randomization of less than one year, Karnofsky performance status of 60 or 70, hemoglobin level less than the lower limit of normal, corrected serum calcium level of greater than 10 mg/dL, serum lactate dehydrogenase level 1.5 times the upper limit of normal, and/or more than one metastatic organ site. The results showed that patients who received temsirolimus alone had a longer overall survival (10.9 months) than interferon alone (7.3 months) or interferon + temsirolimus (8.4 months) [27]. Patients in the temsirolimus arm had more rash, peripheral edema, hyperglycemia and hyperlipidemia in that trial. Comparisons to sunitinib and sorafenib are not easy to make based on this trial because the patient populations are different. However, this study proves temsirolimus has activity in renal cell cancer and further randomized clinical trials are needed to compare it to sorafenib/sunitinib, either alone or in combination.

17.17 Conclusion The discovery of critical tyrosine and serine-threonine kinase signalling pathways that help cancer cells proliferate and prevent apoptosis has led to a windfall of targets and the hence the discovery of inhibitors to help target these enzymes. Aside from c-Kit and BCR-ABL, which were the forerunners in many ways of a new model of cancer therapy and the VEGF, EGFR, HER2, Raf, and mTOR tyrosine kinases which are now the most advanced, there are many other RTK and NRTK that await validation and targeting. Many of these are likely to provide us with new drugs to treat cancer in the coming years. Many cancers appear to be vitally dependent on aberrant signalling through these pathways, which are often mutated in specific patterns in a cancer specific manner. In the coming years, this rich treasure trove

D. Hoda and A. Daud

of targets needs to be tested singly and in combination to yield maximum benefits for patients with cancer. Equally important, the pharmacokinetics, chemistry and target specificity of these newly discovered inhibitors needs to be optimized to reduce side effects and increase their efficacy.

References 1. Arnold AM, Seymour L, Smylie M, Ding K, Ung Y, Findlay B, Lee CW, Djurfeldt M, Whitehead M, Ellis P, Goss G, Chan A, Meharchand J, Alam Y, Gregg R, Butts C, Langmuir P, Shepherd F (2007) Phase II study of vandetanib or placebo in small cell lung cancer patients after complete or partial response to induction chemotherapy with or without radiation therapy. National cancer institute of canada council trials group study BR.20. J Clin Oncol 25:4278–4284 2. Arteaga C (2001) The epidermal growth factor receptor: from mutant oncogene in nonhuman cancers to therapeutic target in human neoplasia. J Clin Oncol 19:32S–40S 3. Blay JY, L. C. (2005) Targeted cancer therapies. Bull Cancer 92:E13–E18 4. Blume-Jensen P, Hunter T (2001) Oncogenic kinase signalling. Nature 411:355–365 5. Bukowski RM, K. F. (2006) Bevacizumab with or without erlotinib in metastatic renal cell carcinoma (RCC) [abstract]. J Clin Oncol 24(suppl):4523a. Abstract 4523 6. Campos S, Hamid O, Seiden MV, Oza A, Plante M, Potkul RK, Lenehan PF, Kaldjian EP, Varterasian ML, Jordan C, Charbonneau C, Hirte H (2005) Multicenter, randomized phase II trial of oral CI-1033 for previously treated ovarian cancer. J Clin Oncol 23:5597–5604 7. Casali PG, Garrett CR, Blackstein ME, Shah M, Verweij J, McArthur G, Judson I, Li J, Baum CM, Demetri GD (2006) Updated results from a phase III trial of sunitinib in GIST patients (pts) for whom imatinib (IM) therapy has failed due to resistance or intolerance. J Clin Oncol ASCO Annual Meeting Proc, Abstract #9513 8. De Groot JF, Gilbert MR, Hess KR, Hanna T, Groves M, Conrad C, Aldape K, Colman H, Puduvalli V, Yung WA (2007) Phase II study of combination carboplatin and erlotinib in patients with recurrent glioblastoma multiforme. J Clin Oncol ASCO Annual Meeting Proc, Abstract #2024 9. Demetri GD, von Mehren M, Blanke CD, Van den Abbeele AD, Eisenberg B, Roberts PJ, Heinrich MC, Tuveson DA, Singer S, Janicek M, Fletcher JA, Silverman SG, Silberman SL, Capdeville R, Kiese B, Peng B, Dimitrijevic S, Druker BJ, Corless C, Fletcher CD, Joensuu H (2002) Efficacy and safety of imatinib mesylate in advanced gastrointestinal stromal tumors. N Engl J Med 347(7):472–480 10. Donato NJ, Wu JY, Stapley J, Gallick G, Lin H, Arlinghaus R, Talpaz M (2003) BCR-ABL independence and LYN kinase overexpression in chronic myelogenous. Blood 101:690–698

17 Protein Kinase Inhibitors 11. Druker BJ, Tamura S, Buchdunger E, Ohno S, Segal GM, Fanning S, Zimmermann J, Lydon NB (1996) Effects of a selective inhibitor of the Abl tyrosine kinase on the growth of BCR-ABL positive cells. Nat Med 5:561–566 12. Druker BJ, Sawyers CL, Kantarjian H, Resta DJ, Reese SF, Ford JM, Capdeville R, Talpaz M (2001) Activity of a specific inhibitor of the BCR-ABL tyrosine kinase in the blast crisis of chronic myeloid leukemia and acute lymphoblastic leukemia with the Philadelphia chromosome. N Engl J Med 344(14):1038–1042 13. Druker BJ, Talpaz M, Resta DJ, Peng B, Buchdunger E, Ford JM, Lydon NB, Kantarjian H, Capdeville R, Ohno-Jones S, Sawyers CL (2001) Efficacy and safety of a specific inhibitor of the BCR-ABL tyrosine kinase in chronic myeloid leukemia. N Engl J Med 344(14): 1031–1037 14. Dvorak H (2002) Vascular permeability factor/vascular endothelial growth factor: a critical cytokine in tumor angiogenesis and a potential target for diagnosis and therapy. J Clin Oncol 20:4368–4380 15. Eisen T, Bukowski RM, Staehler M, Szczylik C, Oudard S, Stadler WM, Schwartz B, Simantov R, Shan M, Escudier B (2006) Randomized phase III trial of soRafenib in advanced renal cell carcinoma (RCC): impact of crossover on survival. ASCO Annual meeting Proc. J Clin Oncol, Abstract 4524 16. Escudier B, Szczylik C, Eisen T, Stadler WM, Schwartz B, Shan M, Bukowski RM (2005) Randomized phase III trial of the Raf kinase and VEGFR inhibitor soRafenib (BAY 43–9006) in patients with advanced renal cell carcinoma (RCC). J Clin Oncol, ASCO Annual Meeting Proc, Abstract 4510 17. Fields ALA, Rinaldi DA, Henderson CA, Germond CJ, Chu L, Brill KJ, Leopold LH, Berger MS (2005) An open-label multicenter phase II study of oral lapatinib (GW572016) as single agent, second-line therapy in patients with metastatic colon cancer. ASCO Annual Meeting Proc, J Clin Oncol, Abstract # 3583 18. Geyer C, Forster J, Lindquist D, Chan S, Romieu CG, Pienkowski T, Jagiello-Gruszfeld A, Crown J, Chan A, Kaufman B, Skarlos D, Campone M, Davidson N, Berger M, Olivia C, Rubin SD, Stein S, Cameron D (2006) Lapatinib plus capecitabine for HER2-positive advanced breast cancer. N Engl J Med 355:2733–2743 19. Gollob JA, Wilhelm S, Carter C, Kelley SL (2006) Role of Raf kinase in cancer: therapeutic potential of targeting the Raf/MEK/ERK signal transduction pathway. Semin Oncol 33:392–406 20. Gorre ME, Mohammed M, Ellwood K, Hsu N, Paquette R, Rao PN, Sawyers CL (2001) Clinical resistance to STI571 cancer therapy caused by BCR-ABL gene mutation. Science 293:876–80 21. Hainsworth JD, Sosman JA, Spigel DR, Edwards DL, Baughman C, Greco A (2005) Phase II trial of bevacizumab and erlotinib in patients with metastatic renal carcinoma. J Clin Oncol 31:7889–7896 22. Hauschild A, A.S (2009) Results of a phase III, randomized, placebo-controlled study of sorafenib in combination with carboplatin and paclitaxel as second-line treatment in patients with unresectable stage III or stage IV melanoma. J Clin Oncol 17:2823–2830

329 23. Herbst RS, G. G. (2004) Gefitinib in combination with paclitaxel and carboplatin in advanced non-small cell lung cancer: a phase III trial- INTACT 2. J Clin Oncol 22:785–794 24. Herbst RS, P. D. (2005) TRIBUTE: a phase III trial of erlotinib hydrochloride (OSI-774) combined with carboplatin and paclitaxel chemotherapy in advanced non-smallcell lung cancer. J Clin Oncol 23:5892–5899 25. Heymach J, P.-A. L.-B. (2007) Randomized phase II study of vandetanib (VAN) alone or in combination with carboplatin and paclitaxel (CP) as first-line treatment for advanced non-small cell lung cancer (NSCLC). J Clin Oncol, ASCO Annual Meeting Proc, Abstract # 7544 26. Heymach JV, J. B. (2007) Randomized, placebo-controlled phase II study of vandetanib plus docetaxel in previously treated non small cell lung cancer. J Clin Oncol 25:4270–4277 27. Hudes G, C. M. (2007) Temsirolimus, interferon alfa or both in advanced renal cell carcinoma. N Engl J Med 356:2271–2281 28. Jänne PA, VP J (2007) Multicenter, randomized, phase II trial of CI-1033, an irreversible pan-ERBB inhibitor, for previously treated advanced non small-cell lung cancer. J Clin Oncol 25:3936–3944 29. Kantarjian H, S. C. (2002) Hematologic and cytogenetic responses to imatinib mesylate in chronic myelogenous leukemia. N Engl J Med 346(9):645–652 30. Kantarjian H, G.F. (2006) Nilotinib in imatinib resistant CML and Philadelphia chromosome positive ALL. N Eng J Med 354:2542–2551 31. Kantarjian HM, T. M. (2006) New insights into the pathophysiology of chronic myeloid leukemia. Ann Int Med 145:913–923 32. Kantarjian H, P. R. (2009) Dasatinib or high-dose imatinib for chronic-phase chronic myeloid leukemia resistant to imatinib at a dose of 400 to 600 milligrams daily: twoyear follow-up of a randomized phase 2 study (START-R). Cancer 115(18):4136–4147 33. Krause D, V.R. (2005) Tyrosine kinases as targets for cancer therapy. N Engl J Med 353:172–187 34. Kris MG, N. R. (2003) Efficacy of gefitinib, an inhibitor of the epidermal growth factor receptor tyrosine kinase, in symptomatic patients with non-small cell lung cancer: a randomized trial. JAMA 290(16):2149–2158 35. Llovet J, R. S. (2007) SoRafenib improves survival in advanced Hepatocellular Carcinoma (HCC): Results of a Phase III randomized placebo-controlled trial (SHARP trial). J Clin Oncol, ASCO Annual Meeting Proc, Abstract LBA1 36. Martin GS (2001) The hinting of the Src. Nat Rev Mol Cell Biol 2:467–475 37. Mauro MJ, D. M. (2006) Chronic myeloid leukemia in 2006: a perspective. Haematologica 91:152 38. McDermott DF, S. J. (2008) Double-blind randomized phase II study of the combination of sorafenib and dacarbazine in patients with advanced melanoma: a report from the 11715 study Groupa. J Clin Oncol 13:2178–2185 39. Mestan J, W. E.-J. (2004) AMN107: in vitro profile of a new inhibitor of the tyrosine kinase activity of BCR-ABL Blood 104:546a. Abstract no. 1978

330 40. Moore MJ, G. D. (2005) Erlotinib plus gemcitabine compared to gemcitabine alone in patients with advanced pancreatic cancer. A phase III trial of the national cancer institute of canada clinical trials group (NCIC-CTG). ASCO Annual Meeting (p Abstract 1) 41. Motzer RJ, H. T. (2006) Phase III randomized trial of sunitinib malate (SU 11248) versus interferon alfa as first line systemic therapy for patients with metastatic renal cell carcinoma (mRCC). J Clin Oncol, ASCO Annual Meeting Proc, Abstract 24 42. Motzer RJ, M. M. (2006) Activity of SU11248, a multitargeted inhibitor of vascular endothelial growth factor receptor, in patients with metastatic renal cell carcinoma. J Clin Oncol 24:16–24 43. Motzer RJ, R. B. (2006) Sunitinib in patients with metastatic renal cell carcinoma. JAMA 295:2516–2524 44. Nelson MH, D. C. (2006) Lapatinib: a novel dual tyrosine kinase inhibitor with activity in solid tumors. Ann Pharmacother 40:261–269 45. Nissim H, S. N. (2004) Upstream and downstream of mTOR. Genes Dev 18:1926–1945 46. Opperman H, L.A. (1979) Uninfected vertébrate cells contain a protein that is closely related to the product of the avian sarcoma virus transforming gene (src). Proc Natl Acad Sci USA 76:1804–1808 47. Perez EA, B. J. (2006) Results of an analysis of cardiac function in 2,812 patients treated with lapatinib. J Clin Oncol, ASCO Annual Meeting Proc, Abstract # 583 48. Ranson M (2004) Epidermal growth factor receptor tyrosine kinase inhibitors. Br J Cancer 90:2250–2255 49. Rixe O, F SX (2009) A randomized, phase II, dosefinding study of the pan-ErbB receptor tyrosine-kinase inhibitor CI-1033 in patients with pretreated metastatic breast cancer. Cancer Chemother Pharmacol 64(6): 1139–1148 50. Rubin BP, S. S. (2001) KIT activation is a ubiquitous feature of gastrointestinal stromal tumors. Cancer Res 61:8118–8121 51. Savage DG , A. K. (2002) Imatinib mesylate – a new oral targeted therapy. N Engl J Med 346(9):683–693

D. Hoda and A. Daud 52. Schlessinger J (2000) Cell signaling by receptor tyrosine kinases. Cell 103:211–225 53. Shah NP, T. C. (2004) Overriding imatinib resistance with a novel ABL kinase inhibitor. Science 305:399–401 54. Shepherd FA, R. P. (2005) Erlotinib in previously treated non-small cell lung cancer. N Engl J Med 353:123–132 55. Soulieres D, S. N. (2004) Multicenter phase II study of erlotinib, an oral epidermal growth factor receptor tyrosine kinase inhibitor, in patients with recurrent or metastatic squamous cell cancer of the head and neck. J Clin Onc 22(1):77–85 56. Sridhar SS, H. D. (2005) Raf kinase as a target for anticancer therapeutics. Mol Cancer Ther 4:677–685 57. Strumberg D, R. H. (2005) Phase I clinical and pharmacokinetic study of the novel Raf kinase and vascular endothelial growth factor receptor inhibitor BAY 43–9006 in patients with advanced refractory solid tumors. J Clin Oncol 23:965–972 58. Talpaz M, S. N. (2006) Dasatinib in imatinib-resistant Philadelphia chromosome-positive leukemias. N Engl J Med 354:2531–2541 59. Thatcher N, C. A.-s.-c.-c. (2005) Gefitinib plus best supportive care in previously treated patients with refractory advanced non-small-cell lung cancer: results from a randomised, placebo-controlled, multicentre study (Iressa survival evaluation in lung cancer). Lancet 366:1527–1537 60. Traxler P (2003) Tyrosine kinases as targets in cancer therapy – successes and failures. Expert Opin Ther Targets 7:215–234 61. Verweij J, C. P. (2004) Progression-free survival in gastrointestinal stromal tumours with high-dose imatinib: randomised trial. Lancet 364(9440):1127–1134 62. Wells S, Y. Y. (2006) A phase II trial of ZD6474 in patients with hereditary metastatic medullary thyroid cancer. J Clin Oncol, ASCO Annual Meeting Proc, Abstract #5533 63. Yu CL, M.D. (1995) Enhanced DNA binding activity of a Stat-3 related protein in cells transformed by the Src oncoprotein. Science 269:81–83

Chapter 18

Inhibitors of Tumor Angiogenesis Anaadriana Zakarija and William J. Gradishar

18.1 Introduction Tumor growth relies on formation of a vascular supply. In 1971, Judah Folkman was the first to propose that in order to grow beyond 2–3 mm in size tumors required a new vascular network [16]. Subsequent research has confirmed that growth of a tumor, both at the primary site and metastases, is dependent on neoangiogenesis [17, 24]. This development of a new vasculature, angiogenesis, is normally regulated by both activators and inhibitors (Table 18.1). Tumors can produce some of these activators or down-regulate expression of inhibitors, therefore altering the balance in favor of an “angiogenic switch” [23]. In addition, the tumorassociated blood vessels differ from normal blood vessels in a number of ways: the capillary network is not organized, loose perivascular cells lead to a leaky basement membrane and tumor cells may become integrated into the new blood vessel [2]. There is recent evidence to suggest that anti-angiogenic therapy may also alter the abnormal tumor blood supply resulting in blood vessels which are more normal, allowing for improved tumor perfusion and better delivery of chemotherapy [34]. Anti-angiogenic therapy is an area of very active investigation. The mechanism of action of anti-angiogenic therapies includes: agents that block degradation of extracellular matrix, e.g. matrix

A. Zakarija () Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Feinberg School of Medicine, 676 N. St. Clair, Suite 850, Chicago, IL 60611, USA e-mail: [email protected]

metalloproteinase inhibitors; drugs that directly inhibit endothelial cell proliferation and/or migration; agents that inhibit endothelial cell-specific integrin/survival signaling; and agents that block promoters of angiogenesis, e.g. anti-vascular endothelial growth factor (VEGF) agents. Numerous agents have been tested in clinical trials. While some agents have failed to demonstrate clinical efficacy, other agents have shown promise and ongoing testing continues. Agents that target VEGF signaling, have shown the most promise to date. Bevacizumab, is the first anti-angiogenic therapy approved by the U.S. Federal Drug Administration (FDA) for clinical use. There is significant difficulty in assessing the efficacy of anti-angiogenic therapy, since their mechanism of action is completely different than standard cytotoxic chemotherapy. Many agents have been tested alone in advanced disease, even though a therapy targeting angiogenesis may not be expected to be tumoricidal. Reduction in tumor size may not be the best measure of clinical efficacy. In addition the maximally tolerated dose (MTD) may not be the dose with optimal biologic activity. Therefore surrogate biologic markers must be identified in order to evaluate the anti-angiogenic activity of these agents.

18.2 Agents Targeting the VEGF Signaling Pathway Physiologic and pathologic angiogenesis is regulated by the VEGF signaling family. The VEGF system is involved in angiogenesis, lymphoangiogenesis, endothelial cell proliferation and survival and vascular permeability [50]. The VEGF family includes at least

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_18, © Springer Science+Business Media B.V. 2011

331

332

A. Zakarija and W.J. Gradishar Table 18.1 Angiogenic activators and inhibitors Activators

Inhibitors

Acidic fibroblast growth factor Angiostatina Angiogenin Endostatin a Basic fibroblast growth factor (bFGF)a Interferons Epidermal growth factor Interleukins 12 and 18 Granulocyte colony stimulating factor Platelet factor 4 Hepatocyte growth factor Prolactin, 16 kD fragment Interleukin 8 Soluble VEGFR-1 Placental growth factor (PlGF) Thrombospondins 1 and 2a Platelet-derived endothelial growth factor B (PDGF) TIMP-1 (tissue inhibitor metalloproteinase-1) Transforming growth factor α (TGF-α) TIMP-2 TGF – β TIMP-3 Tumor necrosis factor α (TNF- α) TIMP-4 Vascular endothelial growth factor (VEGF) a a Most important factors Reprinted with permission from Chabner, ed. Cancer Cheomtherapy and Biotherapy; principles and practice, 4th ed. Edited by Bruce & Chabner and Dan L. Longo. Lippincott Williams & Wilkins

five ligands (VEGF-A, VEGF-B, VEGF-C, VEGF-D and Placental growth factor) which interact with 3 tyrosine-kinase receptors (VEGFR-1, VEGFR-2, and VEGFR-3) [13]. The primary regulator VEGF-A, which is also commonly referred to as VEGF, binds to both VEGFR-1 and VEGFR-2 [50]. VEGF expression can be induced by: hypoxia, hypoxia-inducible factor(HIF-1), cytokines and growth factors (e.g. fibroblastgrowth factor, platelet-derived growth factor, TNF-α), UV-B radiation, and inactivation of the VHL (von Hippel Landau) tumor suppressor gene. Tumors found to overexpress VEGF and its receptors include colorectal, gastric, hepatocellular, lung, and breast cancer, AIDS-associated Kaposi’s sarcoma and AML [12, 51, 58, 60, 71]. The relevance of this overexpression has varied between studies. In one of the largest series, tumors from 259 patients with colorectal cancer were examined and survival was found to be lower in patients whose tumors were positive for VEGF [25]. In breast cancer patients, VEGF overexpression has also been associated with lower survival [18] and poor response to systemic therapy [15]. On the other hand, VEGF expression in patients with gastric and endometrial cancer did not appear to have prognostic significance [14, 60]. More recently, expression of VEGF-D and VEGFR-3 in gastric tumors was found to correlate with decreased survival in patients after surgical resection [37]. Despite the conflicting human studies, animal studies have demonstrated that inhibiting VEGF signaling disrupts tumor growth and invasiveness [41, 44, 52]. Therefore,

a number of agents targeting the VEGF system have been developed and studied.

18.2.1 Bevacizumab (Avastin) Bevacizumab is a recombinant humanized monoclonal antibody that binds to VEGF-A and its biologically active isoforms [3, 20]. It has been FDA-approved for first-line treatment, with 5-fluorouracil (5-FU)-based chemotherapy, in patients with metastatic colorectal cancer. Bevacizumab has been tested in patients with a variety of malignancies and at a many dose levels. The efficacy at different doses suggests that a clear dose-dependent relationship is not seen. In colorectal cancer, a dose of 5 mg/kg was more effective than 10 mg/kg [38]. while in non-small cell lung cancer and renal cell cancer higher doses (up to 15 mg/kg) are more effective than lower doses [35, 69]. At this time a method to determine optimal biologic activity for this agent does not exist. Plasma VEGF levels prior to treatment with bevacizumab have not been predictive of response [20, 30]. Tumor characteristics including expression of VEGF or thrombospondin-2, or microvessel density were shown not to correlate to response to bevacizumab in patients with metastatic colorectal cancer [36]. FDA-approval of bevacizumab for treatment of colorectal cancer was based on two pivotal trials that enrolled 917 patients who had previously untreated metastatic disease. A phase II trial randomized patients

18 Inhibitors of Tumor Angiogenesis

to one of three regimens: 5-FU/leucovorin(LV); 5-FU/LV plus bevacizumab 5 mg/kg every 2 weeks or 5-FU/LV plus bevacizumab 10 mg/kg every 2 weeks [38]. The 5FU/LV was given weekly for the first 6 weeks of an 8 week cycle. The time to progression (TTP) was statistically better in the bevacizumab (5 mg/kg) group when compared to control (9 months vs. 5.2 months, p = 0.005). The cohort treated with the higher dose of bevacizumab had a overall response rate (OR) and a TTP which was similar to the control group. Overall median survival was not statistically different in any of the treatment groups. Hurwitz et al conducted a phase III study which randomized 411 patients to irinotecan, bolus 5-FU, and LV (IFL) and 402 patients to IFL plus bevacizumab 5 mg/kg every 2 weeks [31]. In this trial median survival was significantly better in the group that received bevacizumab (20.3 months) when compared to the control group (15.6 months), p < 0.0001. In addition, this trial initially contained an arm in which patients were to receive only 5-FU/LV plus bevacizumab. A total of 110 patients were enrolled in this arm before it was closed, and subsequent analysis demonstrates that 5-FU/LV plus bevacizumab is as effective as IFL in first line treatment of metastatic colorectal cancer [32]. Overall survival was 18.3 months compared to 15.1 months, respectively. In addition there is evidence that bevacizumab improves outcome in previously treated patients with metastatic colorectal cancer. A phase III study in this group, randomized patients to either FOLFOX4 or FOLFOX4 plus bevacizumab 10 mg/kg. Early results presented at the 2005 Annual meeting of the American Society of Clinical Oncology (ASCO) demonstrate improved overall survival in the group that received bevacizumab, 12.5 months vs. 10.7 months (p = 0.0024) [19]. Therefore the addition of bevacizumab continues to demonstrate efficacy in patients with metastatic colorectal cancer. In most trials with bevacizumab the focus has been on tumor regression, yet the mechanism for this is not understood. Preclinical work suggests that therapies targeting VEGF signaling that result in normalization of the tumor-associated blood vessels can lead to improved delivery of therapy to the tumor [62, 65]. Pilot studies of bevacizumab in patients with rectal cancer have investigated its vascular effects. Willett and colleagues found evidence that in addition to decreased microvessel density, tumor blood vessels acquire characteristics of normal vasculature after

333

bevacizumab therapy [67]. The clinical and therapeutic significance of this finding is not yet established, but it provides important insights into one potential mechanism of bevacizumab therapy. This group continues to study the role of bevacizumab when combined with neo-adjuvant chemoradiation in patients with locally advanced rectal cancer. The efficacy of bevacizumab in breast cancer continues to be studied. The first completed Phase III study evaluated 462 patients with metastatic breast cancer that had progressed after prior therapy with an anthracycline and taxane [45]. Patients were randomized to receive either capecitabine alone or in combination with bevacizumab 15 mg/kg every 3 weeks. The OR rate was better in the bevacizumab arm 19.8% vs. 9.2% in the control arm, p = 0.001, but progression-free survival (PFS) and overall survival (OS) were similar in bother groups. Given the the lack of efficacy in the relapsed metastatic breast cancer cohort, a clinical trial was designed to test the response in patients with previously untreated metastatic breast cancer. This trial randomized patients to either paclitaxel or paclitaxel plus bevacizumab 10 mg/kg every 2 weeks [46]. In patients receiving bevacizumab the OR and PFS were both statistically significantly improved, 28% vs. 14% and 6 months vs. 11 months [47]. We await the further results from this and other trials to better define the patients with breast cancer that would benefit from bevacizumab. Bevacizumab is also promising in treatment of patients with advanced non-small cell lung cancer (NSCLC). Johnson et al randomized patients with Stage IIIB or IV NSCLC to either carboplatin/paclitaxel or carboplatin/paclitaxel plus bevacizumab (7.5 mg/kg or 15 mg/kg) every 3 weeks [35]. Median TTP was higher in the high-dose bevacizumab cohort when compared to control (7.4 months vs. 4.2 months, p=0.023), but differences in OS were not statistically different. The Eastern Cooperative Oncology Group (ECOG) has also conducted a study of bevacizumab in previously untreated patients with advanced NSCLC. Patients were randomized to either paclitaxel and carboplatin alone or with bevacizumab (15 mg/kg) every 3 weeks [55]. After 6 cycles of chemotherapy, patients could continue to receive bevacizumab until disease progression. TTP and OS were improved in the group treated with bevacizumab, 6.4 months vs. 4.5 months and 12.5 months vs. 10.2 months. Toxicity was notable for 5/9 deaths in the

334

bevacizumab arm that were related to hemoptysis [55]. Further trials are ongoing and these results will be important in further defining the efficacy and safety of bevacizumab in these patients. Clinical trials with bevacizumab in other malignancies are ongoing. A recently reported Phase II trial with gemcitabine and bevacizumab in patients with advanced pancreatic cancer suggests activity, with 21% of patients achieving a partial response while 46% had stable disease [42]. Further randomized studies will be necessary to determine if the addition of bevacizumab improves overall survival in this patient population. Clear cell renal carcinoma is also a potentially promising target since most of these tumors have a mutation in the vHL tumor suppressor gene, which leads to HIF-1 mediated VEGF production [13, 69]. Unfortunately monotherapy with bevacizumab in patients with metastatic clear cell renal carcinoma did not demonstrate an improvement in overall survival [69]. Therefore further clinical trials in these patients combine immunotherapy or other novel agents with bevacizumab. Combination therapy with bevacizumab and the epidermal growth factor receptor (EGFR) inhibitor, erlotinib, in patients with metastatic clear cell renal carcinoma appears effective and safe [21]. Of 59 patients treated with this regimen, 25% had a complete or partial response and 61% had stable disease. The targeting of these two separate pathways appears feasible and we await future results of randomized trials. Treatment with bevacizumab generally has been well-tolerated, and antibodies to the recombinant protein have not been observed [20]. The toxicities associated with bevacizumab have been similar across trials, and include hypertension, proteinuria, arterial and venous thrombosis and wound healing complications. In the largest published trial, 402 patients were treated with IFL and bevacizumab and 22% developed hypertension. Grade 3 hypertension was seen in 11% of treated patients [31]. In the phase III randomized study in metastatic breast cancer, 229 patients were treated with capecitabine and bevacizumab and 23.5% developed grade 1–3 hypertension, as compare to 2.4% in the group treated with capecitabine alone [47]. Hypertensive encephalopathy is rare, but has been described in four patients of over 1000 treated on clinical trials.(Bevacizumab (Avastin)) The hypertension in most patients can be treated with anti-hypertensive therapy alone and bevacizumab can be continued. If

A. Zakarija and W.J. Gradishar

significant hypertension develops that cannot be easily managed then bevacizumab should be discontinued. Hemorrhage and visceral perforation have been noted in the trials with colorectal and pancreatic cancer patients [31, 38, 42]. The hemorrhagic tendency may be related to the decreased ability of endothelial cells to respond to an injury if VEGF is inhibited [39]. Minor and major bleeding has been observed with bevacizumab therapy, 59% vs. 11% in the randomized study of 5FU/LV & bevacizumab compared to 5FU/LV alone in metastatic colorectal cancer [38]. The majority are grade 1 or 2 hemorrhages, such as epistaxis. Yet gastrointestinal hemorrhage was seen in 10% of bevacizumab-treated patients in this study, and 43% were grade 3/4. The Phase III study in metastatic colorectal cancer by Hurwitz and colleagues did not find an increased incidence of major hemorrhage [31]. It is important to recognize that patients with central nervous system metastases were excluded from the clinical trials, therefore the safety of this therapy in that group has not been established. The consequences of VEGF signaling inhibition are complex as both hemorrhagic and thrombotic complications have been attributable to bevacizumab therapy. As malignancy itself increases the risk for thrombosis, the additional contribution of bevacizumab to this risk is not clear. In clinical trials thrombotic events have included deep venous thrombosis, pulmonary embolism, catheter-related thrombosis, cerebrovascular events and transient ischemic events. At the 2005 ASCO meeting, information was presented on the incidence of arterial thromboembolic events (ATE) in 1745 patients treated with bevacizumab in 5 randomized clinical trials [57]. The incidence of ATE was higher in patients receiving bevacizumab and chemotherapy when compared to chemotherapy alone, 3.8% vs. 1.7%, p < 0.01 [57]. In this series, independent risk factors for ATE were a history of atherosclerosis and age ≥ 65. Therefore bevacizumab should be used with caution in patients with these additional risk factors. If patients develop a thrombosis while on bevacizumab there does not appear to be an increased risk of bleeding with anticoagulation. In the pivotal Phase III clinical trial in metastatic colorectal cancer, patients with a thrombotic event were placed on full dose anticoagulation. In patients who continued on the study and were anticoagulated, the incidence of grade 3/4 bleeding was 6.7% in the cohort treated with IFL and 3.8% in the group treated with IFL and bevacizumab [31].

18 Inhibitors of Tumor Angiogenesis

Despite this report, a better understanding of the effects of anti-VEGF therapy on the hemostatic system is necessary before recommendations can be made for safe administration of this therapy with anticoagulation.

18.2.2 PTK787/ZK222584 (Vatalanib) PTK787/ZK 222584 (PTK/ZK) is an oral inhibitor of a number of kinases including VEGFR-1, VEGFR-2 and platelet-derived growth factor receptor (PDGF-R) [68]. In animal models, this agent inhibits tumor growth, tumor vessel density and metastases [8]. A phase I trial of PTK/ZK treated 43 patients with a variety of advanced malignancies with doses of PTK/ZK from 150 mg BID to 1000 mg BID [61]. The drug is rapidly absorbed after oral ingestion and has half-life of 3–6 h. In general the agent was well-tolerated, with 7 patients remaining on therapy for at least one year. The doselimiting toxicity was grade 3 lightheadedness, that occurred in 7% of subjects. Other grade 3/4 toxicities included increased ALT (14%), increased AST (7%), hypertension (9%), lethargy (14%), nausea(5%), and emesis (7%). Of the 36 patients assessable for response, 1 patient had a partial response and 24 had stable disease [61]. Phase III studies are ongoing in patients with colorectal cancer. Preliminary results were presented at the 2005 ASCO meeting of a firstline trial in 1,168 patients with metastatic colorectal cancer who were randomized to receive FOLFOX4 with either PTK/ZK 1250 mg daily or placebo [26]. PFS did not seem to be different in the two groups, although subgroup analysis revealed that 316 patients with a high lactate dehydrogenase(LDH) had a statistically significant improvement in PFS 9.6 months vs. 5.8 months. Another trial for first line therapy of metastatic colorectal cancer, treated patients with infusional 5-FU/LV plus irinotecan (FOLFIRI) plus escalating doses of PTK/ZK from 500–1500 mg daily [63]. Preliminary results revealed a partial response in 41% and stable disease in 47%. Further results from this and other studies are necessary to determine efficacy of this agent. Identifying surrogate markers of response will be important in assessing activity of this and other agents in development. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) has been performed in patients treated with PTK/ZK in an attempt to

335

identify early biologic response. A phase I trial with PTK/ZK demonstrates that the reduction in DCE-MRI contrast enhancement is dose-dependent and correlates with tumor response [48]. Changes on DCE-MRI are seen as early as two days after initiation of PTK/ZK at dose of at least 750 mg daily [49]. Further studies of this technique are needed to determine if early imaging results will predict disease response. The potential use for using DCE-MRI imaging to optimize dosing of antiangiogenic therapy also should be investigated. Another small study has found that plasma VEGF-A and basic fibroblast growth factor (bFGF) levels increase after treatment with PTK/ZK, and that an increase greater than 150% above baseline correlated with disease non-progression [9]. It remains to be seen whether these markers will be useful as surrogates for efficacy of therapy.

18.2.3 Sorafenib (Nexavar) Sorafenib, previously known as BAY 43–9006, is another oral inhibitor of multiple kinases, including Raf kinase and the tyrosine kinases: VEGFR-2, VEGFR-3, PDGFR-β, FLT-3, and c-kit [66]. This agent is unique in that it not only inhibits angiogenesis, but affects Raf-kinase mediated tumor cell proliferation. A total of 69 patients with a variety of advanced malignancies were treated in a phase I trial. Side effects included diarrhea, grade 1–3, in 55% of patients [59]. Grade 3 toxicities included diarrhea (9%), hand-foot syndrome (6%), fatigue (6%), pancreatitis (4%) and elevated bilirubin (4%) [59]. Sorafenib has also been combined with oxaliplatin in a phase I study. Only ten patients were treated with the dual therapy but diarrhea was observed in only 20% and therapy was otherwise relatively well-tolerated [43]. Sorafenib has recently received FDA approval for the treatment of patients with advanced renal cell carcinoma. A phase II clinical trial treated patients with advanced renal cell cancer with sorafenib at 400 mg BID. A total of 65 patients with stable disease after 12 weeks of therapy with sorafenib were randomized to sorafenib vs. placebo [53]. The patients treated with sorafenib had a better clinical benefit rate (overall response plus stable disease) compared to those receiving placebo (50% vs. 18%, p=0.007). In addition PFS was improved for those receiving sorafenib (23 vs.

336

6 weeks, p = 0.0001). A phase III placebo controlled study has also been conducted in 769 patients with advanced renal cell cancer, and preliminary results were presented at the 2005 ASCO Annual Meeting [11]. Patients who had failed at least one prior therapy were randomized to either sorafenib 400 mg twice a day or placebo. PFS was 24 weeks in those treated with sorafenib vs. 12 weeks in the placebo-controlled group [11]. Sorafenib appears to be well-tolerated. The grade 3 adverse events in these studies included hypertension, hand-foot syndrome and fatigue. Further data is necessary to reveal the effects of treatment with sorafenib on overall survival, but the early results are promising. Further clinical trials of sorafenib are ongoing in head and neck, lung, pancreatic and prostate cancer, melanoma and sarcoma.

18.2.4 ZD6474 (Zactima) ZD6474 is a small molecule tyrosine-kinase inhibitor of VEGFR-2, VEGFR-3, and EGFR. Animal studies have demonstrated the efficacy of this agent in inhibiting a variety of tumors [54, 64, 70]. In addition preclinical studies with ZD6474 have evaluated a potential biologic surrogate marker. Mice, with Lewis lung carcinoma, that were treated with ZD6474 had an increase in mature circulating endothelial cells (CEC), followed by decreased microvessel density and tumor volume [1]. Various clinical trials in patients are measuring CECs to determine its’ utility as a surrogate marker for biologic activity of anti-angiogenic therapies. A phase I clinical study has been completed which treated 77 patients with a variety of advanced malignancies with ZD6474, at doses from 50 to 600 mg/day [29]. ZD6474 is orally absorbed, and has a half-life of about 120 h. The agent is well-tolerated, and the most common side effects included diarrhea, nausea, rash, hypertension and fatigue [29]. Grade 3 toxicities that were observed in more than one subject included diarrhea (5%), hypertension (5%) or rash (4%). Seven of 77 patients (9%) had asymptomatic QTc prolongation. A phase II trial with ZD6474 alone in patients with metastatic breast cancer was conducted. A total of 46 patients with progressive disease after prior treatment with an anthracycline and taxane, were treated with ZD6474 at 100 or 300 mg daily [45]. Although

A. Zakarija and W.J. Gradishar

treatment was tolerable there were no responses, and only one patient had stable disease for over 24 weeks. Many anti-angiogenic agents have been unsuccessful when used as monotherapy in patients with advanced disease. ZD6474 has been combined with docetaxel in a phase II trial in advanced non-small cell lung cancer patients. A total of 127 patients with disease progression after first-line platinum-based chemotherapy were randomized to docetaxel plus ZD6474 100 mg daily, 300 mg daily or placebo [27]. Early results of this trial were presented at the 2005 ASCO Annual Meeting and suggested efficacy of this combination. The primary endpoint of PFS was better in both cohorts receiving ZD6474 – 18.8 weeks (100 mg daily) and 17 weeks (300 mg daily), while PFS was only 12 weeks in the group receiving docetaxel alone [27]. Additional data from this and other ongoing studies are necessary to determine the role of this therapy in cancer treatment.

18.2.5 VEGF-Trap VEGF-Trap is a protein that avidly binds to VEGF. It was created by fusing a portion of the extracellular domain of the receptors, VEGFR1 and VEGFR2, to a human IgG1 [28]. The affinity for VEGF-A and its naturally occurring splice variants is very high, and VEGF-Trap also binds to placental growth factor [28]. In animal models, this protein was more effective that an anti-VEGF antibody at inhibiting tumor growth [40]. VEGF-Trap not only inhibits formation of new blood vessels but also results in regression of existing blood vessels in mouse tumor models [33]. A phase I study for VEGF-Trap recruited 38 patients with advanced malignancy, including 9 with renal cell cancer and 5 patients with colon cancer [10]. Cohorts were treated at seven dose levels, from 25 to 800 μg/kg subcutaneously once per week and 800 μg/kg biweekly. The half-life of VEGF-Trap, at the 800 μg/kg/week dose is 25±3 days. The maximum tolerated dose has not been achieved. Adverse events associated with therapy include proteinuria (42%), hypertension (15%), and grade 3/4 thrombosis (6%) [10]. There have been no responses in this study, but at the higher doses of 800 μg/kg once or twice a week, 8 of 10 patients have had stable disease after 10 weeks of therapy [10].

18 Inhibitors of Tumor Angiogenesis

337

18.3 Metronomic Dosing of Chemotherapy

necessary to determine appropriate biomarkers and optimally efficacious metronomic dosing regimens.

Traditional cytotoxic therapy may also have an anti-angiogenic effect if administered by an alternate dosing schedule. Normal cytotoxic dosing is given near maximally tolerated doses, while prolonged exposure to low doses of drug may achieve an anti-angiogenic effect [22]. This dosing schedule of chemotherapy has been called metronomic therapy. There is data to suggest that metronomic dosing increases levels of thrombospondin-1, an important physiologic inhibitor of angiogenesis [4]. Animal studies have been conducted using low dose, prolonged conventional chemotherapy. Even in drug-resistant tumors metronomic dosing schedules with cyclophosphamide resulted in apoptosis of tumor endothelial cells, which was then followed by apoptosis of the tumor cells [5]. One difficulty in translating these preclinical studies into human trials is determining the metronomic dosing of chemotherapeutic agents. A clinical trial of low dose oral methotrexate and cyclophosphamide was conducted in patients with metastatic breast cancer. The response rate was 19%, while 13% had stable disease [7]. VEGF levels were measured and decreased with therapy but did not correlate with disease response. More recently metronomic chemotherapy has been combined with bevacizumab in patients with metastatic breast cancer. This phase II trial randomized patients to either metronomic therapy alone (cyclophasphamide 50 mg daily and methotrexate 2.5 mg BID for 2 days/week) or with bevacizumab every 2 weeks [6]. The preliminary results of this trial were presented at the 2005 San Antonio Breast Cancer Symposium, and demonstrated that the addition of bevacizumab to a metronomic chemotherapy regimen increased the percentage of patients achieving a partial response, 29% vs. 10%, and was well-tolerated. This combination of anti-angiogenic therapies deserves further study. Although metronomic therapy may be promising, details on dosing have yet to be worked out. Shaked et al recently reported that optimal biologic dosing of metronomic regimens correlated with a reduction in viable peripheral blood circulating VEGFR2+ endothelial precursors in a mouse model [56]. This may be a biomarker that can be used to help determine dosing in human subjects. Further studies are

18.4 Conclusion The era of anti-angiogenic therapy is just beginning. Numerous anti-angiogenic therapies have been developed and continue to undergo evaluation. Many results are promising, yet the optimal use of these agents is yet to be determined. Clinical trial endpoints that have been used in assessment of cytotoxic chemotherapy may not be the best in determining efficacy of antiangiogenic therapies. Surrogate endpoints that reflect the activity of antiangiogenic therapies need to be incorporated into trial design. Potential biologic markers include measurement of serum markers of angiogenesis (VEGF, bFGF, VCAM-1 [vascular cell adhesion molecule]), or circulating endothelial cells, assessment of endothelial cell and tumor cell apoptosis on biopsy, PET scan assessment of tumor blood flow and DCEMRI contrast enhancement as a reflection of microvessel density. Whether these markers accurately reflect antiangiogenic or antitumor activity remains unclear. Future studies should focus on biomarkers, determining drug schedules which will achieve optimal biologic activity and disease types and stages which will be most amenable to this therapeutic strategy.

References 1. Beaudry P, Force J, Naumov GN, Wang A, Baker CH, Ryan A et al (2005) Differential effects of vascular endothelial growth factor receptor-2 inhibitor zd6474 on circulating endothelial progenitors and mature circulating endothelial cells: implications for use as a surrogate marker of antiangiogenic activity. Clin Cancer Res 11(9): 3514–3522 2. Bergers G, Benjamin LE (2003) Tumorigenesis and the angiogenic switch. Nat Rev Cancer 3(6):401–410 3. Bevacizumab (Avastin). [package insert] (April, 2004) Genentech, San Francisco, CA 4. Bocci G, Francia G, Man S, Lawler J, Kerbel RS (2003) Thrombospondin 1, a mediator of the antiangiogenic effects of low-dose metronomic chemotherapy. Proc Natl Acad Sci USA 100(22):12917–12922 5. Browder T, Butterfield CE, Kraling BM, Shi B, Marshall B, O’Reilly MS et al (2000) Antiangiogenic scheduling of chemotherapy improves efficacy against experimental drug-resistant cancer. Cancer Res 60(7):1878–1886

338 6. Burstein HJ, Spigel D, Kindsvogel K, Parker LM, Bunnell CA, Partridge AH et al (2005) Metronomic chemotherapy with and without bevacizumab for advanced breast cancer: a randomized phase II study. Breast Cancer Res Treat, San Antonio Breast Cancer Symposium 94, S1:4 (abst) 7. Colleoni M, Rocca A, Sandri MT, Zorzino L, Masci G, Nole F et al (2002) Low-dose oral methotrexate and cyclophosphamide in metastatic breast cancer: antitumor activity and correlation with vascular endothelial growth factor levels. Ann Oncol 13(1):73–80 8. Drevs J, Hofmann I, Hugenschmidt H, Wittig C, Madjar H, Muller M et al (2000) Effects of ptk787/zk 222584, a specific inhibitor of vascular endothelial growth factor receptor tyrosine kinases, on primary tumor, metastasis, vessel density, and blood flow in a murine renal cell carcinoma model. Cancer Res 60(17):4819–4824 9. Drevs J, Zirrgiebel U, Schmidt-Gersbach CI, Mross K, Medinger M, Lee L et al (2005) Soluble markers for the assessment of biological activity with ptk787/zk 222584 (ptk/zk), a vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitor in patients with advanced colorectal cancer from two phase I trials. Ann Oncol 16(4):558–565 10. Dupont J, Schwartz L, Koutcher J, Spriggs D, Gordon M, Mendelson D et al (2004) Phase I and pharmacokinetic study of VEGF trap administered subcutaneously(sc) to patients with advanced solid malignancies. J Clin Oncol, Proc Annu Meet Am Soc Clin Oncol 23:3009(abst) 11. Escudier B, Szczylik C, Eisen T, Stadler WM, Schwartz B, Shan M et al (2005) Randomized phase III trial of the Raf kinase and VEGFR inhibitor sorafenib (bay 43– 9006) in patients with advanced renal cell carcinoma. J Clin Oncol, Proc Annu Meet Am Soc Clin Oncol 23, LBA4510 (abst) 12. Ferrara N. (2004) Vascular endothelial growth factor as a target for anticancer therapy. Oncologist 9(Suppl 1):2–10 13. Ferrara N, Gerber HP, LeCouter J (2003) The biology of VEGF and its receptors. Nat Med 9(6):669–676 14. Fine BA, Valente PT, Feinstein GI, Dey T (2000) VEGF, flt-1, and kdr/flk-1 as prognostic indicators in endometrial carcinoma. Gynecol Oncol 76(1):33–39 15. Foekens JA, Peters HA, Grebenchtchikov N, Look MP, Meijer-van Gelder ME, Geurts-Moespot A et al (2001) High tumor levels of vascular endothelial growth factor predict poor response to systemic therapy in advanced breast cancer. Cancer Res 61(14):5407–5414 16. Folkman J (1971) Tumor angiogenesis: therapeutic implications. N Engl J Med 285(21):1182–1186 17. Folkman J (1995) Angiogenesis in cancer, vascular, rheumatoid and other disease. Nat Med 1(1):27–31 18. Gasparini G, Toi M, Gion M, Verderio P, Dittadi R, Hanatani M et al (1997) Prognostic significance of vascular endothelial growth factor protein in node-negative breast carcinoma. J Natl Cancer Inst 89(2):139–147 19. Giantonio BJ, Catalano PJ, Meropol NJ, O’Dwyer PJ, Mitchell EP, Alberts SR et al (2005) High-dose bevacizumab imporves survival when combined with folfox4 in previously treated advanced colorectal cancer: results from the eastern cooperative oncology group (ecog) study e3200. J Clin Oncol, Proc Annu Meet Am Soc Clin Oncol 23:2 (abst)

A. Zakarija and W.J. Gradishar 20. Gordon MS, Margolin K, Talpaz M, Sledge GW Jr, Holmgren E, Benjamin R et al (2001) Phase I safety and pharmacokinetic study of recombinant human anti-vascular endothelial growth factor in patients with advanced cancer. J Clin Oncol 19(3):843–850 21. Hainsworth JD, Sosman JA, Spigel DR, Edwards DL, Baughman C, Greco A (2005) Treatment of metastatic renal cell carcinoma with a combination of bevacizumab and erlotinib. J Clin Oncol 23(31):7889–7896 22. Hanahan D, Bergers G, Bergsland E (2000) Less is more, regularly: metronomic dosing of cytotoxic drugs can target tumor angiogenesis in mice. J Clin Invest 105(8): 1045–1047 23. Hanahan D, Folkman J (1996) Patterns and emerging mechanisms of the angiogenic switch during tumorigenesis. Cell 86(3):353–364 24. Hanahan D, Weinberg RA (2000) The hallmarks of cancer. Cell 100(1):57–70 25. Harada Y, Ogata Y, Shirouzu K (2001) Expression of vascular endothelial growth factor and its receptor kdr (kinase domain-containing receptor)/flk-1 (fetal liver kinase-1) as prognostic factors in human colorectal cancer. Int J Clin Oncol 6(5):221–228 26. Hecht JR, Trarbach T, Jaeger E, Hainsworth J, Wolff R, Lloyd K et al (2005) A randomized, double-blind, placebocontrolled, phase III study in patients with metastatic adenocarcinoma of the colon ore rectum receiving first-line chemotherapy with oxaliplatin/5-fluorouracil/leucovorin and ptk787/zk 222584 or placebo (confirm-1). J Clin Oncol, Proc Annu Meet Am Soc Clin Oncol 23, LBA 3 (abst) 27. Heymach JV, Johnson BE, Rowbottom JA, Fidias P, Lu C, Prager D et al (2005) A randomized, placebo-controlled phase II trial of zd6474 plus docetaxel, in patients with nsclc. J Clin Oncol, Proc Annu Meet Am Soc Clin Oncol 23:3023 (abst) 28. Holash J, Davis S, Papadopoulos N, Croll SD, Ho L, Russell M et al (2002) VEGF-trap: a VEGF blocker with potent antitumor effects. Proc Natl Acad Sci USA 99(17):11393–11398 29. Holden SN, Eckhardt SG, Basser R, de Boer R, Rischin D, Green M et al (2005) Clinical evaluation of zd6474, an orally active inhibitor of VEGF and EGF receptor signaling, in patients with solid, malignant tumors. Ann Oncol 16(8):1391–1397 30. Holden SN, Ryan E, Kearns A, Holmgren E, Hurwitz H (2005) Benefit from bevacizumab (bv) is independent of pretreatment plasma vascular endothelial growth factora (VEGF-a) in patients with metastatic colorectal cancer. J Clin Oncol, Proc Annu Meet Am Soc Clin Oncol 23:3555 (abst) 31. Hurwitz H, Fehrenbacher L, Novotny W, Cartwright T, Hainsworth J, Heim W et al (2004) Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med 350(23):2335–2342 32. Hurwitz HI, Fehrenbacher L, Hainsworth JD, Heim W, Berlin J, Holmgren E et al (2005) Bevacizumab in combination with fluorouracil and leucovorin: an active regimen for first-line metastatic colorectal cancer. J Clin Oncol 23(15):3502–3508 33. Inai T, Mancuso M, Hashizume H, Baffert F, Haskell A, Baluk P et al (2004) Inhibition of vascular endothelial growth factor (VEGF) signaling in cancer causes loss of

18 Inhibitors of Tumor Angiogenesis

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

endothelial fenestrations, regression of tumor vessels, and appearance of basement membrane ghosts. Am J Pathol 165(1):35–52 Jain RK (2005) Normalization of tumor vasculature: an emerging concept in antiangiogenic therapy. Science 307(5706):58–62 Johnson DH, Fehrenbacher L, Novotny WF, Herbst RS, Nemunaitis JJ, Jablons DM et al (2004) Randomized phase II trial comparing bevacizumab plus carboplatin and paclitaxel with carboplatin and paclitaxel alone in previously untreated locally advanced or metastatic non-small-cell lung cancer. J Clin Oncol 22(11):2184–2191 Jubb AM, Hurwitz HI, Bai W, Holmgren EB, Tobin P, Guerrero AS et al (2006) Impact of vascular endothelial growth factor-a expression, thrombospondin-2 expression, and microvessel density on the treatment effect of bevacizumab in metastatic colorectal cancer. J Clin Oncol 24(2):217–227 Juttner S, Wissmann C, Jons T, Vieth M, Hertel J, Gretschel S et al (2006) Vascular endothelial growth factord and its receptor VEGFR-3: two novel independent prognostic markers in gastric adenocarcinoma. J Clin Oncol 24(2):228–240 Kabbinavar F, Hurwitz HI, Fehrenbacher L, Meropol NJ, Novotny WF, Lieberman G et al (2003) Phase II, randomized trial comparing bevacizumab plus fluorouracil (fu)/leucovorin (lv) with fu/lv alone in patients with metastatic colorectal cancer. J Clin Oncol 21(1):60–65 Kilickap S, Abali H, Celik I. (2003) Bevacizumab, bleeding, thrombosis, and warfarin. J Clin Oncol 21(18):3542; author reply 3543 Kim ES, Serur A, Huang J, Manley CA, McCrudden KW, Frischer JS et al (2002) Potent VEGF blockade causes regression of coopted vessels in a model of neuroblastoma. Proc Natl Acad Sci USA 99(17):11399–11404 Kim KJ, Li B, Winer J, Armanini M, Gillett N, Phillips HS et al (1993) Inhibition of vascular endothelial growth factor-induced angiogenesis suppresses tumour growth in vivo. Nature 362(6423):841–844 Kindler HL, Friberg G, Singh DA, Locker G, Nattam S, Kozloff M et al (2005) Phase II trial of bevacizumab plus gemcitabine in patients with advanced pancreatic cancer. J Clin Oncol 23(31):8033–8040 Kupsch P, Henning BF, Passarge K, Richly H, Wiesemann K, Hilger RA et al (2005) Results of a phase I trial of sorafenib (bay 43–9006) in combination with oxaliplatin in patients with refractory solid tumors, including colorectal cancer. Clin Colorectal Cancer 5(3):188–196 Millauer B, Longhi MP, Plate KH, Shawver LK, Risau W, Ullrich A et al (1996) Dominant-negative inhibition of flk-1 suppresses the growth of many tumor types in vivo. Cancer Res 56(7):1615–1620 Miller KD, Chap LI, Holmes FA, Cobleigh MA, Marcom PK, Fehrenbacher L et al (2005) Randomized phase III trial of capecitabine compared with bevacizumab plus capecitabine in patients with previously treated metastatic breast cancer. J Clin Oncol 23(4):792–799 Miller KD, Trigo JM, Wheeler C, Barge A, Rowbottom J, Sledge G et al (2005) A multicenter phase II trial of zd6474, a vascular endothelial growth factor receptor-2 and

339

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

epidermal growth factor receptor tyrosine kinase inhibitor, in patients with previously treated metastatic breast cancer. Clin Cancer Res 11(9):3369–3376 Miller KD, Wang M, Gralow J, Dickler M, Cobleigh MA, Perez EA et al (2005) A randomized phase III trial of paclitaxel versus paclitaxel plus bevacizumab as first-line therapy for locally recurrent or metastatic breast cancer: a trial coordinated by the eastern cooperative oncology group (e2100). Breast Cancer Res Treat, San Antonio Breast Cancer Symposium 94, S1:3 (abst) Morgan B, Thomas AL, Drevs J, Hennig J, Buchert M, Jivan A et al (2003) Dynamic contrast-enhanced magnetic resonance imaging as a biomarker for the pharmacological response of ptk787/zk 222584, an inhibitor of the vascular endothelial growth factor receptor tyrosine kinases, in patients with advanced colorectal cancer and liver metastases: results from two phase I studies. J Clin Oncol 21(21):3955–3964 Mross K, Drevs J, Muller M, Medinger M, Marme D, Hennig J et al (2005) Phase I clinical and pharmacokinetic study of ptk/zk, a multiple VEGF receptor inhibitor, in patients with liver metastases from solid tumours. Eur J Cancer 41(9):1291–1299 Neufeld G, Cohen T, Gengrinovitch S, Poltorak Z (1999) Vascular endothelial growth factor (VEGF) and its receptors. Faseb J 13(1):9–22 Padro T, Bieker R, Ruiz S, Steins M, Retzlaff S, Burger H et al (2002) Overexpression of vascular endothelial growth factor (VEGF) and its cellular receptor kdr (VEGFR-2) in the bone marrow of patients with acute myeloid leukemia. Leukemia 16(7):1302–1310 Prewett M, Huber J, Li Y, Santiago A, O’Connor W, King K et al (1999) Antivascular endothelial growth factor receptor (fetal liver kinase 1) monoclonal antibody inhibits tumor angiogenesis and growth of several mouse and human tumors. Cancer Res 59(20):5209–5218 Ratain MJ, Eisen T, Stadler WM, Flaherty KT, Gore M, Desai A et al (2005) Final findings from a phase II, placebocontrolled, randomized discontinuation trial of sorafenib (bay 43–9006) in patients with advanced renal cell carcinoma. J Clin Oncol, Proc Annu Meet Am Soc Clin Oncol 23:4544 (abst) Rich JN, Sathornsumetee S, Keir ST, Kieran MW, Laforme A, Kaipainen A et al (2005) Zd6474, a novel tyrosine kinase inhibitor of vascular endothelial growth factor receptor and epidermal growth factor receptor, inhibits tumor growth of multiple nervous system tumors. Clin Cancer Res 11(22):8145–8157 Sandler AB, Gray R, Brahmer J, Dowlati A, Schiller JH, Perry MC et al (2005) Randomized phase II/III trial of paclitaxel plus carboplatin with or withhout bevacizumab in patients with advanced non-squamous non-small cell lung cancer: an eastern cooperative oncology group (ecog) trial – e4599. J Clin Oncol, Proc Annu Meet Am Soc Clin Oncol 23:4 (abst) Shaked Y, Emmenegger U, Man S, Cervi D, Bertolini F, Ben-David Y et al (2005) Optimal biologic dose of metronomic chemotherapy regimens is associated with maximum antiangiogenic activity. Blood 106(9):3058–3061 Skillings JR, Johnson DH, Miller K, Kabbinavar F, Bergsland E, Holmgren E et al (2005) Arterial

340

58.

59.

60.

61.

62.

63.

64.

A. Zakarija and W.J. Gradishar thromboembolic events (ates) in a pooled analysis of 5 randomized, controlled trials of bevacizumab with chemotherapy. J Clin Oncol, Proc Annu Meet Am Soc Clin Oncol 23:3019 (abst) Skobe M, Brown LF, Tognazzi K, Ganju RK, Dezube BJ, Alitalo K et al (1999) Vascular endothelial growth factor-c (VEGF-c) and its receptors kdr and flt-4 are expressed in aids-associated kaposi’s sarcoma. J Invest Dermatol 113(6):1047–1053 Strumberg D, Richly H, Hilger RA, Schleucher N, Korfee S, Tewes M et al (2005) Phase I clinical and pharmacokinetic study of the novel raf kinase and vascular endothelial growth factor receptor inhibitor bay 43–9006 in patients with advanced refractory solid tumors. J Clin Oncol 23(5):965–972 Tanigawa N, Amaya H, Matsumura M, Shimomatsuya T (1997) Correlation between expression of vascular endothelial growth factor and tumor vascularity, and patient outcome in human gastric carcinoma. J Clin Oncol 15(2):826–832 Thomas AL, Morgan B, Horsfield MA, Higginson A, Kay A, Lee L et al (2005) Phase I study of the safety, tolerability, pharmacokinetics, and pharmacodynamics of ptk787/zk 222584 administered twice daily in patients with advanced cancer. J Clin Oncol Tong RT, Boucher Y, Kozin SV, Winkler F, Hicklin DJ, Jain RK (2004) Vascular normalization by vascular endothelial growth factor receptor 2 blockade induces a pressure gradient across the vasculature and improves drug penetration in tumors. Cancer Res 64(11):3731–3736 Trarbach T, Schleucher N, Tewes M, Seeber S, Junker U, Laurent D et al (2005) Phase I/II study of ptk787/zk 222584, a novel, oral angiogenesis inhibitor in combination with folfiri as first-line treatment for patients with metastatic colorectal cancer. J Clin Oncol, Proc Annu Meet Am Soc Clin Oncol 23:3605 (abst) Wedge SR, Ogilvie DJ, Dukes M, Kendrew J, Chester R, Jackson JA et al (2002) Zd6474 inhibits vascular

65.

66.

67.

68.

69.

70.

71.

endothelial growth factor signaling, angiogenesis, and tumor growth following oral administration. Cancer Res 62(16):4645–4655 Wildiers H, Guetens G, De Boeck G, Verbeken E, Landuyt B, Landuyt W et al (2003) Effect of antivascular endothelial growth factor treatment on the intratumoral uptake of cpt11. Br J Cancer 88(12):1979–1986 Wilhelm SM, Carter C, Tang L, Wilkie D, McNabola A, Rong H et al (2004) Bay 43–9006 exhibits broad spectrum oral antitumor activity and targets the raf/mek/erk pathway and receptor tyrosine kinases involved in tumor progression and angiogenesis. Cancer Res 64(19):7099–7109 Willett CG, Boucher Y, di Tomaso E, Duda DG, Munn LL, Tong RT et al (2004) Direct evidence that the VEGFspecific antibody bevacizumab has antivascular effects in human rectal cancer. Nat Med 10(2):145–147 Wood JM, Bold G, Buchdunger E, Cozens R, Ferrari S, Frei J et al (2000) Ptk787/zk 222584, a novel and potent inhibitor of vascular endothelial growth factor receptor tyrosine kinases, impairs vascular endothelial growth factor-induced responses and tumor growth after oral administration. Cancer Res 60(8):2178–2189 Yang JC, Haworth L, Sherry RM, Hwu P, Schwartzentruber DJ, Topalian SL et al (2003) A randomized trial of bevacizumab, an anti-vascular endothelial growth factor antibody, for metastatic renal cancer. N Engl J Med 349(5):427–434 Yano S, Muguruma H, Matsumori Y, Goto H, Nakataki E, Edakuni N et al (2005) Antitumor vascular strategy for controlling experimental metastatic spread of human small-cell lung cancer cells with zd6474 in natural killer cell-depleted severe combined immunodeficient mice. Clin Cancer Res 11(24 Pt 1):8789–8798 Yoshiji H, Gomez DE, Shibuya M, Thorgeirsson UP (1996) Expression of vascular endothelial growth factor, its receptor, and other angiogenic factors in human breast cancer. Cancer Res 56(9):2013–2016

Chapter 19

Transcatheter Management of Neoplasms Christos S. Georgiades and Jean-Francois Geschwind

19.1 Introduction

19.2 Hepatic Neoplasms

Though angiography has been part of the Interventional Radiologist’s armamentarium for many decades, in the field of oncology it was initially limited to diagnosing and staging of neoplasms. The last two decades however have witnessed the birth of a multitude of novel transcatheter interventional techniques that have become an integral part of the management of neoplasms. What made this possible is the development of new and improved interventional devices and skills as well as the improved understanding of tumor physiology and discovery of pharmaceuticals that lend themselves to transcatheter use. These developments have in turn altered the approach to the treatment of cancer, transforming it into a multidisciplinary effort and have propelled the Interventional Radiologist to the forefront of the management of neoplasms. The following sections describe the types of transcatheter interventions for the management of neoplasms available today (as well as their indications, efficacy and side effects) and are presented on an organ/neoplasm basis.

Today the bulk of transcatheter interventions are geared towards the management of either unresectable primary liver cancer (Hepatocellular carcinoma (eHCC) or cholangiocarcinoma) or liver metastases. A number of reasons have contributed to this. HCC is the eighth most common malignancy worldwide [1]. The increasing incidence of hepatitis B (in Sub-Saharan Africa and Southeast Asia) and Hepatitis C (in Europe and USA) have resulted in a steady increase in the incidence of HCC and epidemiological models project a continuous steady increase [2] especially in the Western world. Survival for unresectable disease is disappointingly short and estimated at 4–6 months [3]. Given that 80–90% of patients are unresectable at presentation [4, 5], non-surgical treatment options have generated significant interest. The liver tumors themselves (whether primary or secondary) tend to be well defined and for the most part well vascularized (especially hepatomas, neuroendocrine tumors, sarcomas and melanomas). They receive their blood supply nearly exclusively from the hepatic arterial system whereas normal liver parenchyma is mostly dependent on the portal venous blood supply. These factors allow the selection of the hepatic arterial vessel that feeds the tumor and the delivery of the therapeutic medium in situ while at the same time sparing normal liver and the patient many of the side effects seen with systemic chemotherapy. The role of diagnostic angiography for liver neoplasms has greatly diminished since the advent of custom computed tomographic (CT) and magnetic resonance image (MRI) sequences. Dual-phase contrastenhanced CT and MRI studies provide dependably

C.S. Georgiades () Division of Vascular and Interventional Radiology, Department of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD 21287, USA e-mail: [email protected]

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_19, © Springer Science+Business Media B.V. 2011

341

342

high sensitivity and specificity for the detection of liver neoplasms especially in conjunction with tumor markers such as alpha-fetoprotein (AFP) levels. Occasionally, CT and MRI may be inconclusive as to the nature of a liver lesion, a scenario often seen in macronodular cirrhotics, where it is crucial to distinguish between a regenerating nodule and HCC. Transcatheter intra-arterial injection of lipiodol, followed up with a 10–14 day delayed CT is usually diagnostic in such cases. Lipiodol remains sequestered within an HCC nodule for many weeks post-injection, a phenomenon not seen with benign regenerating nodules. Contrary to diagnostic angiography, therapeutic transcatheter interventions have dramatically expanded in scope and variety [6]. Transarterial Chemoembolization (TACE) for liver neoplasms is the most widespread neoplasm related therapeutic transcatheter intervention today. Patient selection is important as only non-surgical candidates must be considered for this procedure. Exclusion criteria are shown on Table 19.1. During TACE a catheter is used to select the branch of the proper hepatic artery feeding the tumor and deliver chemotherapy. At our institution we use a combination of Cisplatin 100 mg, Doxorubicin 50 mg and Mitomycin C 10 mg mixed 1:1 to 1:2 with lipiodol (for opacification and prolongation of chemotherapy residence time in the tumor). Single, two or three drug TACE protocols have been used but no study regarding their relative benefit exists.

C.S. Georgiades and J.-F. Geschwind

Multiple studies have shown significant survival benefit after TACE for unresectable HCC and cholangiocarcinoma when compared to systemic chemotherapy, supportive care as well as blunt (Non chemotherapy) hepatic artery embolization. The 1-, 2and 3-year survival rates for TACE versus supportive care (for HCC) are reported as 57–82, 31–63, 26– 27, and 18–63, 6–27, 0–5%, respectively (Fig. 19.1), [7–10]. Similar encouraging results have been demonstrated with vascular metastatic disease to the liver, especially metastatic carcinoid, renal cell carcinoma and a variety of sarcomas. Unpublished data from our institution regarding TACE for unresectable cholangiocarcinoma suggest a significant survival benefit with a median survival of 20 months for TACE patients compared to a 5–8 month median survival for nonTACE patients (Fig. 19.2). Patient selection begins with establishing unresectability, as surgery is the only possibly curative intervention. The protocol is rather straightforward and is initiated by a contrast enhanced MRI (Dual phase) of the liver followed by the first TACE of the right or left hepatic artery (depending on relative tumor burden). In about 6 weeks a follow up MRI with diffusion sequence is obtained to quantify tumor viability. The six-weekly cycle is repeated until there is no viable tumor by imaging or the patient develops an exclusion criterion. Generally, the patients tolerate the procedure well and about 90% are discharged the day after

Table 19.1 Exclusion criteria for transarterial chemoembolization for unresectable liver neoplasm Exclusion criteria for TACE 1. Resectible disease 2. Total Bilirubin > 4 mg/dl 3. Borderline liver function 4. Encephalopathy 5. Thrombosed portal vein 6. Poor general health TACE is not a substitute for surgery in case of resectible liver disease. If patient is a poor surgical candidate or refuses surgery then TACE can be considered. High bilirubin is a contraindication as it is a marker for borderline liver function and reserve. If hyperbilirubinemia is due to bile outflow obstruction then TACE can be performed after biliary drainage and correction of hyperbilirubinemia. As encephalopathy is also an indication for limited liver function, it is a contraindication to TACE. Portal vein thrombosis used to be an absolute contraindication to TACE. However, during the last few years at our institution, we performed TACE in patients with portal vein thrombosis without any significant complications. Care must be taken however, to ensure patency of the hepatic artery and good liver function overall. Finally, from our experience and despite having no other exclusion criterion, patients who are in poor general health, are physically weak and emaciated have a higher rate of complications including liver dysfunction after TACE. No specific factors have been identified, however, if a patient “looks really sick” TACE is unlikely to be of benefit. Because TACE is continuously being evaluated, the above exclusion criteria are not well established and are changing. They all are currently relative exclusion criteria and the patient’s complete clinical picture, expectations and prognosis should be part of the decision process

19 Transcatheter Management of Neoplasms

343

100% 80%

75%

60%

TACE Non-TACE

46%

40% 20%

30% 20% 4%

0%

1-year

2-year

Fig. 19.1 Survival for patients with unresectable hepatocellular carcinoma treated with TACE vs. non-TACE treated patients. 1-, 2- and 3-year survival after TACE is 75, 46, and 30%, which is

Mean survival from diagnosis, months

25 21

20 15

Non-TACE TACE

10 6.5

5 0

Fig. 19.2 Survival for patients with unresectable cholangiocarcinoma treated with TACE vs. those not treated with TACE. Preliminary, unpublished as of yet data from our institution show a significant survival benefit for patients undergoing TACE for unresectable cholangiocarcinoma vs. those who do not. In addition to the survival benefit, 2 out of the 15 patients included in our study became resectable after significant tumor shrinkage. Exclusion criteria and the procedure are the same as in TACE for HCC

the procedure. A minority of patients will require longer hospitalization to control a significant postembolization syndrome (pain, nausea, vomiting and fever). Poor application of the exclusion criteria however, can have serious consequences. For example, TACE in a patient with borderline liver function may result in fulminant hepatic failure and death. If hyperbilirubinemia is due to biliary obstruction, percutaneous or endoscopic drainage may decrease bilirubin adequately to permit TACE.

0%

3-year

significantly better that patients not treated with TACE (20, 4, and 0% respectively)

While TACE prolongs the chemotherapy residence time within the tumor and reduces systemic concentrations, its effect lasts hours to days and still has significant systemic toxicities. The introduction of drug eluting beads further improves on these advantages. Compared to TACE, DEB embolization results in even longer chemotherapy contact within the tumor and even less systemic release. Specifically, the effective half life of DEB is days to weeks and the systemic levels of chemotherapy are significantly lower. As expected, toxicity rates are also fewer in patients treated with DEB compared to those treated with TACE. Response rates appear also to be significantly improved with DEB with some studies reporting a complete response rate of up to 40–50% [11]. An alternative to TACE for unresectable neoplastic liver disease is the infusion of radioactive particles impregnated with Yttrium-90. Prior to treatment, the patient undergoes a shunt study of the liver by injecting a known amount of Technicium-99-MAA into the hepatic artery to be treated. The shunt is calculated by using a detection camera to quantify the radioactivity that remains in the liver and that shunted to the lungs. A shunt fraction of more that 15–20% (lung activity/total delivered in hepatic artery × 100%) is considered a contraindication to treatment as significant lung damage may ensue. Once a shunt of less than 15–20% has been established, the patient undergoes catheterization and instillation of Yttrium-90 into the hepatic artery supplying the tumor [12, 13]. Preliminary studies have shown a survival advantage for patients with

C.S. Georgiades and J.-F. Geschwind Median survival, months

344 10 8 6 9.3

4 2

4.5

0 No Treatment

Y-90

Fig. 19.3 Survival for patients with unresectable hepatocellular carcinoma treated with hepatic intra-arterial Yttrium90 microsphere infusion. Median survival for unresectable

disease (bar 1) is 4.5 months. For all patients undergoing transcatheter Y-90 treatment median survival is 9.3 months

unresectable liver disease (Fig. 19.3). Average survival for patients treated with Yttrium-90 is 40 weeks, which increases to 56 weeks with a total treatment dose of at least 120 Gy.

When however, patients are carefully selected, recent studies have shown a significant survival advantage. For unresectable disease with metastases, Onishi et al report a 1-, 2- and 3-year survival of 29, 15 and 10% respectively in the TAE group compared to 13, 7 and 3% in the control group (Fig. 19.4) [15]. TAE utilized pure alcohol and there were no pre-procedure differences between the two groups except the TAE group had more paraneoplastic signs. The procedure its self is technically simple and aims at embolizing with pure ethanol all the renal arterial branches that feed the tumor, including the main renal artery if necessary. Embolization of normal renal parenchyma should be avoided. Occasionally, accessory arterial feeders may be seen, such as from the lumbar, phrenic or adrenal arteries, and they may be embolized as well. Zielinski et al. [16] also report improved survival for patients who undergo pre-operative embolization followed by radical nephrectomy compared to those who undergo radical nephrectomy alone. The overall 5- and 10-year survival for patients who underwent embolization followed by nephrectomy was 62 and 47% respectively, whereas for only nephrectomy, the corresponding survival was 35 and 23% (Fig. 19.5). Though renal angiomyolipomas are benign tumors they can precipitate serious symptoms, including pain, hemorrhage and hematuria. Transcatheter embolization of the branch of the renal artery that supplies the tumor with particles, is extremely effective and safe in alleviating such symptoms (Alcohol embolization is reserved in pre-surgical cases as alcohol causes tissue necrosis and may be complicated by infection/abscess formation). As with transcatheter interventions in

19.3 Urological Malignancies Contrary to liver neoplasms, the majority of renal cell carcinomas (RCC) are rescectable at time of presentation. Nephrectomy is the standard procedure for unilateral RCC, however, nephron-sparing surgery is an attractive alternative. When the patient is unresectable, percutaneous radiofrequency ablation (RFA) is an increasingly popular alternative as well. Because only a small minority of patients are unresectable, intra-arterial interventions have not been adequately explored as a treatment option. However, certain indications do exist. Currently, these are limited to (1) pre-surgical embolization for improved intra- and postsurgical hemostasis, (2) palliate symptoms (pain and hematuria) and (3) slow local spread of unresectable disease, in decreasing order of frequency. Within this context, trans-arterial embolization (TAE) has been very successful, with significant or complete symptom resolution is 70–90% of patients. Morbidity and mortality is very low and mostly accounted for by the post-embolization syndrome which is relatively easily controlled [14, 15]. Despite the clear benefits of TAE for RCC symptoms, its use as a therapeutic alternative is controversial. Prospective studies are limited due to the small number of patients and results are mixed.

19 Transcatheter Management of Neoplasms

345

50% 45% 40% 35% 30%

29% TAE

25%

Non-TAE

20% 15%

15%

13%

10% 10%

7% 3%

5% 0% 1-year

2-year

Fig. 19.4 Survival for patients with unresectable renal cell carcinoma with metastases. Patients who underwent blunt (non-chemotherapy) embolization (trans-arterial embolization

3-year

or TAE) of the renal artery branch supplying the tumor had a 29, 15, and 10% 1-, 2-, and 3-year survival, compared to 13, 7, and 3% survival for non-TAE patients

100% 90% 80% 70%

62%

60%

40%

TAE

47%

50%

Non-TAE 35%

30%

23%

20% 10% 0% 5-year

10-year

Fig. 19.5 Survival for patients with resectible renal cell carcinoma. Patients who underwent blunt (non-chemotherapy) embolization (trans-arterial embolization or TAE) of the renal

artery branch supplying the tumor prior to radical nephrectomy had a 62 and 47% 5- and 10-year survival, compared to 35 and 23% for non-TAE patients

general, patient recovery is faster and with much less discomfort. Initial results regarding the use of intra-arterial chemoembolization for invasive bladder neoplasm are encouraging and show an 84–91% complete response rate, possibly improving the odds for bladder preservation [17].

19.4 Head and Neck Cancers Though endovascular interventions for Head and Neck neoplasms are sought mainly to palliate hemorrhage, recent studies have shown other benefits especially for intra-arterial chemotherapy treatment. Vascular Head

346

and Neck tumors include paragangliomas and angiofibromas, though the less vascular but most common types – squamous cell and lymphomas – can also hemorrhage. Intra-arterial embolization is nearly 100% effective in eliminating intractable hemorrhage and is associated with minimal morbidity [18–21]. A particular problem, especially after radiation treatment for nasopharyngeal carcinoma is intractable epistaxis. Selective transcatheter embolization is very effective and safe and in most cases, the only treatment option [21, 22, 23]. Pre-operative blunt embolization is also a common indication to limit intra- and post-operative bleeding. The transcatheter infusion of chemotherapy into the arteries that supply head and neck tumors has shown considerable promise with studies showing complete response rates of 60–80% after treatment with Cisplatin. Morbidity was limited to the postembolization syndrome (pain, swelling, fever) and one case of swelling induced tracheotomy [24, 25]

19.5 Metastases Blunt (non-chemotherapy) embolization of metastatic disease has long been utilized for palliation, especially for pain and hemorrhage control. Owing to more favourable vascular anatomy, bone metastases account for most of the target lesions, and because of their high vascularity the most common type of neoplasms involved are renal cell and thyroid carcinoma. Embolization (with alcohol, gelfoam, particles and/or coils) of bone metastases has been shown to be quite effective in controlling symptoms as well as intra-and post-operative hemorrhage [26, 27]. Lower extremity and spine metastases were the most commonly treated sites and results were equally encouraging. Smit et al [28] report prompt symptom resolution (starting within hours) after embolization of spine metastases from thyroid cancer. The procedure was technically successful in all subjects and without adverse effects and the palliative effect lasted from months to years. Soft tissue metastases have also been treated with embolization, especially head and neck lesions that can have serious consequences such as persistent epistaxis, dysphagia, and airway obstruction, again with minimal morbidity and good results [29].

C.S. Georgiades and J.-F. Geschwind

References 1. Yu MC, Yuan JM, Govindarajan S et al (2000) Epidemiology of hepatocellular carcinoma. Can J Gastroenterol 14:703–709 2. El-Serag HB, Mason AC (2000) Risk factors for the rising primary liver cancer in the United States. Arch Intern Med 27:3227–3230 3. Seong J, Keum CK, Han HK et al (1999) Combined transcatheter arterial chemoembolization and local radiotherapy of unresectable hepatocellular carcinoma. Int J Radiation Oncol Biol Phys 43:393–397 4. Vogl JT, Trapp M, Schroeder H et al (2000) Transarterial chemoambolization for hepatocellular carcinoma: volumetric and morphologic CT criteria for assessment of prognosis and therapeutic success-results from a liver transplantation center. Radiology 214:349–357 5. De Sanctis TJ, Goldberg NS, Mueller RP (1998) Percutaneous treatment of hepatic neoplasms: a review of current techniques. Cardiovasc Intervent Radiol 21: 273–296 6. Georgiades CS, Ramsey DE, Solomon S, Geschwind JF (2001) New non-surgical therapies in the treatment of hepatocellular carcinoma. Tech Vasc Intervent Radiol 4(3): 193–199 7. Geschwind J-F (2002) Chemoembolization for hepatocellular carcinoma: where does the truth lie? J Vasc Intervent Radiol 13:991–994 8. Bronowicki JP, Vetter D, Dumas F et al (1994) Transcatheter oily chemoembolization for hepatocellular carcinoma: a 4-year study of French 127 patients. Cancer 74:16–24 9. Llovet J, Real MI, Montana X et al (2002) Arterial embolization or chemoembolization versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomized controlled trial. Lancet 359: 1734–1739 10. Lo CM, Ngan H, Tso WK et al (2002) Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology 35:1164–1171 11. Liapi E, Lee KH, Georgiades CS et al (2007) Drug eluting particles for interventional pharmacology. Tech Vasc Interv Radiol 10:261–269 12. Lau WY, Leung WT, Ho S et al (1994) Treatment of inoperable hepatocellular carcinoma with intrahepatic arterial yttrium-90 microspheres: a phase I and II study. Br J Cancer 70:994–999 13. Lau WY, Ho S, Leung TW et al (1998) Selective internal radiation therapy for nonresectable hepatocellular carcinoma with intraarterial infusion of yttrium-90 microspheres. Int J Radiation Oncol Biol Phys 40:583–592 14. Munro NP, Woodhams S, Nawrocki JD, Fletcher MS, Thomas PJ (2003) The role of transarterial embolization in the treatment of renal cell carcinoma. BJU Int 92(3): 240–244 15. Onishi T, Oishi Y, Suzuki Y, Asano K (2001) Prognostic evaluation of transarterial embolization for unresectable renal cell carcinoma with distant metastases. BJU Int 87(4):312–315

19 Transcatheter Management of Neoplasms 16. Zielinski H, Szmigielski S, Petrivich Z (2000) Comparison of pre-operative embolization followed by radical nephrectomy with radical nephrectomy alone for renal cell carcinoma. Am J Clin Oncol 23(1):6–12 17. Mistumori K, Sato K, Kato T (2002) Intraarterial chemotherapy in urological cancers. Gan To Kagaku Ryoho 29(2):197–203 18. Persky MS, Setton A, Niimi Y, Hartman J, Frank D, Berenstein A (2002) Combined endovascular and surgical treatment of head and neck paragangliomas-a team approach. Head Neck 24(5):423–431 19. Sittel C, Gossmann A, Jungehusling M, Zahringer M (2001) Superselective embolization as palliative treatment of recurrent hemorrhage in advanced carcinoma of the head and neck. Annal Otol Rhinol Laryngolo 110(12): 1126–1128 20. Morrissey DD, Andersen PE, Nesbit GM, Barnwell SL, Everts EC, Cohen JI (1997) Endovascular management of hemorrhage in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 123(1):15–19 21. Turner L, Zitsch R (2000) Waldeyer’s ring lymphoma presenting as massive oropharyngeal hemorrhage. Mo Med 97(2):63–65 22. Mok JS, Marshall JN, Chan M, van Hasselt CA (1999) Percutaneous embolization to control intractable epistaxis in nasopharyngeal carcinoma. Head Neck 21(3):211–216

347 23. Luo CB, Teng MM, Lirng JF, Chang FC, Chen SS, Guo WY, Chang CY (2000) Endovascular embolization of intractable epistaxis. Zhonghua Yi Xue Za Zhi 63(3): 20–215 24. Kovacs AF, Obitz P, Wagner M (2002) Monocomponent chemoembolization in oral and oropharyngeal cancer using an aqueous crystal suspension of cisplatin. Br J Cancer 86(2):196–202 25. Kovacs AF, Turowski B (2002) Chemoemboluization of oral and oropharyngeal cancer using a high-dose cisplatin crystal suspension and degradable starch microspheres. Oral Oncol 38(1):87–95 26. Layalle I, Flandroy P, Trotteur G, Dondelinger RF (1998) Arterial embolization of bone metastases: is it worth it? J Belge Radiol 81(5):223–225 27. Prabhu VC, Bilski MH, Jambhekar K, Panageas KS, Boland PJ, Nelson PK (2003) Results of preoperative embolization for metastatic spinal neoplasms. J Neurosurg 98(2 suppl):156–164 28. Smit JW, Vielvoye GJ, Goslings BM (2000) Embolization for vertebral metastases of follicular thyroid carcinoma. J Clin Endocrinol Metabol 85(3):989–994 29. Pritchyk KM, Schiff BA, Newkirk KA, Krowak E, Deeb ZE (2002) Metastatic renal cell carcinoma to the head and neck. Laryngoscope 112(9):1598–1602

Chapter 20

Tumor Stem Cells: Therapeutic Implications of a Paradigm Shift in Multiple Myeloma Neil H. Riordan, Thomas E. Ichim, Famela Ramos, Samantha Halligan, Rosalia De Necochea-Campion, Grzegorz W. Basak, Steven F. Josephs, Boris R. Minev, and Ewa Carrier

20.1 Introduction Various tissues are known to possess an endogenous reservoir of resident stem cells, or “progenitor cells”. The oldest and most well characterized stem cell compartment is in the hematopoietic system, where a selfrenewing population of cells is responsible for maintaining all hematopoietic lineages. Physiologically, the hematopoietic stem cell compartment is very flexible in the sense that blood cell production does not occur at a fixed rate but responds to cues from the external environment. For example, blood loss or migration to a high altitude results in renal production of erythropoietin, which causes increased erythrocyte production. Infections simulate immunocytes to secrete factors such as G-CSF which upregulate bone marrow production of neutrophils, which then act in combating the infection [1]. Other tissues possess endogenous stem cells, for example in the heart, cardiac specific stem cells, characterized by expression of c-kit, are known to be activated after myocardial infarction and contribute to de novo formation of cardiomyocytes [2]. Neural stem cells in the subventricular zone undergo entry into cell cycle and migrate to injured areas after experimental stroke [3]. Hepatic stem cells are known to be at least partially responsible for the profound regenerative capacity of the liver [4]. Thus although in humans the endogenous regenerative capacity is not as profound as in, for example, the salamander, where whole limbs can be regenerated by endogenous stem

N.H. Riordan () Medistem Inc, San Diego, CA, USA e-mail: [email protected]

cells [5], endogenous stem cells are still believed to play an important role in tissue turnover and integrity. The process of oncogenesis involves a series of genetic insults and propagation of the altered cells, resulting in selection of cellular populations resistant to natural inhibitory signals. As tumors form, various factors such as abnormal angiogenesis [6, 7], high interstitial pressure [8], acidosis [9, 10], and local hypoxia [11] all contribute to localized inflammatory responses and development of a complex three dimensional architecture comprised of non-malignant cells intertwined with malignant cells. For the past century cancer research has primarily viewed tumors as a monoclonal population that could be represented by cultured cell lines or animal models in which said cell lines have been implanted. However, the concept was proposed that tumors may be viewed as a “functional tissue”, in that a tumor mass contains a stem cell population in manner similar to non-malignant tissues, and that differentiated cells from the tumor stem cells are what comprises the bulk of the tumor mass [12]. Further application of this idea would be that since tumor stem cells respond to injury in a manner similar to non-malignant stem cells, the halting of such injury signals may block cell cycle entry of the tumor stem cell, and therefore result in suppression of the tumor mass. The demonstration that tumor populations, despite being monoclonal in origin are not homogenous in vivo is supported by numerous studies which will be discussed herein. This concept, however, directly threatens the relevance of more than a century of cancer research in which tumors were viewed as relatively homogenous populations and were believed to be represented by in vitro cell lines. Perhaps the discrepancy between in vitro selected cell lines and in vivo three dimensional tumors may account for

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_20, © Springer Science+Business Media B.V. 2011

349

350

the overall dismal rate of clinical successes despite promising preclinical results [13]. We will discuss below some of the evidence that brought up the notion of tumor stem cells, followed by application of the tumor stem cell theory to multiple myeloma (MM), and conclude by touching upon possible therapeutic interventions aimed at targeting MM stem cells and not their differentiated progeny.

20.2 Support for the Tumor Stem Cell Hypothesis In the early 1960s, a series of studies demonstrated that in contrast to in vitro tumor cell lines, in which a general homogeneity of growth was observed, tumors in vivo consisted of “growth fractions”, which were highly proliferative, and “dormant fractions” [14, 15]. These studies based on thymidine incorporation in murine tumors were supported by calculations of human tumor doubling times, in which it was demonstrated that theoretical tumor growth curves were much steeper than actual ones [16]. Additionally, calculations between log killing in acute myeloid leukemia (AML) achieved by standard cytotoxic therapy, compared with time to relapse, demonstrated a marked discrepancy [17]. Cumulatively, these data suggest the possibility that not all tumor cells within a malignant population have equivalent growth potential in vivo. Thus some researchers discussed the possibility that a dormant subfraction of tumor cells resides in tumor masses that is capable of “seeding” and replenishing tumors. Initial investigations into human tumor stem cells were performed in leukemia. In 1994, Lapidot et al. sought to identify the “leukemia initiating cell” from leukemic blasts isolated from patients with AML [18]. Given that the non-malignant blood making (hematopoietic stem cells) express the markers CD34 and lack expression of CD38, the investigators reasoned that the cell initiating leukemia may actually have the same phenotypic markers. It is important to keep in mind that the normal hematopoietic stem cell comprises less than 1 in 1 million cells of the blood. The investigators used magnetic separation techniques and purified cells from AML patients into CD34+, CD34+ CD38+, CD38+, and CD34+ CD38–. These groups of cells were injected into immune

N.H. Riordan et al.

compromised mice and assessed for ability to form leukemic colony forming units. Colony forming units are the human leukemic cells that when implanted into immune deficient mice form colonies in the spleens of recipients. The larger the number of colony forming units there is, the more aggressive the leukemia is. This is known by previous studies that have demonstrated correlation between colony forming units in the spleens of mice and poor patient prognosis [19]. The investigators found that only the CD34 + CD38− subgroup of leukemic cells had the ability to generate substantially more leukemic colonies in the mouse as compared to the other subtypes. While at first glance these findings may seem obvious (i.e. the hematopoietic stem cell is CD34+ CD38−, so it would make sense that the leukemic stem cell has the same characteristics), it is important to point out that the vast majority of the drug discovery efforts targeting leukemia previous to this study were using either leukemic cell lines or leukemic blasts. Unfortunately the majority of leukemic cell lines do not have the phenotype of CD34+ CD38−, and the vast majority of blast cells also lack this phenotype. Accordingly these data were the first to demonstrate that a qualitatively different cancer cell exists as compared to the bulk cancer tissue, which can be isolated and used for research/drug discovery. Regarding solid tumors, identification of breast cancer stem cells was reported in 2003 by Al-Hajj et al. [20]. The investigators obtained patients samples of primary and metastatic infiltrating ductal carcinoma, adenocarcinoma, invasive lobular carcinoma, and inflammatory breast carcinoma. All metastatic tumors were obtained from plural effusions. The investigators observed that the cells had ability to grow in immune deficient mice. To identify markers found on tumor cells that have the ability to form tumors, cells were dissociated into single cell suspensions and purified based on expression of several markers. The adhesion molecules CD24 and CD44 were assessed, as well as B38.1, a breast cancer-specific marker. It was found that injection of 2–8 hundred thousand cells were capable of inducing tumor growth in all animals when the cells were selected for: CD44+ (8/8); B38.1+ (8/8), or CD24/low cells (12/12) gave rise to visible tumors within 12 wk of injection, but none of the CD44 negative cells (0/8), or B38.1 negative cells (0/8) formed detectable tumors. In a representative example, as little as 20,000 CD44+

20 Tumor Stem Cells

CD24 negative cells induced in vivo tumor formation in the mouse, whereas CD44+ CD24+ cells did not. These data support the notion that in the breast cancer tumor mass, numerous subpopulations of cells exist. Some subpopulations have higher tumor-initiating potential than other sub-populations. The existence of specific markers that allows for determination of tumor-causing potential provides the first step for obtaining cells with “tumor-initiating” or “stem cell” qualities.

351

cells express higher levels of complement inhibitors, theoretically to block antibody mediated cytolysis [24]. Additionally, microarray studies have demonstrated expression of CD200 on tumor stem cells [27]. CD200 is known to inhibit the maturation of dendritic cells [47], as well as being involved in direct suppression of Th1 immunity through stimulation of T regulatory cells [48].

20.4 Multiple Myeloma Stem Cells 20.3 Tumor Stem Cells Resemble Non-malignant Tissue Stem Cells The concept that the stem cell of a tumor is similar to normal stem cells of same tissue and has a similar phenotype and properties to the stem cells of non-malignant tissue was not only demonstrated in the leukemia model discussed above but also in numerous models of solid tumors. For example, the marker CD133 is known to reside on non-malignant tissue resident stem cells. CD133 positive stem cells have been described in liver stem cell cells, called “oval cells” [21], prostate stem cells [22], muscle stem cells [23], hematopoietic stem cells [24], and stem cells of the small intestine [25]. Accordingly, it is reasonable to believe that tumor stem cells would also express this marker. Indeed, CD133 has been detected to date on tumor stem cells of the following tissue of origin: colon [26–28], ovarian [29], liver [30], brain [31–33], prostate [34], and head and neck cancer [35]. Numerous other markers and properties of nonmalignant stem cells have been associated with cancer stem cells, for example, expression of CD44 [36], ckit [37], multiple drug resistance protein [38–41], and DAF [42]. It is important to note that cancer stem cells have unique properties from other stem cells that render them particularly difficult to target. For example, the cancer stem cell is normally regarded as a non-cycling cell [43, 44] thus making it resistant to chemotherapy and radiotherapy that effectively targets the cycling cells. Additionally, cancer stem cells express high concentrations of multiple drug resistance protein, an ABC efflux protein that pumps out small molecules making the cells resistant to chemotherapeutic agents [45, 46]. From an immunological perspective tumor stem

Multiple myeloma (MM) is considered a malignant transformation of plasma cells, clinically manifested by bone pathology (lytic bone lesions, diffuse osteoporosis), anemia, and renal dysfunction associated with hypercalcemia which originates from the bone loss. MM is believed to occur as an evolution of monoclonal gammapathy of unknown significance (MGUS), a condition in which plasma cells produce excess amounts of antibody in an asymptomatic manner. Approximately 1% of MGUS patients per year transform into MM [49, 50]. Current treatments for MM include steroids, alkylating agents, immunomodulatory agents (thalidomide, lenalidomide) and proteasome inhibitors, and stem cell transplantation [51]. However, the median survival for patients with MM treated by standard means is approximately 3 years with some survival improvement seen with high-dose therapy and stem cell rescue. Allogeneic transplantation provides the only potential for cure, but has been largely abandoned because of high mortality rates [52]. The applicability of the tumor stem cell concept to MM was first described in the late 1960s in experiments using murine plasma tumors elicited by immunization of the Th2 prone BALB/c strain with a strong immunogen. Although plasma tumor cells appeared morphologically homogenous both in vitro and in vivo, when these cells were transferred to genetically identical mice, the engraftment rate was extremely low. It was demonstrated, however, that of the cells that engrafted, it was possible to derive colony forming cells, which suggested to the authors that subpopulations of cells must exist that are capable of maintaining the bulk of the tumor mass in vivo [53]. About a decade later, similar experiments using MM patient samples were conducted which revealed that primary MM cells

352

isolated from the bone marrow are characterized by low in vitro colony forming ability [54]. These data suggested that either the conditions for in vitro growth needed optimization because they were selecting for only a subset of MM cells, or that MM cells were comprised of two populations, one that was capable of high self replication and another population that was clonally dormant. Further studies supported the concept of an MM stem cell since the few clones that were generated, were in fact capable of continuous self replication in vitro, as well as ability to form secondary colonies [55]. In vivo studies have revealed difficulties in engraftment of bulk MM cells in immune deficient mice, supporting the notion of small numbers of clones maintaining the tumor mass [56].

20.5 Clonal B Cells in MM In contrast to other types of tumors, it is relatively simple to demonstrate clonality in MM. MM is a plasma cell neoplasia, and plasma cells are terminally differentiated B cells. B cells possess unique immunoglobulin idiotypes, which essentially allows for each B cell to have a specific signature that can be traced. When B cells are activated and mature into plasma cells, the plasma cell secretes antibodies that express the same idiotype as the original B cell. Therefore, if an expansion of B cells having the same immunoglobulin signature is observed, this is a very good indication that all the B cells originated from a single clone. If the patient has MM with the same immunoglobulin signature as circulating B cells, it is likely that the MM originated from that same circulating B cell. The concept of such circulating “clonotypic” B cells that give rise to MM initially was made by Pilarski’s group in a study demonstrating existence of an abnormal population of late B/early pre-plasma cells in MM patients. Similar B cell populations expressing the same BCR were also found in patients with the premalignant MGUS condition [57, 58]. These data support similarity of the clonotypic B cells to MM cells due to the fact that progression to plasma cell phenotype is dependent on allelic exclusion of the light chains. Confirmatory data that came in the form of Ig Fingerprinting revealed IgH

N.H. Riordan et al.

rearrangements in the circulating clonal B cells, identical to those expressed by the bone marrow malignant plasma cells [59–62]. Perhaps most convincingly, in vitro culture of clonotypic B cells was used to demonstrate the ability of these cells to differentiate into cells resembling MM cells [63, 64]. These experiments have formed the intellectual foundation for circulating clonal B cells as being directly related to the MM cells found in the bone marrow. Despite the existence of clones B cells that are idiotypically identical, they are not necessarily phenotypically and morphologically identical. This poses the possibility that from the same tumor clone, various steps of differentiation and/or loss of tumorigenic potential may be found. Broadly speaking, there exists two main designations of myeloma B cells when size is used as a distinguishing characteristic. Flow cytometric analysis by forward and side scatter profiles revealed that “small” B cells and “large” B cells exist possessing the same idiotype in MM patients. The small B cells phenotypically resemble non-malignant B lymphocytes by expressing CD45RO and PCA-1, but unlike polyclonal B cells, have reduced expression of CD56 and high expression of CD38. Conversely, large B cells express characteristic memory B cell markers such as CD19, CD20, and CD45RO [57, 61, 65–68]. CD34 expression, which is a prototypic marker of hematopoietic stem cells and endothelial precursors was initially demonstrated to be absent on MM cells [61, 69], however subsequent studies [70, 71] demonstrated that a minor proportion of MM clones express CD34 and also lack lineage markers (similar to hematopoietic stem cells). It appears that the putative MM “stem cell” is associated with the “small B cell” phenotype. In a recent study, bone marrow from MM patients was sorted into a CD138 positive fraction (resembling plasma cells) and CD138 negative fraction (similar to circulating B cells). Clonogenic cells were found exclusively in the CD138 negative fraction. This fraction correlated with high expression of adlehyde dehydrogenase, a side population phenotype, and with the ability to reconstitute immune deficient recipients. The clonotypic cells had a CD34-CD19+CD20+ phenotype and were substantially resistant to conventional drugs used in MM treatment, likely related to the observation that the majority of the cells were in the G0 phase of cell

20 Tumor Stem Cells

cycle [72]. Interestingly, cells of this population are reported to belong to the “small” subset based on flow cytometric profiling [66].

20.6 Differentiation Hierarchy Having made the case that physical size is associated with aggressiveness and possible cancer stem cell activity, we will now discuss some of the phenotypic markers that may provide clues as to differentiation stage of the MM cells. CD45 is a transmembrane phosphatase found in the majority of cells of the hematopoietic lineage in various isoforms, said isoforms associated with naïve (CD45RA) and memory (CD45RO) phenotypes. Several studies have used expression of CD45 isoforms by clonotypic B cells as a means of addressing differentiation state of MM cells. It is known that non-malignant mature B cells highly express total CD45 and that during activation and differentiation into plasma cells overall expression is downregulated. When one examines MM patients, the cells capable of forming colonies in vitro are associated with high expression of the memory phenotype isoform CD45RO [62, 65, 73]. These cells may be found circulating or in secondary lymphoid organs, but not in high concentrations in the bone marrow [65, 67]. This is an important point since memory B cells are one of the few cells in the body to be capable of self-renewal in a stem cell-like fashion. For example, CD45RO purified non-malignant B cells were demonstrated to have potently upregulated telomerase expression and activity subsequent to stimulation in vitro [74]. In the bone marrow of MM patients the plasma cells possessing idiotype associated with malignancy are primarily low expressors of CD45, thus similar in some ways to non-malignant plasma cells [65, 67]. These data suggest that clonotypic B cells in the peripheral blood make up a population of cells that are at the late Bcell stage differentiating constantly through the early plasma cell stages to an end stage plasma cell [57, 65, 67]. Accordingly, if CD45high (CD45R0+) clonotypic B cells represent the proliferating fraction of MM, their high expression of CD45 seems to be consistent with findings showing that fraction of MM cells with high proliferating potential is CD45 high expressing [55].

353

Thus it appears that small B cells with high expression of CD45 RO are associated with a “stem cell-like” phenotype in MM. Another method of characterizing differentiation status of B cells involves genetic identification of immunoglobulin gene rearrangement. Variable (V) gene rearrangement, immunoglobulin heavy chain class switching and somatic hypermutations are all irreversible events that occur after B cell activation in the germinal center. Since MM cells are known to be generated after maturation in the germinal center, clones from patients exclusively express either IgG, IgA, IgM, kappa or lambda light chains. In all cases, including MM of the IgM type, the immunoglobulin genes in MM plasma cells are hypermutated with a consistent pattern of hypermutations within the clone that confirms their post-germinal center maturation status [75]. Interestingly, not all clones isolated from patients express these characteristics. For example, in some studies, cells expressing MM-type Vh gene sequences (clonotypic), but linked to different class of Ig heavy chain constant region genes have been found [71, 76–78]. Frequently, the existence of clonotypic cells of different immunoglobulin classes, including preswitch (IgM) immunoglobulins were identified in the same single patients, also in light-chain type MMs. The cells with varying classes of Ig heavy chains were shown to have identical pattern of hypermutations [77]. The preswitch clonotypic cells have been identified in bone marrow in a majority of patients, however their frequency is very low, requiring highly sensitive diagnostic methods and the frequency in peripheral blood is even lower [76, 78]. These cells do not seem to be mobilized to peripheral blood during peripheral blood stem cell harvest [71, 78]. Interestingly, some patients have been reported to have persistent expression of pre-switch clonotypic transcripts in the blood despite therapy, including high-dose chemotherapy with stem cell rescue, and after SCT suggestive of their drug resistance [78]. It is therefore possible that these pre-switch, early clones may either represent a “stem cell-like” cell, or a precursor to the neoplasia. Supporting the notion that the pre-switch clones may be associated with stem cell properties is their apparent resistance to chemotherapy. A study demonstrated that higher numbers of pre-switch clonotypic isotypes are associated with reduced survival and with more advanced disease at the time of diagnosis [78].

354

Moreover, both pre-switched and post-switched cells from single patients were able to engraft into primary and secondary mice [77, 78].

20.7 Migratory Characteristics of Early Versus Late MM Cells Developing the notion that clonotypic B cells may be a precursor to MM, or a constant “feeding” source of cells that maintains the bulk of the MM mass, we need to discuss migratory activities. On the one hand, if the bone marrow resident mature MM cells have a self-renewal population, then these cells should have migratory ability so as to populate other anatomically distinct areas. On the other hand, if the clonotypic extramedullary circulating B cells are the seeding cells, they must possess the ability to enter bone marrow niches. The simple entry into the bone marrow affords to MM cells a degree of resistance. This can be confusing in observations undertaken to determine whether the self-maintaining MM population is extramedullary or in the marrow. The fundamental importance of bone marrow entry is exemplified by the fact that MM cells are dependent on cytokines and extracellular matrix components in the marrow for viability. These components include fibronectin (FN), collagen types I and IV, laminin and the glycosaminoglycans: heparan sulfate (HS), chondroitin sulfate and hyaluronan (HA) [79]. Mature MM cells express multiple adhesion molecules, some of them binding components of ECM. Laminin and FN are being bound by β1integrins [80], collagen-1 by syndecan-1 [81] while HA is recognized by CD44 [82] and the receptor for HA-mediated motility (RHAMM) [83]. The interactions of MM cells with these components protects against apoptosis and appears to allow for abnormal proliferation in response to naturally secreted growth factors. The most clinically relevant result of these interactions is a spontaneous drug resistance of the tumor known as cell adhesion-mediated drug resistance (CAM-DR) [84]. Contrary to other mechanisms of drug resistance, which develop in the course of the disease (e.g. due to chemotherapy induced selection process), ECM-related drug resistance is thought to occur de novo, in untreated patients. CAM-DR has commonly been attributed to properties of FN and HA.

N.H. Riordan et al.

While mature MM cells in the bone marrow appear resistant to various cytotoxic agents, it is unlikely that they are capable of seeding other sites than in the local implantation area [73]. This is supported by studies demonstrating the difference in adhesion molecules between clonotypic B cells and the resident plasma MM cells. For example, the beta 2-integrin CD11b is a sine qua non element of transendothelial migration to the bone marrow [58]. This molecule is exclusively expressed on clonotypic B cells but not resident bone marrow MM plasma cells [73]. Other migration associated molecules are also found in the clonotypic B cells, such as CXCR5 which is involved in chemotaxis to secondary lymphoid organs [67]. The hyaluronic receptor RHAMM is found on both clonotypic B cells and MM plasma cells, however its activity has only been demonstrated on the clonotypic B cells [68, 83, 85]. Therefore the observations discussed above support the view that while some aspects of MM plasma cells may resemble stem cells (drug/apoptosis resistance), these may be occurring as a result of protection mediated by the bone marrow niche. In order for the MM populations to be capable of seeding new sites and maintaining bulk of the tumor, the cells would need migratory capacity, which appears to be lacking in the mature MM plasma cells. In contrast, the clonotypic B cells appear to have this characteristic. It is important to note that non-malignant memory B cells also have a high migratory ability [86], thus it may be that MM is initiated as a disease of the memory B cell, which would be the equivalent of a stem cell, and that upon differentiation into plasma cells, bone marrow MM cells lead to pathology, but these cells are not capable of continuous reseeding of the tumor.

20.8 Pathological Characteristics of Early MM Cells Although the clonotypic B cells described above possess several of the features associated with MM, it is important to note that these are found only when patients also have plasma MM cells in the bone marrow. In premalignant states the role of the clonotypic B cell is not as clear. It is known based on genetic identification of immunoglobulin idiotypes that the

20 Tumor Stem Cells

clones giving rise to full-blown MM belong to the clonotypic B cell. Studies in MGUS patient populations have demonstrated this unequivocally [87, 88] and that karyotypic abnormalities in clonotypic B cells are similar to those in MM plasma cells [88, 89]. Thus the picture is emerging that the initial clonotypic B cell expansion may be a premalignant cell, which subsequently acquires additional mutations in various proto-oncogenes, which subsequently allows it to seed the bone marrow and give rise to the MM plasma cell which causes pathology. Subsequently a population of clonotypic B cells remains which continually self-renews and provides “seeds” to maintain the bulk of the bone marrow MM population. Such a multi-step acquisition of mutations in a premalignant clone can be paralleled to the situation in chronic myeloid leukemia where the initial bcr-abl translocation provides a competitive advantage to myeloid clones, but only after additional mutations is the full-blown neoplasia initiated that is characterized by a failure to differentiate and blast crisis [90]. It is known in patients with MM that CD38−/CD19+/CD27+ clonotypic B cells recirculate from the bone marrow, to peripheral blood, and secondary lymphoid organs [67]. Cells with this phenotype haven been demonstrated to engraft in immunocompromised mice and to differentiate in vivo into mature MM plasma cells that secrete monoclonal protein and produce osteolytic lesions resembling human disease [71, 91, 92]. The indirect evidence that these cells can also self-renew in vivo was also provided by use of secondary transplants. Thus it appears that clonotypic B cells may be initiating cells in the initial stages of MM, which then act as a reservoir of uncommitted progenitors that continually seed the population of mature plasma cells in the bone marrow. If this is correct, it would be interesting to examine the effect of various therapeutic interventions on the clonotypic B cells in MM patients. It has been reported that a positive correlation exists between MM progression and increased numbers of clonotypic B cells [66]. Early studies showed that these cells are not eliminated by any of the chemotherapy regimens analyzed and remain at high levels during transient remissions [60, 66]. However, more detailed examinations revealed selective modulation of large versus small clonotypic B cells after VAD chemotherapy. Rasmussen et al. described a case, when the number of large but not small B cells markedly decreased

355

after chemotherapy and transplantation [69]. Such cells remained at the low level despite recurrence with massive involvement of the bone marrow. The relative unresponsiveness to therapy of clonotypic B cells in the blood would suggest their drug resistance. In MM patients the multidrug resistance transport pump, Pglycoprotein (P-gp), was shown to be expressed at moderate to high density on blood B cells in majority of patients. In these patients, 6–57% of the small B cells and 75–84% of large B cells expressed P-gp. Patients in temporary remission had an increased proportion of P-gp+ small B cells, patients responding to therapy, had a significant reduction in the proportion of P-gp+ small B cells and a large number of patients lacked detectable P-gp on their small PBMC B cells. Pgp expression on large blood B cells was considerably increased after chemotherapy, with the highest proportions, 80–90% of CD19+ B cells expressing P-gp, among patients with progressing disease and those in temporary remission [89]. Moreover, P-gp expressed by clonotypic B cells seemed to be functional, as shown by dye efflux studies and resistance to adriamycin treatment, which could be reversed by CsA and verapamil [89, 93]. Thus it appears that circulating clonotypic B cells are associated with a chemoresistant phenotype, in some ways similar to that described for tumor stem cells described in other tissues [94–96]. Besides chemoresistance, it appears that clonotypic B cells have altered adhesion to the bone marrow niche in comparison to non-malignant cells. For example, it was determined that bone marrow mobilization by administration of G-CSF is associated with increased frequency of mobilized malignant B cells [60]. Another study demonstrated that approximately 1–5% of leukocytes in apheresis product are clonotypic, and approximately 4 × 107 clonotypic B cells were reinfused per liter of apheresis product [71]. This seems to be consistent with observations of another group which revealed that CD19+ MM cells were present in peripheral blood, and that these increased in number especially within last days of PBSC collection [97]. However, for patients whose clonotypic B cells were only mildly depleted by VAD conditioning regimen and present at transplantation, the cell numbers were reduced 28-fold at 7 months, and became undetectable at 14 months after transplant. This can suggest that while they are drug-resistant, they are subject to immunological pressures [60].

356

20.9 MM Stem Cells in the Context of Other Cancer Stem Cells The literature discussed above seems to point to a strong possibility that within the MM cell population there exists at least one stem cell phenotype. In order to put this context, let us first review properties of stem cells from other tissues. A main property of tumor stem cells is that they primarily reside in a quiescent state. The property of basal quiescence is common between malignant and non-malignant stem cells. Cardiac [98], hematopoietic [99], brain [100], and hepatic [101] stem cells have all been demonstrated to reside in the G0/G1 state, and only upon tissue injury do they enter cell cycle. In the hematopoietic and hepatic stem cell systems, the autocrine production of inhibitory factors such as TGF-beta has been demonstrated to actively maintain quiescence [102, 103]. Conceptually, a quiescent state would assist in maintaining genomic integrity of the stem cell by reducing the possibility of mutation associated with replication. In tumor stem cells the situation seems to be analogous. Preferential quiescence of tumor stem cells in contrast to the bulk mass of tumor cells has been observed in numerous cancers. Quiescence has been demonstrated in CML CD34 positive leukemia initiating cells [104], prostate cancer CD133 positive, CD44 positive stem cells [105], breast cancer stem cells [106], lung cancer [38], and numerous other tumors [107–109]. It appears that the putative non-plasma cells, CD138 negative MM cells, which resemble the circulating clonotypic B cell primarily reside in a quiescent state [110]. In an elegant ex vivo system replicating the bone marrow microenvironment, Pilarsk’s group demonstrated a CD20 positive stem cell population originating from primary MM patient samples [111]. These cells were resistant to melphalan and appeared to reside in a mainly quiescent state, with entry into cell cycle only after cytotoxic insult. The ability to efflux various dyes such as rhodamine 123 and Hoechst 33342 by ATP Binding Cassette (ABC) transporters is a common feature of tissue resident stem cells, being the basis for the designation of “side population” [112]. These transporters, which include P-glycoprotein and Breast Cancer Resistance

N.H. Riordan et al.

Protein, have been found on healthy stem cells of the heart [113], brain [114], liver [115], pancreas [116], and bone marrow [117]. Given that the natural role of ABC transporters is to detoxify cells for potential genotoxins, it is conceptually appealing to postulate that expression of these proteins, along with the general state of stem cell quiescence, acts as a mechanism of maintaining genomic integrity to cells with high self-renewal potential. Unfortunately, it is these same proteins that are associated with drug resistance in tumor cells. The question is whether development of resistance is associated with expansion of tumor stem cells expressing these proteins, or whether differentiated tumor cells that are not capable of self-renewal acquire expression. Tumor stem cells in a variety of cancers have been demonstrated to express ABC transporters, including melanoma [118], pancreatic cancer [119], lung [120], and glioma [121]. In MM expression of ABC transporters was demonstrated in CD138 negative cells that possessed SCID-repopulating potential [110]. Although the occurrence of MM stem cells is considered to be relatively rare (approximately 1 in 100–1000), frequency of ABC transporter expressing cells amongst the bulk MM population is higher, thus arguing that while MM stem cells may express ABC transporters, not all cells that express these proteins are MM stem cells [122]. Expression of various cell membrane surface markers such as c-kit and CD133 has been reported on healthy and malignant stem cells [123–126]. Additionally, signaling pathways associated with selfrenewal such as Notch, Wnt, and hedgehog, are also commonly expressed between malignant and nonmalignant stem cells and have been proposed as targets for inhibition of MM stem cells [127]. In an interesting report, Matsui’s group demonstrated that inhibition of MM stem cell clonogenicity could be achieved by inhibition of the Hedgehog pathway through administration of the naturally occurring hedgehog inhibitor cyclopamine [128]. Thus from the above discussion, one can obtain the impression that in general, tumor stem cells share various characteristics with their non-malignant counterparts, and that MM stem cells appears to possess features of other types of tumor stem cells. Given our knowledge of stem cell and tumor biology, we will propose some possible approaches to MM.

20 Tumor Stem Cells

20.10 Conclusion: Therapy of the MM Stem Cell As discussed above, the MM stem cell appears to exist in a quiescent state protected from genotoxic damage by various drug transporters. This alone would make MM stem cells very difficult to target using conventional approaches. The independent work of the groups of Matsui, Pilarsky, and Huff demonstrated that several of the therapeutic agents used clinically do not target the MM stem cell, but selectively target the proliferating downstream MM cells that make up the disease mass [110, 111, 129]. Immunotherapeutic approaches are conceptually promising, however tumor-specific antigens for MM stem cells have yet to be identified. A clinical trial targeting CD20 with Ritiximab was performed under the basis that CD20 is found on circulating clonotypic B cells, however results were mediocre [130]. This may be because CD20 is also found on non-malignant B cells that are needed for various immune activities. Furthermore since tumor stem cells are known to contain enhanced levels of immune suppressive molecules, immune therapies may be at a disadvantage [24]. However, recently it has been reported that Th-1 (T8) responses can surmount such suppression under certain circumstances (48). On promising area of investigation may be induction of tumor stem cell differentiation into nonmalignant cells. Differentiation therapy of cancer has been effective in acute promyelocytic leukemia through administration of retinoic acid [131], and is currently under investigation for liposarcomas using PPAR modulators [132]. Specific differentiation of glioblastoma was demonstrated by targeting tumor stem cells using the regenerative protein BMP-4 [133]. Theoretically, the most natural way of inducing tumor cell differentiation is to provide a cell population that migrates to the tumor stem cells and induces “guided differentiation”. Indeed, it is known that injection of various tumor cells into developing embryos results in the differentiation of the cancer cell and the formation of a normal chimera. Additionally, microenvironmental cues inducing differentiation of cancer cells are clearly seen in experiments in which melanoma cells are injected into developing chick embryos and the melanoma cells lose tumor-causing potential and

357

differentiate into neurons and skin cells (reviewed in [134]). One interesting possibility would be administration of non-malignant differentiating stem cells and assessing whether non-malignant cells can promote differentiation of tumor stem cells. The ability to grow en masse various types of tumor stem cells conceptually opens the possibility of highthroughput screening for inhibitors that selectively target progenitor cells. Lander’s group recently published an elegant study in which breast cancer stem cells were expanded in vitro and used for screening [135]. Quite unexpectedly, the chicken feed antibacterial agent salinomycin was found to possess a hundred-fold higher ability to inhibit breast cancer stem cells as compared to paclitaxel. The mechanism of inhibition, both in vitro and in vivo was associated with induction of differentiation. In conclusion, the new area of “cancer stem cells” offers for the first time identification of the putative “cause” of malignancy. Combined with the revolution in proteomics and high-throughput screening, the discipline is positioned to tackle issues that previously were unimaginable. However, numerous basic questions remain unanswered, such as, the identity of the signals stimulating cancer stem cells to enter cell cycle, the “paradox” between initial clinical response to therapy and overall survival [129], and the importance of the non-malignant microenvironment that surrounds the tumor.

References 1. Hai-Jiang W, Xin-Na D, Hui-Jun D (2008) Expansion of hematopoietic stem/progenitor cells. Am J Hematol 83:922–926 2. Fransioli J, Bailey B, Gude NA, Cottage CT, Muraski JA, Emmanuel G, Wu W, Alvarez R, Rubio M, Ottolenghi S et al (2008) Evolution of the c-kit-positive cell response to pathological challenge in the myocardium. Stem Cells 26:1315–1324 3. Hayashi T, Iwai M, Ikeda T, Jin G, Deguchi K, Nagotani S, Zhang H, Sehara Y, Nagano I, Shoji M et al (2005) Neural precursor cells division and migration in neonatal rat brain after ischemic/hypoxic injury. Brain Res 1038:41–49 4. Zhang L, Theise N, Chua M, Reid LM (2008) The stem cell niche of human livers: symmetry between development and regeneration. Hepatology 48:1598–1607 5. Young HE, Duplaa C, Romero-Ramos M, Chesselet MF, Vourc’h P, Yost MJ, Ericson K, Terracio L, Asahara T,

358

6.

7.

8.

9.

10.

11.

12. 13. 14. 15.

16. 17. 18.

19.

20.

21.

22.

23.

N.H. Riordan et al. Masuda H et al (2004) Adult reserve stem cells and their potential for tissue engineering. Cell Biochem Biophys 40:1–80 Ruiter DJ, Schlingemann RO, Westphal JR, Denijn M, Rietveld FJ, De Waal RM (1993) Angiogenesis in wound healing and tumor metastasis. Behring Inst Mitt 258–272 Yonenaga Y, Mori A, Onodera H, Yasuda S, Oe H, Fujimoto A, Tachibana T, Imamura M (2005) Absence of smooth muscle actin-positive pericyte coverage of tumor vessels correlates with hematogenous metastasis and prognosis of colorectal cancer patients. Oncology 69:159–166 Lunt SJ, Chaudary N, Hill RP (2009) The tumor microenvironment and metastatic disease. Clin Exp Metastasis 26:19–34 Fukumura D, Jain RK (2007) Tumor microenvironment abnormalities: causes, consequences, and strategies to normalize. J Cell Biochem 101:937–949 Raghunand N (2006) Tissue pH measurement by magnetic resonance spectroscopy and imaging. Methods Mol Med 124:347–364 Gillies RJ, Gatenby RA (2007) Hypoxia and adaptive landscapes in the evolution of carcinogenesis. Cancer Metastasis Rev 26:311–317 Meng X, Riordan NH (2006) Cancer is a functional repair tissue. Med Hypotheses 66:486–490 Sporn MB (1997) The war on cancer: a review. Ann N Y Acad Sci 833:137–146 Mendelsohn ML (1962) Chronic infusion of tritiated thymidine into mice with tumors. Science 135:213–215 Baserga R, Kisieleski WE (1962) Comparative study of the kinetics of cellular proliferation of normal and tumorous tissues with the use of tritiated thymidine. I. Dilution of the label and migration of labeled cells. J Natl Cancer Inst 28:331–339 Steel GG, Lamerton LF (1966) The growth rate of human tumours. Br J Cancer 20:74–86 Ichim CV, Wells RA (2006) First among equals: the cancer cell hierarchy. Leuk Lymphoma 47:2017–2027 Lapidot T, Sirard C, Vormoor J, Murdoch B, Hoang T, Caceres-Cortes J, Minden M, Paterson B, Caligiuri MA, Dick JE (1994) A cell initiating human acute myeloid leukaemia after transplantation into SCID mice. Nature 367:645–648 Jacobs P, Wood L (2005) Clonogenic growth patterns correlate with chemotherapy response in acute myeloid leukaemia. Hematology 10:321–326 Al-Hajj M, Wicha MS, Benito-Hernandez A, Morrison SJ, Clarke MF (2003) Prospective identification of tumorigenic breast cancer cells. Proc Natl Acad Sci USA 100:3983–3988 Rountree CB, Barsky L, Ge S, Zhu J, Senadheera S, Crooks GM (2007) A CD133-expressing murine liver oval cell population with bilineage potential. Stem Cells 25:2419–2429 Richardson GD, Robson CN, Lang SH, Neal DE, Maitland NJ, Collins AT (2004) CD133, a novel marker for human prostatic epithelial stem cells. J Cell Sci 117:3539–3545 Torrente Y, Belicchi M, Sampaolesi M, Pisati F, Meregalli M, D’Antona G, Tonlorenzi R, Porretti L, Gavina M,

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36. 37.

38.

39.

Mamchaoui K et al (2004) Human circulating AC133(+) stem cells restore dystrophin expression and ameliorate function in dystrophic skeletal muscle. J Clin Invest 114:182–195 Wognum AW, Eaves AC, Thomas TE (2003) Identification and isolation of hematopoietic stem cells. Arch Med Res 34:461–475 Katoh Y, Katoh M (2007) Comparative genomics on PROM1 gene encoding stem cell marker CD133. Int J Mol Med 19:967–970 O’Brien CA, Pollett A, Gallinger S, Dick JE (2007) A human colon cancer cell capable of initiating tumour growth in immunodeficient mice. Nature 445: 106–110 Ieta K, Tanaka F, Haraguchi N, Kita Y, Sakashita H, Mimori K, Matsumoto T, Inoue H, Kuwano H, Mori M (2007) Biological and Genetic Characteristics of TumorInitiating Cells in Colon Cancer. Ann Surg Oncol Ricci-Vitiani L, Lombardi DG, Pilozzi E, Biffoni M, Todaro M, Peschle C, De Maria R (2007) Identification and expansion of human colon-cancer-initiating cells. Nature 445:111–115 Ferrandina G, Bonanno G, Pierelli L, Perillo A, Procoli A, Mariotti A, Corallo M, Martinelli E, Rutella S, Paglia A et al (2007) Expression of CD133–1 and CD133–2 in ovarian cancer. Int J Gynecol Cancer 18:506–514 Yin S, Li J, Hu C, Chen X, Yao M, Yan M, Jiang G, Ge C, Xie H, Wan D et al (2007) CD133 positive hepatocellular carcinoma cells possess high capacity for tumorigenicity. Int J Cancer 120:1444–1450 Singh SK, Clarke ID, Terasaki M, Bonn VE, Hawkins C, Squire J, Dirks PB (2003) Identification of a cancer stem cell in human brain tumors. Cancer Res 63:5821–5828 Hemmati HD, Nakano I, Lazareff JA, Masterman-Smith M, Geschwind DH, Bronner-Fraser M, Kornblum HI (2003) Cancerous stem cells can arise from pediatric brain tumors. Proc Natl Acad Sci USA 100: 15178–15183 Beier D, Hau P, Proescholdt M, Lohmeier A, Wischhusen J, Oefner PJ, Aigner L, Brawanski A, Bogdahn U, Beier CP (2007) CD133(+) and CD133(-) glioblastoma-derived cancer stem cells show differential growth characteristics and molecular profiles. Cancer Res 67:4010–4015 Wei C, Guomin W, Yujun L, Ruizhe Q (2007) Cancer Stem-like cells in human prostate carcinoma cells DU145: the seeds of the cell line? Cancer Biol Ther 6:763–768 Harper LJ, Piper K, Common J, Fortune F, Mackenzie IC (2007) Stem cell patterns in cell lines derived from head and neck squamous cell carcinoma. J Oral Pathol Med 36:594–603 Sales KM, Winslet MC, Seifalian AM (2007) Stem cells and cancer: an overview. Stem Cell Rev 3:249–255 Lennartsson J, Ronnstrand L (2006) The stem cell factor receptor/c-Kit as a drug target in cancer. Curr Cancer Drug Targets 6:65–75 Ho MM, Ng AV, Lam S, Hung JY (2007) Side population in human lung cancer cell lines and tumors is enriched with stem-like cancer cells. Cancer Res 67:4827–4833 Salmaggi A, Boiardi A, Gelati M, Russo A, Calatozzolo C, Ciusani E, Sciacca FL, Ottolina A, Parati EA, La Porta C et al (2006) Glioblastoma-derived tumorospheres

20 Tumor Stem Cells

40.

41.

42.

43. 44. 45.

46.

47.

48.

49.

50. 51.

52.

53. 54. 55.

56.

identify a population of tumor stem-like cells with angiogenic potential and enhanced multidrug resistance phenotype. Glia 54:850–860 Szotek PP, Pieretti-Vanmarcke R, Masiakos PT, Dinulescu DM, Connolly D, Foster R, Dombkowski D, Preffer F, Maclaughlin DT, Donahoe PK (2006) Ovarian cancer side population defines cells with stem cell-like characteristics and Mullerian Inhibiting Substance responsiveness. Proc Natl Acad Sci USA 103:11154–11159 Donnenberg VS, Donnenberg AD (2005) Multiple drug resistance in cancer revisited: the cancer stem cell hypothesis. J Clin Pharmacol 45:872–877 Xu JX, Morii E, Liu Y, Nakamichi N, Ikeda J, Kimura H, Aozasa K (2007) High tolerance to apoptotic stimuli induced by serum depletion and ceramide in side-population cells: high expression of CD55 as a novel character for side-population. Exp Cell Res 313: 1877–1885 Nishikawa SI, Osawa M (2006) Niche for normal and cancer stem cells. Ernst Schering Found Symp Proc 5:1–12 Guo W, Lasky JL 3rd, Wu H (2006) Cancer stem cells. Pediatr Res 59:59R–64R Hirschmann-Jax C, Foster AE, Wulf GG, Goodell MA, Brenner MK (2005) A distinct "side population" of cells in human tumor cells: implications for tumor biology and therapy. Cell Cycle 4:203–205 Hirschmann-Jax C, Foster AE, Wulf GG, Nuchtern JG, Jax TW, Gobel U, Goodell MA, Brenner MK (2004) A distinct "side population" of cells with high drug efflux capacity in human tumor cells. Proc Natl Acad Sci USA 101:14228–14233 Cameron CM, Barrett JW, Liu L, Lucas AR, McFadden G (2005) Myxoma virus M141R expresses a viral CD200 (vOX-2) that is responsible for down-regulation of macrophage and T-cell activation in vivo. J Virol 79:6052–6067 Gorczynski RM, Lee L, Boudakov I (2005) Augmented induction of CD4+CD25+ Treg using monoclonal antibodies to CD200R. Transplantation 79:488–491 Blade J, Rosinol L, Cibeira MT, de Larrea CF (2008) Pathogenesis and progression of monoclonal gammopathy of undetermined significance. Leukemia 22: 1651–1657 Kyle RA, Rajkumar SV (2004) Multiple myeloma. N Engl J Med 351:1860–1873 Orlowski RZ (2006) Initial therapy of multiple myeloma patients who are not candidates for stem cell transplantation. Hematology Am Soc Hematol Educ Program 338–347 Pant S, Copelan EA (2007) Hematopoietic stem cell transplantation in multiple myeloma. Biol Blood Marrow Transplant 13:877–885 Bergsagel DE, Valeriote FA (1968) Growth characteristics of a mouse plasma cell tumor. Cancer Res 28:2187–2196 Hamburger A, Salmon SE (1977) Primary bioassay of human myeloma stem cells. J Clin Invest 60:846–854 Robillard N, Pellat-Deceunynck C, Bataille R (2005) Phenotypic characterization of the human myeloma cell growth fraction. Blood 105:4845–4848 Epstein J, Yaccoby S (2005) The SCID-hu myeloma model. Methods Mol Med 113:183–190

359 57. Jensen GS, Mant MJ, Belch AJ, Berenson JR, Ruether BA, Pilarski LM (1991) Selective expression of CD45 isoforms defines CALLA+ monoclonal B-lineage cells in peripheral blood from myeloma patients as late stage B cells. Blood 78:711–719 58. Jensen GS, Belch AR, Kherani F, Mant MJ, Ruether BA, Pilarski LM (1992) Restricted expression of immunoglobulin light chain mRNA and of the adhesion molecule CD11b on circulating monoclonal B lineage cells in peripheral blood of myeloma patients. Scand J Immunol 36:843–853 59. Bergsagel PL, Masellis Smith A, Belch AR, Pilarski LM (1995) The blood B-cells and bone marrow plasma cells in patients with multiple myeloma share identical IgH rearrangements. Curr Top Microbiol Immunol 194: 17–24 60. Szczepek AJ, Seeberger K, Wizniak J, Mant MJ, Belch AR, Pilarski LM (1998) A high frequency of circulating B cells share clonotypic Ig heavy-chain VDJ rearrangements with autologous bone marrow plasma cells in multiple myeloma, as measured by single-cell and in situ reverse transcriptase-polymerase chain reaction. Blood 92:2844– 2855 61. Berenson JR, Vescio RA, Hong CH, Cao J, Kim A, Lee CC, Schiller G, Berenson RJ, Lichtenstein AK (1995) Multiple myeloma clones are derived from a cell late in B lymphoid development. Curr Top Microbiol Immunol 194:25–33 62. Billadeau D, Ahmann G, Greipp P, Van Ness B (1993) The bone marrow of multiple myeloma patients contains B cell populations at different stages of differentiation that are clonally related to the malignant plasma cell. J Exp Med 178:1023–1031 63. Bergui L, Schena M, Gaidano G, Riva M, CaligarisCappio F (1989) Interleukin 3 and interleukin 6 synergistically promote the proliferation and differentiation of malignant plasma cell precursors in multiple myeloma. J Exp Med 170:613–618 64. Caligaris-Cappio F, Bergui L, Tesio L, Pizzolo G, Malavasi F, Chilosi M, Campana D, van Camp B, Janossy G (1985) Identification of malignant plasma cell precursors in the bone marrow of multiple myeloma. J Clin Invest 76:1243–1251 65. Jensen GS, Mant MJ, Pilarski LM (1992) Sequential maturation stages of monoclonal B lineage cells from blood, spleen, lymph node, and bone marrow from a terminal myeloma patient. Am J Hematol 41:199–208 66. Bergsagel PL, Smith AM, Szczepek A, Mant MJ, Belch AR, Pilarski LM (1995) In multiple myeloma, clonotypic B lymphocytes are detectable among CD19+ peripheral blood cells expressing CD38, CD56, and monotypic Ig light chain. Blood 85:436–447 67. Rasmussen T, Lodahl M, Hancke S, Johnsen HE (2004) In multiple myeloma clonotypic CD38–/CD19+/CD27+ memory B cells recirculate through bone marrow, peripheral blood and lymph nodes. Leuk Lymphoma 45:1413– 1417 68. Masellis-Smith A, Belch AR, Mant MJ, Turley EA, Pilarski LM (1996) Hyaluronan-dependent motility of B cells and leukemic plasma cells in blood, but not of bone marrow plasma cells, in multiple myeloma: alternate use

360

69.

70.

71.

72.

73.

74.

75.

76.

77.

78.

79.

80.

81.

N.H. Riordan et al. of receptor for hyaluronan-mediated motility (RHAMM) and CD44. Blood 87:1891–1899 Rasmussen T, Kastrup J, Knudsen LM, Johnsen HE (1999) High numbers of clonal CD19+ cells in the peripheral blood of a patient with multiple myeloma. Br J Haematol 105:265–267 Szczepek AJ, Bergsagel PL, Axelsson L, Brown CB, Belch AR, Pilarski LM (1997) CD34+ cells in the blood of patients with multiple myeloma express CD19 and IgH mRNA and have patient-specific IgH VDJ gene rearrangements. Blood 89:1824–1833 Pilarski LM, Belch AR (2002) Clonotypic myeloma cells able to xenograft myeloma to nonobese diabetic severe combined immunodeficient mice copurify with CD34 (+) hematopoietic progenitors. Clin Cancer Res 8: 3198–3204 Matsui W, Huff CA, Wang Q, Malehorn MT, Barber J, Tanhehco Y, Smith BD, Civin CI, Jones RJ (2004) Characterization of clonogenic multiple myeloma cells. Blood 103:2332–2336 Pilarski LM, Jensen GS (1992) Monoclonal circulating B cells in multiple myeloma. A continuously differentiating, possibly invasive, population as defined by expression of CD45 isoforms and adhesion molecules. Hematol Oncol Clin North Am 6:297–322 Hu BT, Lee SC, Marin E, Ryan DH, Insel RA (1997) Telomerase is up-regulated in human germinal center B cells in vivo and can be re-expressed in memory B cells activated in vitro. J Immunol 159: 1068–1071 Sahota SS, Garand R, Mahroof R, Smith A, JugeMorineau N, Stevenson FK, Bataille R (1999) V(H) gene analysis of IgM-secreting myeloma indicates an origin from a memory cell undergoing isotype switch events. Blood 94:1070–1076 Corradini P, Boccadoro M, Voena C, Pileri A (1993) Evidence for a bone marrow B cell transcribing malignant plasma cell VDJ joined to C mu sequence in immunoglobulin (IgG)- and IgA-secreting multiple myelomas. J Exp Med 178:1091–1096 Bakkus MH, Van Riet I, Van Camp B, Thielemans K (1994) Evidence that the clonogenic cell in multiple myeloma originates from a pre-switched but somatically mutated B cell. Br J Haematol 87:68–74 Reiman T, Seeberger K, Taylor BJ, Szczepek AJ, Hanson J, Mant MJ, Coupland RW, Belch AR, Pilarski LM (2001) Persistent preswitch clonotypic myeloma cells correlate with decreased survival: evidence for isotype switching within the myeloma clone. Blood 98: 2791–2799 Vincent T, Mechti N (2005) Extracellular matrix in bone marrow can mediate drug resistance in myeloma. Leuk Lymphoma 46:803–811 Uchiyama H, Barut BA, Chauhan D, Cannistra SA, Anderson KC (1992) Characterization of adhesion molecules on human myeloma cell lines. Blood 80: 2306–2314 Ridley RC, Xiao H, Hata H, Woodliff J, Epstein J, Sanderson RD (1993) Expression of syndecan regulates human myeloma plasma cell adhesion to type I collagen. Blood 81:767–774

82. Aruffo A, Stamenkovic I, Melnick M, Underhill CB, Seed B (1990) CD44 is the principal cell surface receptor for hyaluronate. Cell 61:1303–1313 83. Pilarski LM, Masellis-Smith A, Belch AR, Yang B, Savani RC, Turley EA (1994) RHAMM, a receptor for hyaluronan-mediated motility, on normal human lymphocytes, thymocytes and malignant B cells: a mediator in B cell malignancy? Leuk Lymphoma 14: 363–374 84. Damiano JS, Cress AE, Hazlehurst LA, Shtil AA, Dalton WS (1999) Cell adhesion mediated drug resistance (CAM-DR): role of integrins and resistance to apoptosis in human myeloma cell lines. Blood 93:1658–1667 85. Turley EA, Belch AJ, Poppema S, Pilarski LM (1993) Expression and function of a receptor for hyaluronanmediated motility on normal and malignant B lymphocytes. Blood 81:446–453 86. Rodrigo Mora J, Von Andrian UH (2006) Specificity and plasticity of memory lymphocyte migration. Curr Top Microbiol Immunol 308:83–116 87. Pilarski LM, Masellis-Smith A, Szczepek A, Mant MJ, Belch AR (1996) Circulating clonotypic B cells in the biology of multiple myeloma: speculations on the origin of myeloma. Leuk Lymphoma 22:375–383 88. Hideshima T, Bergsagel PL, Kuehl WM, Anderson KC (2004) Advances in biology of multiple myeloma: clinical applications. Blood 104:607–618 89. Pilarski LM, Belch AR (1994) Circulating monoclonal B cells expressing P glycoprotein may be a reservoir of multidrug-resistant disease in multiple myeloma. Blood 83:724–736 90. Williams RT, Sherr CJ (2008) The INK4-ARF (CDKN2A/B) Locus in Hematopoiesis and BCRABL-induced Leukemias. Cold Spring Harb Symp Quant Biol 91. Pilarski LM, Hipperson G, Seeberger K, Pruski E, Coupland RW, Belch AR (2000) Myeloma progenitors in the blood of patients with aggressive or minimal disease: engraftment and self-renewal of primary human myeloma in the bone marrow of NOD SCID mice. Blood 95:1056–1065 92. Pilarski LM, Seeberger K, Coupland RW, Eshpeter A, Keats JJ, Taylor BJ, Belch AR (2002) Leukemic B cells clonally identical to myeloma plasma cells are myelomagenic in NOD/SCID mice. Exp Hematol 30:221–228 93. Pilarski LM, Szczepek AJ, Belch AR (1997) Deficient drug transporter function of bone marrow-localized and leukemic plasma cells in multiple myeloma. Blood 90:3751–3759 94. Okamoto A, Chikamatsu K, Sakakura K, Hatsushika K, Takahashi G, Masuyama K (2008) Expansion and characterization of cancer stem-like cells in squamous cell carcinoma of the head and neck. Oral Oncol 45:633–639 95. Steiniger SC, Coppinger JA, Kruger JA, Yates J 3rd, Janda KD (2008) Quantitative mass spectrometry identifies drug targets in cancer stem cell containing side population. Stem Cells 26:3037–3046 96. Zhang S, Balch C, Chan MW, Lai HC, Matei D, Schilder JM, Yan PS, Huang TH, Nephew KP (2008) Identification and characterization of ovarian cancer-initiating cells from primary human tumors. Cancer Res 68:4311–4320

20 Tumor Stem Cells 97. Gazitt Y, Tian E, Barlogie B, Reading CL, Vesole DH, Jagannath S, Schnell J, Hoffman R, Tricot G (1996) Differential mobilization of myeloma cells and normal hematopoietic stem cells in multiple myeloma after treatment with cyclophosphamide and granulocytemacrophage colony-stimulating factor. Blood 87: 805–811 98. Campa VM, Gutierrez-Lanza R, Cerignoli F, Diaz-Trelles R, Nelson B, Tsuji T, Barcova M, Jiang W, Mercola M (2008) Notch activates cell cycle reentry and progression in quiescent cardiomyocytes. J Cell Biol 183:129–141 99. Boxall SA, Cook GP, Pearce D, Bonnet D, El-Sherbiny YM, Blundell MP, Howe SJ, Leek JP, Markham AF, de Wynter EA (2008) Haematopoietic repopulating activity in human cord blood CD133(+) quiescent cells. Bone Marrow Transplant 100. Quinones-Hinojosa A, Chaichana K (2007) The human subventricular zone: a source of new cells and a potential source of brain tumors. Exp Neurol 205:313–324 101. Kordes C, Sawitza I, Haussinger D (2008) Canonical Wnt signaling maintains the quiescent stage of hepatic stellate cells. Biochem Biophys Res Commun 367:116–123 102. Ducos K, Panterne B, Fortunel N, Hatzfeld A, Monier MN, Hatzfeld J (2000) p21(cip1) mRNA is controlled by endogenous transforming growth factor-beta1 in quiescent human hematopoietic stem/progenitor cells. J Cell Physiol 184:80–85 103. Deneme MA, Ok E, Akcan A, Akyildiz H, Soyuer I, Muhtaroglu S (2006) Single dose of anti-transforming growth factor-beta1 monoclonal antibody enhances liver regeneration after partial hepatectomy in biliaryobstructed rats. J Surg Res 136:280–287 104. Yong AS, Keyvanfar K, Hensel N, Eniafe R, Savani BN, Berg M, Lundqvist A, Adams S, Sloand EM, Goldman JM et al (2008) Primitive quiescent CD34+ cells in chronic myeloid leukemia are targeted by in vitro expanded natural killer cells, which are functionally enhanced by bortezomib. Blood 113:875–882 105. Maitland NJ, Collins AT (2008) Prostate cancer stem cells: a new target for therapy. J Clin Oncol 26:2862–2870 106. Li HZ, Yi TB, Wu ZY (2008) Suspension culture combined with chemotherapeutic agents for sorting of breast cancer stem cells. BMC Cancer 8:135 107. Sanchez-Garcia I, Vicente-Duenas C, Cobaleda C (2007) The theoretical basis of cancer-stem-cell-based therapeutics of cancer: can it be put into practice? Bioessays 29:1269–1280 108. Lou H, Dean M (2007) Targeted therapy for cancer stem cells: the patched pathway and ABC transporters. Oncogene 26:1357–1360 109. Schulenburg A, Ulrich-Pur H, Thurnher D, Erovic B, Florian S, Sperr WR, Kalhs P, Marian B, Wrba F, Zielinski CC et al (2006) Neoplastic stem cells: a novel therapeutic target in clinical oncology. Cancer 107:2512–2520 110. Matsui W, Wang Q, Barber JP, Brennan S, Smith BD, Borrello I, McNiece I, Lin L, Ambinder RF, Peacock C et al (2008) Clonogenic multiple myeloma progenitors, stem cell properties, and drug resistance. Cancer Res 68:190–197 111. Kirshner J, Thulien KJ, Martin LD, Debes Marun C, Reiman T, Belch AR, Pilarski LM (2008) A unique

361

112.

113.

114.

115. 116.

117.

118. 119.

120.

121.

122.

123.

124.

125.

126.

three-dimensional model for evaluating the impact of therapy on multiple myeloma. Blood 112:2935–2945 Huls M, Russel FG, Masereeuw R (2009) The role of ABC transporters in tissue defense and organ regeneration. J Pharmacol Exp Ther 328:3–9 Oyama T, Nagai T, Wada H, Naito AT, Matsuura K, Iwanaga K, Takahashi T, Goto M, Mikami Y, Yasuda N et al (2007) Cardiac side population cells have a potential to migrate and differentiate into cardiomyocytes in vitro and in vivo. J Cell Biol 176:329–341 Lin T, Islam O, Heese K (2006) ABC transporters, neural stem cells and neurogenesis – a different perspective. Cell Res 16:857–871 Nakauchi H (2004) Isolation and clonal characterization of hematopoietic and liver stem cells. Cornea 23:S2–7 Lechner A, Leech CA, Abraham EJ, Nolan AL, Habener JF (2002) Nestin-positive progenitor cells derived from adult human pancreatic islets of Langerhans contain side population (SP) cells defined by expression of the ABCG2 (BCRP1) ATP-binding cassette transporter. Biochem Biophys Res Commun 293:670–674 Gordon MY, Levicar N, Pai M, Bachellier P, Dimarakis I, Al-Allaf F, M’Hamdi H, Thalji T, Welsh JP, Marley SB et al (2006) Characterization and clinical application of human CD34+ stem/progenitor cell populations mobilized into the blood by granulocyte colony-stimulating factor. Stem Cells 24:1822–1830 Zabierowski SE, Herlyn M (2008) Melanoma stem cells: the dark seed of melanoma. J Clin Oncol 26:2890–2894 Huang P, Wang CY, Gou SM, Wu HS, Liu T, Xiong JX (2008) Isolation and biological analysis of tumor stem cells from pancreatic adenocarcinoma. World J Gastroenterol 14:3903–3907 Kim YH, Ishii G, Goto K, Ota S, Kubota K, Murata Y, Mishima M, Saijo N, Nishiwaki Y, Ochiai A (2008) Expression of breast cancer resistance protein is associated with a poor clinical outcome in patients with small-cell lung cancer. Lung Cancer 65:105–115 Decleves X, Amiel A, Delattre JY, Scherrmann JM (2006) Role of ABC transporters in the chemoresistance of human gliomas. Curr Cancer Drug Targets 6: 433–445 Kumar V, Varma N, Varma S, Vohra H, Malhotra P, Dutta U, Sharma SC (2004) Flow cytometric analysis of DNA indices, expression of p53 and multidrug resistance genes in multiple myeloma patients. Anal Quant Cytol Histol 26:271–277 Hombach-Klonisch S, Panigrahi S, Rashedi I, Seifert A, Alberti E, Pocar P, Kurpisz M, Schulze-Osthoff K, Mackiewicz A, Los M (2008) Adult stem cells and their trans-differentiation potential-perspectives and therapeutic applications. J Mol Med 86:1301–1314 Guan K, Hasenfuss G (2007) Do stem cells in the heart truly differentiate into cardiomyocytes? J Mol Cell Cardiol 43:377–387 Edling CE, Hallberg B (2007) c-Kit – a hematopoietic cell essential receptor tyrosine kinase. Int J Biochem Cell Biol 39:1995–1998 Woodward WA, Sulman EP (2008) Cancer stem cells: markers or biomarkers? Cancer Metastasis Rev 27: 459–470

362 127. Ghosh N, Matsui W (2009) Cancer stem cells in multiple myeloma. Cancer Lett 277:1–7 128. Peacock CD, Wang Q, Gesell GS, Corcoran-Schwartz IM, Jones E, Kim J, Devereux WL, Rhodes JT, Huff CA, Beachy PA et al (2007) Hedgehog signaling maintains a tumor stem cell compartment in multiple myeloma. Proc Natl Acad Sci USA 104: 4048–4053 129. Huff CA, Matsui W, Smith BD, Jones RJ (2006) The paradox of response and survival in cancer therapeutics. Blood 107:431–434 130. Kapoor P, Greipp PT, Morice WG, Rajkumar SV, Witzig TE, Greipp PR (2008) Anti-CD20 monoclonal antibody therapy in multiple myeloma. Br J Haematol 141: 135–148 131. Degos L (1991) Phenotypic reversion in acute promyelocytic leukemia. Nouv Rev Fr Hematol 33: 511–515

N.H. Riordan et al. 132. Demetri GD, Fletcher CD, Mueller E, Sarraf P, Naujoks R, Campbell N, Spiegelman BM, Singer S (1999) Induction of solid tumor differentiation by the peroxisome proliferator-activated receptor-gamma ligand troglitazone in patients with liposarcoma. Proc Natl Acad Sci USA 96:3951–3956 133. Piccirillo SG, Reynolds BA, Zanetti N, Lamorte G, Binda E, Broggi G, Brem H, Olivi A, Dimeco F, Vescovi AL (2006) Bone morphogenetic proteins inhibit the tumorigenic potential of human brain tumour-initiating cells. Nature 444:761–765 134. Postovit LM, Seftor EA, Seftor RE, Hendrix MJ (2006) Influence of the microenvironment on melanoma cell fate determination and phenotype. Cancer Res 66:7833–7836 135. Gupta PB, Onder TT, Jiang G, Tao K, Kuperwasser C, Weinberg RA, Lander ES (2009) Identification of selective inhibitors of cancer stem cells by high-throughput screening. Cell 138:645–659

Part IV

Hyperthermia

Chapter 21

Induced Hyperthermia in the Treatment of Cancer Bert Hildebrandt, Johanna Gellermann, Hanno Riess, and Peter Wust

21.1 Basic Principles of Clinical Hyperthermia 21.1.1 Classification of Hyperthermia Techniques In oncology, the term “hyperthermia” describes various techniques that are applied to increase the temperature of a tumor-loaded body region to 39–43◦ C, using an external energy source. The different approaches are best categorized by the physical mode of power deposition (radiant vs. capacitive vs. convective), and their target volume (local vs. regional vs. whole-body hyperthermia). Thereby, radiant local and regional hyperthermia is distinguished from capacitive hyperthermia, radiant whole-body hyperthermia (rWBH), and convective techniques. The latter comprise methods in which the patients’ blood is warmed up by an external device before it is retransfused to the target volume (e.g. isolated limb perfusion and convective whole-body hyperthermia), and those utilizing contact heating (hyperthermic peritoneal and vesical perfusion) [1–5]. When classifying the distinct modalities according to the above-mentioned categories, special attention has to be paid to the interstitial and endoluminal hyperthermia techniques. Interstitial hyperthermia is generally employed to treat localized disease, and

B. Hildebrandt () Medizinische Klinik für Hämatologie und Onkologie, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Humboldt-Universität, D-13344 Berlin, Germany e-mail: [email protected]

may be induced by radiant, capacitive, and convective applicators. Endoluminal hyperthermia is based on the same principle, but the antennas are positioned in natural cavities of hollow organs. The efficacy of interstitial and endoluminal applications is hampered by a number of physical limitations, but all of them aim to enhance the effect of concomitant radiation or chemotherapy, at temperatures in the range of 39–43◦ C [4, 5]. Thus they have to be distinguished from the interstitial ablation techniques such as radiofrequency ablation and laser-induced thermotherapy [6]. The latter are also associated with the application of elevated temperatures, but primarily aim at the physical destruction of tumor tissues by induction of coagulation necrosis, occurring at temperatures >50◦ C. Therefore, they do not represent interstitial hyperthermia in the narrower sense and thus are not discussed in this chapter.

21.1.1.1 Thermal Dose and Dose-Response Correlation One fundamental observation in clinical hyperthermia research is the clear-cut relationship between the thermal dose applied and clinical outcome parameters. This dose-response correlation is best established for the radiant locoregional approaches [7]. The most common tool to estimate the thermal dose is the “cumulative equivalent minutes at 43◦ C” (CEM 43◦ C) which has been introduced by Sapareto and Dewey [8]. The CEM 43◦ C is calculated from the heat exposure time (t), the given temperature (T), and a constant (R) which is 0.5 when the temperature is higher than 43◦ C, and 0.25 if it is below 43◦ C, according to the formula: CEM 43◦ C = tR(43−T) .

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_21, © Springer Science+Business Media B.V. 2011

365

366

In clinical trials, the CEM 43◦ C is mostly reported as “CEM 43◦ C T90 ”, defined as CEM attained at 90% of tumour related measurement points. Indeed, CEM 43◦ C T90 is one of the most accurate thermal parameters predicting a favourable outcome with the use of local and regional radiofrequency hyperthermia. For capacitive approaches such detailed dose-response evaluations are not available (as discussed in detail in [9–11]). For hyperthermic chemoperfusion, there is only little evidence that the thermal dose is correlated with clinical outcome, but certain thermal parameters have been identified to be associated with toxicity and efficacy in hyperthermic isolated limb perfusion and radiant whole-body hyperthermia, [1, 12, 13]. In the opinion of the authors, the lack of a dose-response correlation for these modalities may indicate a mode of action that is different from that in radiofrequency hyperthermia [7].

21.1.1.2 Clinical Application All hyperthermia modalities have in common that their efficacy is not enough to replace one of the established treatment modalities, but some of them have been demonstrated to improve the results of radio- and chemotherapy when applied in repetitively short intervals. Thus the administration of hyperthermia aims at improving the results of the classic treatment strategies within the framework of multimodal treatment concepts. Most randomised studies have been performed on hyperthermic radiotherapy [4, 5, 7], where clinical improvements have been observed in patients with superficial lymph node metastases of various primaries and in patients with locally advanced malignancies of the pelvis. In addition, the postoperative application of hyperthermic limb perfusion and hyperthermic peritoneal perfusion in patients with malignant melanoma and gastric cancer, respectively, has been demonstrated to improve local recurrence and/or survival when compared with no adjuvant treatment (recent reviews in [1, 3–5, 14]). Discussing the different hyperthermia approaches in a general context, one has to be aware that therapeutical potentials, expenditure of treatment, technical problems and evidence of efficacy of the different methods are very dissimilar. Today, local and

B. Hildebrandt et al.

regional radiofrequency hyperthermia can be regarded as well-established, non-toxic treatment which is carried out according standardised protocols worldwide [15, 16]. On the contrary, local and regional capacative hyperthermia is also well tolerated, and a number of (mostly Asian) studies demonstrated a beneficial outcome in conjunction with radiotherapy and chemotherapy. However, capacitive hyperthermia suffers from lacking detailed technical evaluations and – from a physical point of view – major drawbacks with regard to efficacy [9–11, 17, 18]. Finally, hyperthermic peritoneal and isolated limb perfusion have been demonstrated efficacy for certain indications in randomized trials, but are associated with high technical expenditure and occurrence of potentially severe side-effects [1, 19]. Wholebody hyperthermia (WBH) appears to be feasible when radiant heat devices are employed, whereas convective WBH is generally regarded as obsolete today [2]. As a conclusion, locoregional radiofrequency hyperthermia, hyperthermic isolated limb perfusion and hyperthermic intraperitoneal chemoperfusion can be regarded as well-established and effective treatment options today, whereby the radiative techniques are generally less toxic than perfusional approaches.

21.1.2 Locoregional Approaches 21.1.2.1 Local Hyperthermia Local hyperthermia describes the procedure of heating superficial tumours by means of antennas or applicators emitting microwaves or radiowaves (e.g. at an ISM-frequency of 434 MHz) after they have been placed on the tumour surface with a contacting medium. Early clinical experience with local hyperthermia has been gained by comparing radiotherapy and hyperthermic radiotherapy in patients suffering from more than one superficial tumor manifestation (e.g. lymph-node metastases). By treating one lesion by radiation, and a similar lesion by radiation plus hyperthermia, the comparison of “matched-pair lesions” revealed a doubling of complete response and local control rates by adjunctive hyperthermia in most studies [20, 21]. These very convincing results

21 Induced Hyperthermia in the Treatment of Cancer

367

Table 21.1 Randomized trials on radiative local, interstitial und regional hyperthermia References

Author

Year

Modality

Tumor entity

Standard arm

Number of patients

Primary objective

Ht better? (p = 0.05)?

[22]

Emami

1996

Interstitial

Brachytherapy

184

Jones

2005

Local

Radiation

122

Best response Rate of CR

(x)

[23] [24]

Overgaard

1996

Local

Radiation

68

Perez

1991

Local

Radiation

245

[28]

Sneed

1998

Interstitial

Brachytherapy

79

[24]

Valdagni

1993

Local

Radiation

44

[27]

Vernon

1996

Local

Head and neck (N3) Breast Cancer

Radiation

307

[43]

Zee

2000

Regional

CR at 3 months Initial response Median survival Response at 3 months. Initial response Rate of CR

x

[25]

Superficial lesions Superficial lesions Malignant melanoma Superficial lesions Glioblastoma

x

(x) (x) x x

Cervix, rectum, Radiation 361 x bladder CR complete response, (X): advantage for hyperthermia treatment only with regard to secondary objective/subgroup analysis

prompted the initiation of randomized trials on patients with superficial lymph node metastases and chest wall recurrences of breast cancer, head and neck tumors, melanomas, and others [22–27]. Most of those studies actually demonstrated an improved response or local control rate, some of them even a survival benefit, when local hyperthermia was added to a standard radiotherapy course (Table 21.1). For interstitial hyperthermia, a phase III-trial on patients with glioblastoma multiforme revealed a 2-year survival benefit of 15% vs. 31% (p = 0.008) when interstitial hyperthermia was added to standard brachytherapy after tumour resection [28]. However, not all randomised trials on local hyperthermia were positive [22, 25]. Subgroup analyses of one of the negative trials showed that in particular patients with lesions >3 cm did not benefit from additional hyperthermia [25]. This observation focussed the attention onto a standardization of thermal parameters, because it was postulated that the cumulative thermal dose was inadequate in patients with larger lesions [23]. In addition, it could be demonstrated that the number of heating sessions was positively correlated to response, although the respective trials did not prospectively control for cumulative thermal doses [29, 30]. A number of concomitant analyses were performed to investigate the relationship between thermal dose and clinical outcome parameters in local hyperthermia.

Oleson and coworkers demonstrated that an improvement in median T90 (defined as the temperature exceeded by 90% of measurements during the course of treatment) by 1.2 by 1.5 degrees centigrade is associated with a favourable response in superficial tumors [31]. Others could demonstrate that the CEM 43◦ C T90 most accurately predicts the probability of complete response [23, 32]. Regardless of the optimal thermal parameter predicting response in local hyperthermia, available data, on principle, demonstrate a close dose-response relationship for radiative local hyperthermia. Results suggest that the addition of local hyperthermia to radiation largely improves response rates in superficial manifestations of breast cancer, head and neck tumours and melanomas, especially in pre-irradiated patients. Therefore, adjunctive local hyperthermia may be regarded as standard application in the reirradiation of superficial tumors.

21.1.2.2 Regional Radiofrequency Hyperthermia In regional radiofrequency hyperthermia, larger target volumes (e.g. deep seated-tumours of the extremities or pelvis) can be heated by using arrays of antennas, which are operating at a frequency of 70–100 MHz. Most experiences have been gained with the use of the BSDTM -2000 system (BSD Medical Inc., Salt Lake

368

City, USA), with more than 10,000 treatments performed worldwide so far. The “Sigma-60” applicator of the BSD-system consists of four dipole antenna pairs arranged in a ring around the patient. More recently, the “Sigma-eye”-applicator has been introduced into clinical practice which consists of three shorter rings, each with four flat dipole-antenna pairs [33]. In addition, the introduction of specific planning systems has led to improved pre-therapeutic calculation of power-density and temperature distribution depending on various treatment variables. [34, 35]. But despite these technical advantages, there are still some fundamental restrictions with the use of regional hyperthermia. Those are mostly caused by the distribution of the specific absorption rate (SAR) in body regions with high vascular perfusion (e.g. part of the upper abdomen), or those that are not accessible to appropriate power input due to electromagnetic shielding by bony structures (e.g. thorax) [4]. Another unresolved problem is the occurrence of a temperature elevations at the interface of tissues with different density, thermal capacity and impedance. Such “hot spots” typically occur at the border between bone and adjacent soft tissues (muscle) and may limit the power input by causing painful sensations to the patient [36, 37]. The first generation of phase I and II-trials demonstrated that regional hyperthermia in conjunction with radiotherapy, chemotherapy, or radiochemotherapy can be safely applied to patients with various pelvic tumors and sarcomas of the extremities, thereby achieving promising response rates (reviewed in [4, 5]). Similar to the results in local hyperthermia, a dose-response relationship could be established by correlating thermal dose parameters to clinical outcome for the relevant treatment indications (such as cancers of the cervix, rectum, bladder, prostate, and sarcomas of the extremities and trunk) [31, 38–42]. In 2000, the first randomized trial on regional radiofrequency hyperthermia as an adjunct to radiotherapy has been published, disclosing a significant benefit for the addition of hyperthermia to standard radiotherapy in patients with locally advanced, unresectable tumours of the cervix, rectum or bladder [43]. Regarding the primary study objective, the risk to achieve no complete remission was reduced by 59 % (p = 0.00003) in the hyperthermia group. Exploratory analyses, moreover, revealed that patients with cancer of the uterine cervix mostly benefit from

B. Hildebrandt et al.

hyperthermic radiotherapy. For this subgroup, the 3-year survival was nearly twofold higher than in the group of patients treated with radiotherapy alone (51 vs. 27%, p = 0.009). The fact that 80% of cervix cancer patients included suffered from a tumor stage FIGO IIIb or higher, impressively underlines the efficacy of hyperthermia in these patients. The results of the Dutch trial have prompted detailed discussions throughout the hyperthermia community [44–48, 49]. The most important perception was that cancer of the uterine cervix turned out as the pelvic tumour entity most susceptible to heat treatment. From a technical point of view, this can be best explained by the location of the cervix uteri in the center of the pelvis and probably by the low perfusion in central parts of the tumour, making it easily accessible for adequate power input and homogenous temperature distributions (“easy-to-heat” tumour). The realization of a worldwide hyperthermia trial on patients with cervix cancer has attracted considerable interest among the different hyperthermia research groups. However, the design of such a study was an important matter of controversity between the Dutch group on the one, and the American and German groups on the other hand. The major issue of concern was the definition of the standard arm, due to dissimilarities in the interpretion of the most recent trials on locally advanced cervix cancer. Those – to the opinion of most opinion leaders – define cisplatinbased radiochemotherapy as novel standard of care. However, in the Netherlands, hyperthermic radiotherapy is regarded as nationwide standard after the persuading results of the Dutch Deep Hyperthermia Trial were published. Unfortunately, these different points of view prevented the implementation of a common study of all groups. Whereas the Rotterdam group is now proceeding an own trial comparing hyperthermic radiotherapy with hyperthermic radiochemotherapy, various German and the Amsterdam group are participating in the US-American trial where radiochemotherapy is compared with hyperthermic radiochemotherapy [50]. Results of two further randomised studies on regional hyperthermia are expected soon. At our institution, we are performing a trial in which patients with primary, locally advanced (uT3/4, Nx, M0) rectal cancer are assigned to preoperative radiochemotherapy alone or in conjunction with

21 Induced Hyperthermia in the Treatment of Cancer

regional pelvic hyperthermia [51, 52]. The Munich group is proceeding a study in patients with nonmetastatic “high-risk” soft tissue sarcomas, comparing neoadjuvant chemotherapy with etoposide, ifosfamide and doxorubicin alone with hyperthermic chemotherapy [53]. The results of both trials are supposed to further define the role of regional radiofrequency hyperthermia in the treatment of locally advanced malignancies of the extremities and pelvis.

21.1.2.3 Capacitive Methods in Locoregional Hyperthermia In capacitive hyperthermia, the target volume is placed between two electrodes emitting a radiofrequency electric field, similar to the principle of a condensator. In case of sufficient power density, this results in heating of the interjacent tissue. As the power deposition is based on the appearance of radiowaves of low-frequency, the physical principle of capacitive heating is basically different from that of radiofrequency hyperthermia and thus has to be discussed separately. The main advantage of capacitive hyperthermia is that it is very easy to apply. In a number of randomised trials – which have mainly performed in Asian countries – adjunctive local, endoluminal and regional approaches were compared with sole radiation, radiochemotherapy, or chemotherapy in

369

patients with cancers of the head and neck, esophagus, or pelvis [11, 54–60] (Table 21.2). With one exception [11], all of them demonstrated a benefit for adjunctive hyperthermia (although many of them have been criticized for methodological reasons such as small patient number, no appropriate randomisation procedure, poor statistics etc.). However, the major concern with the use of capacitive hyperthermia is that no detailed data on the actual efficacy of the heating procedure are available. Some recent studies have propelled the evaluation of the physical properties of the most commonly used Japanese deep hyperthermia system Thermotron RF8 (Yamamoto Vinita Co, Osaka, Japan) which is operating at frequencies of 8 MHz [18]. Anyway, there are urgent caveats in transferring the results obtained in Asian patients to the Western population, where the body-mass index and the thickness of the subcutaneous layer of fat is on average higher. Indeed, one basic principle of capacitive heating is that the power density is inversely correlated to the distance from the electrode. As a rule, the depth of the target volume should not exceed the diameter of the electrodes. Thus there are legitimate doubts that capacitive hyperthermia is actually capable to induce sufficient deep hyperthermia in the majority of European and North American patients. This is leading us to the recommendation that capacitive hyperthermia should not be used outside of controlled clinical trials yet.

Table 21.2 Randomized trials on capacitive local, endoluminal, and regional hyperthermia Tumor Number of References Author Year Modality entity Standard arm patients

Primary objective

Ht better? (p<0.05)?

[54]

Berdov

1996

Response

x

[55] [56]

Datta Datta

1989 1990

x x

[57]

Harima

2001

Response Response at 8 weeks. Rate of CR

[58]

Kitamura

1991

x

[59]

Sharma

1987

[60]

Sugimachi

1994

Rate of histologically confirmed CR Local control rate Response

[11]

Vasanthan

2005

Endoluminal Regional Local Regional HT Endoluminal

Regional HT Endoluminal Regional

T4-Rectal cancer Cervix Head and neck Cervix

Radiation

115

Radiation Brachytherapy

52 65

Radiation

40

Esophagus

Radiochemotherapie

66

Cervix

Radiation

50

Esophagus

Chemotherapy

40

Cervix

Radiation

110

Local control rate

x

x x

370

21.1.3 Whole-Body Hyperthermia (WBH) Whole-body hyperthermia (WBH) represents the only hyperthermic modality available for patients with disseminated malignancies. In “extreme” WBH, the patient’s body-core temperature is raised to 41.8– 42.1◦ C for 60 min or longer under deep sedation or general anaesthesia. In moderate, “fever-range” WBH, the patient is subject to a body-core temperature of maximal of 40◦ C for a longer period of time (e.g. 4–6 h). Moderate WBH does not achieve temperatures that are suitable to enhance the cytotoxic effect of concomitant chemotherapy or radiation, but rather aims to induce immunological effects without administration of additional drugs instead. The chapter herein will be restricted to the discussion of “extreme” WBH. Methods to induce WBH include convective and radiative techniques. The convective procedures are based on contact with heated media on the one, and extracorporal heating on the other hand, all of them being associated with excess toxicity. Except for the extracorporal techniques, they are even ineffective in achieving a body-core temperature to 41.5–42.0◦ C [4, 5] Regarding radiant WBH at 41.5–42◦ C, feasibility and safety of this approach has been demonstrated in a number of phase I-trials since the mid 1980s. In the late 1990s, the concept has regained interest, particularly in Germany and the Netherlands. Indeed, ten phase II-trials on radiant WBH in conjunction with chemotherapy have been published since 2000, and mostly revealed promising results. As a consequence, first phase III-trials comparing chemotherapy alone with chemotherapy plus radiative WBH have been initiated [2]. In a recent survey, we analysed the available data on radiant WBH at 41.5–42◦ C and found that a total of 1300 radiative WBH-treatments in more than 450 patients have been documented in the scope of clinical trials until 2004. The rate of severe toxicities was in the range of 3%, and the rate of deaths within 30 days after WBH-treatment was 0.8%. All fatalities reported occurred in the neutropenic phase following a combination of WBH and dose-intensive chemotherapy, and thus were rather attributable to the dose-intensive chemotherapy applied than to the WBH procedure itself [2].

B. Hildebrandt et al.

Today, radiant WBH can be regarded as a feasible form of therapy, but its precise role in multi-modal oncological concept still needs to be defined. The major obstacle of this method is that it consumes a vast amount of time, medical staff and financial resources. Future research will reveal if “extreme” WBH can be established as a useful option which can be put to the disposal for the majority of cancer patients, or if it is more promising to refine novel and less toxic technologies instead (such as radiowave-induced part-body, see below).

21.1.4 Hyperthermic Chemoperfusion 21.1.4.1 Hyperthermic Isolated Perfusion of a Limb, the Liver, and Lung In Hyperthermic isolated limb perfusion (HILP), hyperthermic perfusion is applied through an intravascular access. It is performed by isolating a tumourloaded limb by clamping and cannulation the major artery and vein. After the extremity is connected to an oxygenated extracorporeal circuit, collateral vessels are ligated, and a tourniquet is applied. Once the extremity is isolated, drugs are injected into the perfusion circuit at temperatures between 38 and 41◦ C [1]. This results in an intratumoral drug concentration that is more than ten-fold higher than it would be after systemic drug administration. With regard to the hyperthermic conditions of chemoperfusion, HILP enables a temperature distribution that is much more homogeneous than with radiative hyperthermia. On the other hand, the method carries the risk of severe and persisting adverse effects such as neuropathy and amputation of limbs [1, 4, 61]. Most experience with hyperthermic isolated limb perfusion (HILP) has been gained by using melphalan (L-PAM)-based induction therapy in locally advanced, non-resectable soft-tissue sarcomas (STS) of the limb, as well as, in non-metastatic malignant melanomas of different clinical stages. For both indications, the introduction of TNF-α as second drug has largely increased response rates, in particular in patients with bulky STS. This success is explained by the effect of TNF on the tumour vasculature [1, 61]. Two prospective randomized studies on the role of adjuvant HILP after surgery for limb melanomas are

21 Induced Hyperthermia in the Treatment of Cancer

available. In both of these trials, HILP was performed by using single-agent L-PAM (e.g. the impact of additional TNF-α has not been investigated in the scope of a randomised trial yet). In one study, it was found that adjunctive HILP with melphalan improved both local control and survival in patients with stage I–III limb melanomas of after wide excision and regional lymphnode dissection. However, the design was not appropriate to detect differences according to stage [62]. In another study, which included 832 patients, no benefit in distant failure free and overall survival was found, but melphalan-based HILP reduced the rate of local recurrence and regional lymph-node metastases [63] (Table 21.3). In locally advanced STS, combinations of L-PAM and TNF-α achieved limb salvage in more than 70% in some studies. As the situation in adult patients with STS is very complex (due to the different histological subtypes and the distinct risks of systemic progress), no randomised trial was carried out for this indication yet [1, 4, 61]. Taken together, it appears that adjuvant HILP may improve local control after surgery alone in

371

melanoma, and is suitable to induce extraordinarily high response rates in patients with STS of the limbs. This is why the method is recommended in certain clinical situations patients with locally advanced melanoma and soft tissue sarcoma of the limb today [64, 65]. The role of the hyperthermic conditions associated with the use of HILP has not been clearly defined. Available data suggest that temperatures >39◦ C are rather associated with excess toxicity than with an increase in response [1, 61]. Therefore, data published so far do not support the hypothesis that HILP is actually more effective than normothermic limb perfusion. Regarding further vascular perfusion techniques, isolated hepatic perfusion (IHP) with melphalan and TNF-α is currently evaluated in a number of specialized treatment centres worldwide for the treatment of patients with irresectable liver neoplasms. Recent surveys on this method are provided in [66, 67]. Isolated lung perfusion has been demonstrated to be feasible, but a more detailed evaluation of the approach is pending [68].

Table 21.3 Randomized trials on hyperthermic isolated limb perfusion (HILP) and hyperthermic intraperitoneal chemotherapy (HIPEC) Number of Primary Ht better? References Author Year Modality Tumor entity Standard arm patients objective (p = 0.05)? [62]

Ghussen

1989

Adjuvant HILP

[63]

Koops

1998

Adjuvant HILP

[71]

Fujimoto

1999

[72]

Hamazoe

1994

[73]

Kim∗

2001

[75]

Rosen

1998

Adjuvant HIPEC Adjuvant HIPEC Adjuvant HIPEC Adjuvant HIPEC

Malignant melanoma (CS 1-3) Malignant melanoma (CS 1-3) Gastric cancer(≥T3) Gastric cancer (≥T3) Gastric cancer (≥T3) Gastric cancer (T2-4)

[76]

Sautner

1994

[12]

Yonemura

2001

Adjuvant HIPEC Adjuvant HIPEC

Gastric cancer (CS III-IV) Gastric cancer (T2-4)

[74]

Yu

2001

Surgery

107

Disease-free survival

x

Surgery

832

Disease-free survival

(x)

Surgery

141

Surgery

82

5-year overall x survival Local control x

Surgery

103

Surgery

91

Surgery

67

Surgery +/– normothermic perfusion Surgery

139

5-year overall (x) survival Recurrencefree survival Median survival 5-year overall x survival

Adjuvant Gastric cancer 248 5-year overall x HIPEC (CS III-IV) survival CS Clinical stage; CR complete response; ∗ prospective, non-randomized, (X): advantage for hyperthermia treatment only with regard to secondary objective/subgroup analysis

372

21.1.4.2 Hyperthermic Intraperitoneal and Vesical Perfusion In hyperthermic intraperitoneal chemotherapy (HIPEC), the perfusion circuit usually consists of an inflow catheter which is placed into abdominal cavity through the laparatomy wound, outflow catheters (which may be supplemented by placements in the pelvis below left and right diaphragm), a roller pump, and a heat exchanger. A plastic sheet may be used to cover the laparotomy opening in order to reduce heat loss and to avoid drug spilling. For perfusion, isotonic fluid at an inflow temperature of 41–42◦ C is employed, and cytostatic drugs are added to the perfusate when a predefined temperature (between 40 and 48◦ C) is achieved, maintaining the perfusion for 90 min [69]. HIPEC may be performed as postoperative adjuvant treatment in tumours where the peritoneum is usually the site of first relapse, or in patients who underwent peritonectomy for distant metastases of abdominal primaries. Most of the randomized studies available so far refer to the adjuvant treatment of gastric cancer patients (reviewed in [70]). A single study has worked out a benefit for adjuvant HIPEC in metastatic colorectal cancer after peritonectomy [19]. In addition, profound experience has been gained with adjuvant HIPEC after resection of appendix cancer/pseudomyxoma peritonei in selected treatment centres [69]. Regarding adjuvant therapy of gastric cancer, five prospective studies performed in different Asian countries have demonstrated a benefit in terms of peritoneal recurrence and survival for HIPEC using mitomycin [12, 71–74]. A significant survival benefit was observed in three of the trials, defining mitomycinbased HIPEC as a standard option in the adjuvant treatment of locally advanced stomach cancer. Unfortunately, some of the studies suffer from methodological shortcomings (in particular those of Kim and Bae). In addition, the persuading results of the Asian investigators trials were not reproduced by Western groups yet, although the respective studies were either too small to detect a survival benefit, or the application was associated with relevant postoperative morbidity [75, 76]. High morbidity and relevant mortality has also been detected as major obstacle in a Dutch study comparing adjuvant HIPEC to postoperative standard therapy in

B. Hildebrandt et al.

colorectal cancer patients after resection of the primary and palliative peritonectomy [19]. However, particularly patients in with limited peritoneal spread, as well as, those in which the tumour could be completely removed, exhibited an abundantly clear benefit from HIPEC. The effect in those patients was so pronounced that it overbalanced the early death rate of 16%, finally resulting in a clear-cut overall survival benefit in favour of adjuvant HIPEC-arm (median survival 22.3 vs. 12.6 months, p = 0.03). Summing up the results on HIPEC in gastric and colorectal cancer, it seems as the method is suitable to improve the outcome of patients with a substantial risk of or manifest peritoneal carcinomatosis on principle. However, the fact that particularly the Western trials on HIPEC have been hampered by inacceptable complication rates is still preventing the widespread evaluation of this method. On the other hand, hundreds of American patients suffering from appendix carcinoma and pseudomyxoma peritonei have been successfully treated with peritonectomy and adjuvant chemoperfusion, suggesting that the approach can safely applied in experienced hands. Another point to consider, at least the results of one randomised study suggest that the effect of adjuvant peritoneal chemoperfusion in patients with gastric is actually enhanced by the application of elevated temperatures [12]. This makes the peritoneum a worthwhile target for abdominal partbody hyperthermia, a novel application of regional radiofrequency hyperthermia [77].

21.1.5 Future Developments 21.1.5.1 Technological Innovations in Radiofrequency Hyperthermia The introduction of the “Sigma Eye” applicator for the regional hyperthermia system “BSD-2000” and corresponding planning systems have already contributed to an individualized treatment planning. The threedimensional configuration of antennas is enabling improved controllability of the power distribution, particular in the longitudinal direction. In addition, the introduction of more advanced applicators is anticipated within the next few years [78, 79]. One crucial step in the development of regional hyperthermia was the introduction of so-called

21 Induced Hyperthermia in the Treatment of Cancer

“hybrid-systems” where an applicator for regional hyperthermia is implemented into an MR-tomograph. This technology enables online temperaturemonitoring on the one, and an improved treatment regulation on the other hand. Corresponding systems are already under evaluation in a number of hyperthermia centres worldwide, having installed the Sigma-Eye applicator of the BSD-system into an 0.2 Tesla (Munich) or 1,5 Tesla (Berlin, Durham) MR-tomograph. First experiences suggest that the proton-resonancefrequency shift (PFS) method is the most suitable application to perform online thermometry in tumours of the pelvis and extremities in a reliable way. However, the most appropriate method for abdominal part-body hyperthermia still needs to be defined. Improvements in applicator technology and noninvasive temperature monitoring have enabled to apply regional hyperthermia to larger target volumes, e.g. the entire abdomen. First clinical phase I/II-results on abdominal part-body hyperthermia are expected in the very near future. [77, 80–82].

21.1.5.2 Novel Interstitial (“Corpuscular”) Technologies During the past few years, novel interstitial technologies using corpuscular temperature media have been introduced into clinical research that fill intermediate positions between the established hyperthermia approaches. In magnetic fluid hyperthermia (MFH), the contact medium is consisting of magnetic nanoparticles which are directed into the tumour and heated within an alternating magnetic field (e.g. 100 kHz). Although the development of MFH goes back to the 1950ies, first applicator systems only recently became commercially available [83, 84]. Results available so far suggest that MFH is the only method by which heat can be either applied at a “hyperthermic” or “ablational” target temperature [85, 86]. As another innovation, a new generation of thermosensitive liposomes has been developed which reliably enable the liberation of drugs into a heated tissue at predefined temperatures. Recent studies suggest that those technologies may largely improve the thermal control of hyperthermia-guided drug-targeting [87, 88].

373

21.1.5.3 Immunological and Genetic Targets Pharmacodynamics and pharmacokinetics of conventional cytotoxic drugs can be influenced by heat application in different ways. Basically, the term “thermal chemosensitization” describes a super-agonistic effect that can be observed when (cultured) tumour cells are exposed to a cytostatic drug under hyperthermic conditions, and which can be primarily explained by pharmacodynamic interactions (acceleration of primary mode of action, increased drug uptake by alterations of the cell membrane and cellular proteins). In addition, heat applied to the living organism is influencing the pharmacokinetics of an antineoplastic agent by means of drug uptake, distribution, metabolism and excretion. In addition, heat application is suitable to reverse certain forms of drug resistance, although particular heating schedules may also be involved into the phenomenon of thermotolerance (which is sometimes associated with drug resistance) [7, 89, 90]. The properties of hyperthermia to favourably influence the efficacy of cytostatic drugs on a pharmacological level have recently stimulated research on the interaction of heat with therapeutic monoclonal antibodies (tMAbs), a novel class of drugs which have already revolutionized the pharmacotherapy of malignant lymphoma and distinct solid malignancies [91]. Data suggest that the synergism between heat and both, native and radiolabelled, tMAbs goes beyond sole thermal radio- and chemosensitization. Additional interactions such as disproportionally high increase in drug-target-interactions, and interferences with the immunological target (e.g. receptor density) are suggested to be the major reasons for this observation, as well as, a more uniform intratumoral drug distribution [92–94]. To sum it up, the combination of hyperthermia with tMAbs appears to be a promising principle, although experiences are still restricted to animal experiments. Hyperthermia-induced gene therapy (HIGT) is based on the principle that heat application and other mediators of cellular stress are suited to induce the expression of some highly-conserved, ubiquitary genes, thereby linking a heat-inducible promotor with a corresponding effector gene such as TNF-α or IL-12. Most experience with HIGT have been gained with adenoviral vectors under control of the promotor of the heat-shock protein 70b (hsp-70b). First clinical studies evaluating this novel approach are immanent [95–97].

374

B. Hildebrandt et al.

21.1.6 Conclusion 4.

Different hyperthermia techniques are suitable to enhance the temperature of a tumour-loaded body region up to 40–43◦ C. Most of them have been demonstrated to be feasible and to enhance the efficacy of radio- or/and chemotherapy in clinical studies of the phases I–III. There is firm evidence that local hyperthermia combined with radiotherapy improves local control in superficial manifestations and local recurrences of cancers of the breast, head and neck, as well as, of malignant melanomas. Regional pelvic hyperthermia as an adjunct to radiotherapy has been demonstrated to improve local control in patients with neoplasms of the uterine cervix, bladder and rectum in one, and to improve local control and survival in more than two clinical trials. In addition, postoperative adjuvant hyperthermic limb perfusion improves at least local control in patients with in-transit metastases of malignant melanoma, whereas adjuvant hyperthermic peritoneal perfusion in gastric cancer patients has been shown to improve survival in three randomised Asian studies. Whole-body hyperthermia combined with chemotherapy has proved to be feasible in a number of recent phase II-trials. Recent innovations in the field of clinical hyperthermia comprise technological advances enabling the administration of abdominal part-body hyperthermia under non-invasive MR-monitoring, the introduction of novel interstitial technologies such as magnetic fluid hyperthermia and thermolabile liposomes, application of therapeutic monoclonal antibodies under hyperthermic conditions, and hyperthermia-induced gene therapy.

5. 6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

References 1. Eggermont AM, Brunstein F, Grunhagen D, ten Hagen TL (2004) Regional treatment of metastasis: role of regional perfusion. State of the art isolated limb perfusion for limb salvage. Ann Oncol 15(Suppl 4):iv107–iv112 2. Hildebrandt B, Hegewisch-Becker S, Kerner T, Nierhaus A, Bakhshandeh-Bath A, Janni W et al (2005) Current status of radiant whole-body hyperthermia at temperatures > 41.5◦ C and practical guidelines for the treatment of adults. The German “interdisciplinary working group on hyperthermia”. Int J Hyperthermia 21(2):169–183 3. Stewart JHT, Shen P, Levine EA (2005) Intraperitoneal hyperthermic chemotherapy for peritoneal surface

16.

17.

18.

19.

malignancy: current status and future directions. Ann Surg Oncol 12(10):765–777 Wust P, Hildebrandt B, Sreenivasa G, Rau B, Gellermann J, Riess H et al (2002) Hyperthermia in combined treatment of cancer. Lancet Oncol 3(8):487–497 van Der Zee J (2002) Heating the patient: a promising approach? Ann Oncol 13(8):1173–1184 Diederich CJ (2005) Thermal ablation and hightemperature thermal therapy: overview of technology and clinical implementation. Int J Hyperthermia 21(8): 745–753 Hildebrandt B, Wust P, Ahlers O, Dieing A, Sreenivasa G, Kerner T et al (2002) The cellular and molecular basis of hyperthermia. Crit Rev Oncol Hematol 43(1):33–56 Sapareto SA, Dewey WC (1984) Thermal dose determination in cancer therapy. Int J Radiat Oncol Biol Phys 10(6):787–800 Jones EL, Prosnitz LR, Dewhirst MW, Vujaskovic Z, Samulski TV, Oleson JR et al (2005) In regard to Vasanathan et al (Int J Radiat Oncol Biol Phys 2005;61:145–153). Int J Radiat Oncol Biol Phys 63(2):644 van der Zee J, van Rhoon GC, Wust P (2005) In regard to Dr. Vasanthan et al (Int J Radiat Oncol Biol Phys 2005;61:145–153). Int J Radiat Oncol Biol Phys 62(3):940–941 Vasanthan A, Mitsumori M, Park JH, Zhi-Fan Z, Yu-Bin Z, Oliynychenko P et al (2005) Regional hyperthermia combined with radiotherapy for uterine cervical cancers: a multi-institutional prospective randomized trial of the international atomic energy agency. Int J Radiat Oncol Biol Phys 61(1):145–153 Yonemura Y, de Aretxabala X, Fujimura T, Fushida S, Katayama K, Bandou E et al (2001) Intraoperative chemohyperthermic peritoneal perfusion as an adjuvant to gastric cancer: final results of a randomized controlled study. Hepatogastroenterology 48(42):1776–1782 Wust P, Riess H, Hildebrandt B, Loffel J, Deja M, Ahlers O et al (2000) Utilizing the Iratherm-2000 infrared system for whole-body hyperthermia at 42◦ C – a feasibility study. Int J Hyperthermia 16(4):325–339 Sugarbaker PH (2006) New standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome? Lancet Oncol 7(1):69–76 Lagendijk JJ, Van Rhoon GC, Hornsleth SN, Wust P, De Leeuw AC, Schneider CJ et al (1998) ESHO quality assurance guidelines for regional hyperthermia. Int J Hyperthermia 14(2):125–133 Wust P, Fähling H, Felix R, Rahman S, Issels R, Feldmann HJ et al (1995) Quality control of the SIGMA applicator using a lamp phantom: a 4-center comparison. Int J Hyperthermia 11:755–767 Hildebrandt B, Rau B, Gellermann J, Kerner T, Nicolaou A, Blohmer JU et al (2004) Standards and perspectives in locoregional hyperthermia. Wien Med Wochenschr 154 (7–8):148–158 Kroeze H, van de Kamer JB, de Leeuw AA, Kikuchi M, Lagendijk JJ (2003) Treatment planning for capacitive regional hyperthermia. Int J Hyperthermia 19(1):58–73 Verwaal VJ, van Ruth S, de Bree E, van Sloothen GW, van Tinteren H, Boot H et al (2003) Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy

21 Induced Hyperthermia in the Treatment of Cancer

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol 21(20):3737–3743 Overgaard J (1989) The current and potential role of hyperthermia in radiotherapy. Int J Radiat Oncol Biol Phys 16(3):535–549 van der Zee J, Treurniet-Donker AD, The SK, Helle PA, Seldenrath JJ, Meerwaldt JH et al (1988) Low dose reirradiation in combination with hyperthermia: a palliative treatment for patients with breast cancer recurring in previously irradiated areas. Int J Radiat Oncol Biol Phys 15(6):1407–1413 Emami B, Scott C, Perez CA, Asbell S, Swift P, Gringsby P et al (1996) Phase III study of interstitial thermoradiotherapy compared with interstitial radiotherapy alone in the treatment of recurrent or persistant human tumors. A prospectively controlled randomized study by the radiation therapy group. Int J Radiat Oncol Biol Phys 34(5): 1097–1104 Jones EL, Oleson JR, Prosnitz LR, Samulski TV, Vujaskovic Z, Yu D et al (2005) Randomized trial of hyperthermia and radiation for superficial tumors. J Clin Oncol 23(13):3079–3085 Overgaard J, Gonzalez Gonzalez D, Huslhof MCCH et al (1996) Hyperthermia as an adjuvant to radiation therapy of recurrent or metastatic malignant melanoma. A multicentre randomized trial by the European society for hyperthermic oncolgy. Int J Hyperthermia 12:3–20 Perez CA, Pajak T, Emami B, Hornback NB, Tupchong L, Rubin P (1991) Randomized phase III study comparing irradiation and hyperthermia with irradiation alone in superficial measurable tumors. Final report by the radiation therapy oncology group. Am J Clin Oncol 14(2): 133–141 Valdagni R, Amichetti M (1993) Report of a long-term follow-up in a randomized trial comparing radiation therapy and radiation plus hyperthermia to metastatic lymph nodes in stage IV head and neck cancer patients. Int J Radiat Oncol 28:163–169 Vernon C, Hand JW, Field SB et al (1996) Radiotherapy with or without hypethermia in the treatment of superficial localized breast cancer: results from five randomized controlled trials. Int J Radiat Oncol Biol Phys 35:731–744 Sneed PK, Stauffer PR, McDermott MW et al (1998) Survival benefit of hyperthermia in a prospective randomised trial of brachytherapy boost +/– hyperthermia for glioblastoma multiforme. Int J Radiat Oncol Biol Phys 40:287–295 Engin K, Tupchong L, Moylan DJ, Alexander GA, Waterman FM, Komarnicky L et al (1993) Radomized trial of one versus two adjuvant hyperthermia treatments per week in patients with superficial tumors. Int J Hyperthermia 9(3):327–340 Kapp DS, Petersen IA, Cox RS, Hahn GM, Fessenden P, Prionas SD et al (1990) Two or six hyperthermia treastments as an adjunct to radiation therapy yield similar tumor resonses: results of a randomized trial. Int J Radiat Oncol Biol Phys 19:1481–1495 Oleson JR, Samulski TV, Leopold KA, Clegg ST, Dewhirst MW, Dodge RK et al (1993) Sensitivity of hyperthermia trial outcomes to temperature and time: implications for

375

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

thermal goals of treatment. Int J Radiat Oncol Bio Phys 25(2):289–297 Hand JW, Machin D, Vernon CC, Whaley JB (1997) Analysis of thermal parameters obtained during phase III trials of hyperthermia as an adjunct to radiotherapy in the treatment of breast carcinoma. Int J Hyperthermia 13(4):343–364 Wust P, Beck R, Berger J, Fahling H, Seebass M, Wlodarczyk W et al (2000) Electric field distributions in a phased-array applicator with 12 channels: measurements and numerical simulations. Med Phys 27(11):2565–2579 Gellermann J, Wust P, Stalling D, Seebass M, Nadobny J, Beck R et al (2000) Clinical evaluation and verification of the hyperthermia treatment planning system hyperplan. Int J Radiat Oncol Biol Phys 47(4):1145–1156 Seebass M, Beck R, Gellermann J, Nadobny J, Wust P (2001) Electromagnetic phased arrays for regional hyperthermia: optimal frequency and antenna arrangement. Int J Hyperthermia 17(4):321–336 Kroeze H, Van Vulpen M, De Leeuw AA, Van de Kamer JB, Lagendijk JJ (2001) The use of absorbing structures during regional hyperthermia treatment. Int J Hyperthermia 17(3):240–257 Sreenivasa G, Gellermann J, Rau B, Nadobny J, Schlag P, Deuflhard P et al (2003) Clinical use of the hyperthermia treatment planning system HyperPlan to predict effectiveness and toxicity. Int J Radiat Oncol Biol Phys 55(2):407–419 Dinges S, Harder C, Wurm R, Buchali A, Blohmer J, Gellermann J et al (1998) Combined treatment of inoperable carcinomas of the uterine cervix with radiotherapy and regional hyperthermia. Results of a phase II trial. Strahlenther Onkol 174(10):517–521 Issels R, Prenninger SW, Nagele A, Boehm E, Sauer H, Jauch K-W et al (1990) Ifosfamide plus etoposide combined with regional hyperthermia in patients with locally advanced sarcomas. J Clin Oncol 11:1818–1829 Rau B, Wust P, Tilly W, Gellermann J, Harder C, Riess H et al (2000) Preoperative radiochemotherapy in locally advanced or recurrent rectal cancer: regional radiofrequency hyperthermia correlates with clinical parameters. Int J Radiat Oncol Biol Phys 48(2):381–391 Tilly W, Wust P, Rau B, Harder C, Gellermann J, Schlag P et al (2001) Temperature data and specific absorption rates in pelvic tumors: predicitve factors and correlations. Int J Hyperthermia 17(2):172–188 Wust P, Stahl H, Dieckmann K, Scheller S, Löffel J, Riess H et al (1996) Local hypert-hermia of N2/N3 cervical lymphnode metastases: correlation of technical/ thermal parameters and response. Int J Radiat Oncol Biol Phys 34:635–646 van der Zee J, Gonzalez Gonzalez D, van Rhoon GC, van Dijk JD, van Putten WL, Hart AA (2000) Comparison of radiotherapy alone with radiotherapy plus hyperthermia in locally advanced pelvic tumours: a prospective, randomised, multicentre trial. Dutch deep hyperthermia group. Lancet 355(9210):1119–1125 Dahl O, Mella O (2002) Referee: hyperthermia alone or combined with cisplatin in addition to radiotherapy for advanced uterine cervical cancer. Int J Hyperthermia 18(1):25–30

376 45. Hildebrandt B, Wust P, Rau B, Schlag PM, Riess H (2000) Regional hyperthermia in rectal cancer. Lancet 356(9231):771–772 46. Prosnitz L (2002) A new phase III trial for treatment of carcinoma of the cervix. Int J Hyperthermia 18(1):31–32 47. Prosnitz L, Jones E (2002) Counterpoint: test the value of hyperthermia in patients with carcinoma of the cervix being treated with concurrent chemotherapy and radiation. Int J Hyperthermia 18(1):13–18 48. van der Zee J, Gonzalez GD (2002) The Dutch Deep Hyperthermia Trial: results in cervical cancer. Int J Hyperthermia 18(1):1–12 49. van der Zee J, Koper PC, Lutgens LC, Burger CW (2002) Point-counterpoint: what is the optimal trial design to test hyperthermia for carcinoma of the cervix? Point: addition of hyperthermia or cisplatin to radiotherapy for patients with cervical cancer; two promising combinations – no definite conclusions. Int J Hyperthermia 18(1):19–24 50. Westermann AM, Jones EL, Schem BC, van der SteenBanasik EM, Koper P, Mella O et al (2005) First results of triple-modality treatment combining radiotherapy, chemotherapy, and hyperthermia for the treatment of patients with stage IIB, III, and IVA cervical carcinoma. Cancer 104(4):763–770 51. Rau B, Wust P, Hohenberger P, Loffel J, Hunerbein M, Below C et al (1998) Preoperative hyperthermia combined with radiochemotherapy in locally advanced rectal cancer: a phase II clinical trial. Ann Surg 227(3):380–389 52. Riess H, Loffel J, Wust P, Rau B, Gremmler M, Speidel A et al (1995) A pilot study of a new therapeutic approach in the treatment of locally advanced stages of rectal cancer: neoadjuvant radiation, chemotherapy and regional hyperthermia. Eur J Cancer 31A:1356–1360 53. Wendtner CM, Abdel-Rahman S, Krych M, Baumert J, Lindner LH, Baur A et al (2002) Response to neoadjuvant chemotherapy combined with regional hyperthermia predicts long-term survival for adult patients with retroperitoneal and visceral high-risk soft tissue sarcomas. J Clin Oncol 20(14):3156–3164 54. Berdov BA, Menteshashvili GZ (1990) Thermoradiotherapy of patients with locally advanced carcinoma of the rectum. Int J Hyperthermia 6(5):881–890 55. Datta NR, Bose AK, Kapoor HK (1987) Thermoradiotherapy in the management of carcinoma of the cervix (stage IIIb): a controlled clinical study. Indian Med Gazette 121:68–71 56. Datta NR, Bose AK, Kapoor HK, Gupta S (1990) Head and neck cancers: results of thermoradiotherapy versus radiotherapy. Int J Hyperthermia 6(3):479–486 57. Harima Y, Nagata K, Harinma K, Ostapenko VV, Tanaka Y, Sawada S (2001) A randomized clinical trial of radiation therapy versus thermoradiotherapy in stage III cervical carcinoma. Int J Hyperthermia 17(2): 97–105 58. Kitamura K, Kuwano H, Watanabe M, Nozoe T, Yasuda M, Sumiyoshi K et al (1995) Prospective randomized study of hyperthermia combines with chemoradiotherapy for esophageal carcinoma. J Surg Oncol 60:55–58 59. Sharma S, Patel FD, Sandhu APS, Gupta BD, Yadav NS (1989) A prospective ramdomised study of local hyperthermia as a supplement to and radiosensitiser in the

B. Hildebrandt et al.

60.

61.

62.

63.

64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

74.

treatment of carcinoma of the cervix with radiotherapy. Endocurietherapy/Hypertherm Oncol 5:151–159 Sugimachi K, Kuwano H, Ide T, Toge T, Saku M, Oshiumi Y (1994) Chemotherapy combined with or without hyperthermia for patients with oesophageal carcinoma: a prospective randomized trial. Int J Hyperthermia 10(4):485–493 Eggermont AM, de Wilt JH, ten Hagen TL (2003) Current uses of isolated limb perfusion in the clinic and a model system for new strategies. Lancet Oncol 4(7):429–437 Ghussen F, Krüger I, Smalley R, Groth W (1989) Hyperthermic perfusion with chemotherapy for melanoma of the extremeties. World J Surg 13:598–602 Koops HS, Vaglini M, Suciu S, Kroon BBR, Thompson JF, Göhl J et al (1998) Prophylactic isolated limb perfusion for localized, high-risk limb melanomas: results of a multicenter randomized phase III trial. J Clin Oncol 16:2906–2912 Jost LM, Jelic S, Purkalne G (2005) ESMO Minimum Clinical Recommendations for diagnosis, treatment and follow-up of cutaneous malignant melanoma. Ann Oncol 16(Suppl 1):i66–i68 Leyvraz S, Jelic S (2005) ESMO Minimum Clinical Recommendations for diagnosis, treatment and follow-up of soft tissue sarcomas. Ann Oncol 16(Suppl 1):i69–i70 Grover A, Alexander HR Jr (2004) The past decade of experience with isolated hepatic perfusion. Oncologist 9(6):653–664 Rothbarth J, Tollenaar RA, Schellens JH, Nortier JW, Kool LJ, Kuppen PJ et al (2004) Isolated hepatic perfusion for the treatment of colorectal metastases confined to the liver: recent trends and perspectives. Eur J Cancer 40(12):1812–1824 Van Putte BP, Hendriks JM, Romijn S, Van Schil PE (2003) Isolated lung perfusion for the treatment of pulmonary metastases current mini-review of work in progress. Surg Oncol 12(3):187–193 Sugarbaker PH (2004) Managing the peritoneal surface component of gastrointestinal cancer. Part 2. Perioperative intraperitoneal chemotherapy. Oncology (Williston Park) 18(2):207–219; discussion 220–222, 227–228, 230 Silberman H (2005) Perioperative adjunctive treatment in the management of operable gastric cancer. J Surg Oncol 90(3):174–186; discussion 186–187 Fujimoto S, Takahashi M, Mutou T, Kobayashi K, Toyosawa T (1999) Successful intraperitoneal hyperthermic chemoperfusion for the prevention of postoperative peritoneal recurrence in patients with advanced gastric carcinoma. Cancer 85(3):529–534 Hamazoe R, Maeta M, Kaibara N (1994) Intraperitoneal thermochemotherapy for prevention of peritoneal recurrence of gastric cancer. Cancer 73:2048–2052 Kim JY, Bae HS (2001) A controlled clinical study of serosa-invasive gastric carcinoma patients who underwent surgery plus intraperitoneal hyperthermo-chemo-perfusion (IHCP). Gastric Cancer 4(1):27–33 Yu W, Whang I, Chung HY, Averbach A, Sugarbaker PH (2001) Indications for early postoperative intraperitoneal chemotherapy of advanced gastric cancer: results of a prospective randomized trial. World J Surg 25(8): 985–990

21 Induced Hyperthermia in the Treatment of Cancer 75. Rosen HR, Jatzko G, Repse S, Potrc S, Neudorfer H, Sandbichler P et al (1998) Adjuvant intraperitoneal chemotherapy with carbon-adsorbed mitomycin in patients with gastric cancer: results of a randomized multicenter trial of the Austrian working group for surgical oncology. J Clin Oncol 16(8):2733–2738 76. Sautner T, Hofbauer F, Depisch D, Schiessel R, Jakesz R (1994) Adjuvant intraperitoneal cisplatin chemotherapy does not improve long-term survival after surgery for advanced gastric cancer. J Clin Oncol 12(5):970–974 77. Hildebrandt B, Rau B, Gellermann J, Wust P, Riess H (2004) Hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinosis. J Clin Oncol 22(8):1527–1529 78. Nadobny J, Wlodarczyk W, Westhoff L, Gellermann J, Felix R, Wust P (2005) A clinical water-coated antenna applicator for MR-controlled deep-body hyperthermia: a comparison of calculated and measured 3-D temperature data sets. IEEE Trans Biomed Eng 52(3):505–519 79. Nadobny J, Wlodarczyk W, Westhoff L, Gellermann J, Rau B, Monich G et al (2003) Development and evaluation of a three-dimensional hyperthermia applicator with WaterCoated Antennas (WACOA). Med Phys 30(8):2052–2064 80. Gellermann J, Wlodarczyk W, Feussner A, Fahling H, Nadobny J, Hildebrandt B et al (2005) Methods and potentials of magnetic resonance imaging for monitoring radiofrequency hyperthermia in a hybrid system. Int J Hyperthermia 21(6):497–513 81. Gellermann J, Wlodarczyk W, Hildebrandt B, Ganter H, Nicolau A, Rau B et al (2005) Noninvasive magnetic resonance thermography of recurrent rectal carcinoma in a 1.5 Tesla hybrid system. Cancer Res 65(13):5872–5880 82. Wust P, Gellermann J, Seebass M, Fahling H, Turner P, Wlodarczyk W et al (2004) Part-body hyperthermia with a radiofrequency multiantenna applicator under online control in a 1.5 T MR-tomograph. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 176(3):363–374 83. Jordan A, Wust P, Fahling H, John W, Hinz A, Felix R (1993) Inductive heating of ferromagnetic particles and magnetic fluids: physical evaluation of their potential for hyperthermia. Int J Hyperthermia 1993(9):51–68 84. Moroz P, Jones SK, Gray BN (2002) Magnetically mediated hyperthermia: current status and future directions. Int J Hyperthermia 18(4):267–284

377 85. Johannsen M, Gneveckow U, Eckelt L, Feussner A, Waldofner N, Scholz R et al (2005) Clinical hyperthermia of prostate cancer using magnetic nanoparticles: presentation of a new interstitial technique. Int J Hyperthermia 21(7):637–647 86. Johannsen M, Thiesen B, Gneveckow U, Taymoorian K, Waldofner N, Scholz R et al (2006) Thermotherapy using magnetic nanoparticles combined with external radiation in an orthotopic rat model of prostate cancer. Prostate 66(1):97–104 87. Kong G, Dewhirst MW (1999) Hyperthermia and liposomes. Int J Hyperthermia 15(5):345–370 88. Lindner LH, Issels R (2003) Thermosensitive liposomes for regional hyperthermia. German. Dt Med Wschr 128:2020–2022 89. Hettinga JV, Konings AW, Kampinga HH (1997) Reduction of cellular cisplatin resistance by hyperthermia – a review. Int J Hyperthermia 13(5):439–457 90. Vanakoski J, Seppälä T (1998) Heat exposure and drugs. Clin Pharmacokinet 34(4):311–322 91. Harris M (2004) Monoclonal antibodies as therapeutic agents for cancer. Lancet Oncol 5(5):292–302 92. Hauck ML, Zalutsky MR (2005) Enhanced tumour uptake of radiolabelled antibodies by hyperthermia. Part II: application of the thermal equivalency equation. Int J Hyperthermia 21(1):13–27 93. Hauck ML, Zalutsky MR (2005) Enhanced tumour uptake of radiolabelled antibodies by hyperthermia: part I: timing of injection relative to hyperthermia. Int J Hyperthermia 21(1):1–11 94. Kinuya S, Yokoyama K, Michigishi T, Tonami N (2004) Optimization of radioimmunotherapy interactions with hyperthermia. Int J Hyperthermia 20(2): 190–200 95. Brade AM, Szmitko P, Ngo D, Liu FF, Klamut HJ (2003) Heat-directed suicide gene therapy for breast cancer. Cancer Gene Ther 10(4):294–301 96. Li CY, Dewhirst MW (2002) Hyperthermia-regulated immunogene therapy. Int J Hyperthermia 18(6):586–596 97. Huang Q, Hu JK, Lohr F, Zhang L, Braun R, Lanzen J et al (2000) Heat-induced gene expression as a novel targeted cancer gene therapy strategy. Cancer Res 60(13):3435–3439

Part V

Supporting Measures

Chapter 22

Hematologic Support of the Patient with Malignancy Thomas A. Lane

22.1 Introduction Patients with malignancy frequently have significant anemia, thrombocytopenia, neutropenia, and coagulation disorders, and therefore frequently require blood component transfusion. As a result, patients with malignancy collectively represent one of the major classes of patients who use blood resources and transfusion services. This chapter will review the transfusion support of patients with malignancy and will not address the role of hematopoietic growth factors in the hematologic support of patients with malignancy, which has recently been reviewed elsewhere [13, 50, 27, 58, 85, 86, 138, 184, 205, 210, 240]. Hematologic disorders in cancer patients may be due either to the disease itself, blood loss, marrow replacement, or cancer treatment [32, 60, 145, 207]. A meta-analysis of the scientific literature regarding anemia in patients with malignancy reported that the prevalence of anemia in cancer patients varies greatly and is a function of the definition of anemia, the type of malignancy, the stage of disease, and the effects of treatment [118]. Focusing on studies that reported anemia not due to therapy (i.e., prior to cancer therapy or in the absence of treatment-related anemia), the authors reported that patients with hematologic malignancy and lymphoma had the highest rates of anemia, exceeding 90%, followed in general order of prevalence and severity by patients with a variety

T.A. Lane () UCSD Transfusion Services and Stem Cell Processing Lab, Moores UCSD Cancer Center, La Jolla, CA 92093-0960, USA e-mail: [email protected]

of solid tumors including gynecologic malignancy (26–85%), breast (41–82%), bone (78%), gastrointestinal (30–67%), head and neck (16–65%), brain (59%), kidney (39%), and lastly prostate cancer (5–32%) [118]. Thus, while patients with malignancy, and especially hematologic malignancy are prone to varying degrees of marrow failure, cancer treatment imparts an added stress on the marrow and represents the principal cause of anemia, thrombocytopenia and leukopenia in cancer patients and increases the likelihood of transfusion [32, 49, 93, 175, 207]. Dramatic evidence of the critical support role for transfusion in patients with hematologic malignancy is provided by the reports of generally poor outcome of treatment of patients with AML who refuse transfusion [54, 122, 137]. Anemia is common in pediatric as well as adult patients with malignancy. It has been reported that anemia occurs in approximately 12% of pediatric patients after standard dose chemotherapy, and the prevalence of anemia increases to approximately 60% after administration of intensive chemotherapy [186]. Considerable resources are required to provide hematologic support for patients with malignancy. Recent reports indicate that from 15 to 48% of all transfusions are administered to patients with malignancy [45, 129, 139, 223, 241, 254] and it has been reported that patients with acute myelogenous leukemia (AML) used more blood resources (8% of total hospital transfusions) than patients with any other individual diagnosis [129]. The intense use of blood by leukemia patients is also reflected by the fact that, in comparison with other disease-related groups (DRG), acute leukemia is reported to be associated with the highest individual mean cost for blood as a percent of total hospital costs (12.7%), followed by bone marrow transplant (8.7%) [112]. Blood resource utilization

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_22, © Springer Science+Business Media B.V. 2011

381

382

by patients with malignancy has been reported to vary by component. Studies report that 28–42% of all red blood cell units (rbc) transfused, 13–32% of fresh frozen plasma units (FFP) and 53–76% of platelet units (plt) were administered to patients with neoplasms [129, 139]. Furthermore, in the latter study AML patients alone accounted for 17.5% of all plt use. The total cost of blood and component transfusion for the cancer patient includes the direct cost of the unit, which represents approximately 35% of the total cost of blood administration and also the costs involved in storing, handling, testing and infusing the blood and dealing with transfusion reactions and adverse effects. It has been reported that the overall cost of administration of a single unit of rbc to a cancer patient in 1998 varied from $274 to $512 per unit [39, 53]. An accurate understanding of the local cost of blood transfusion is required in order to evaluate the comparative costs, risks and benefits of treating anemia in cancer patients with blood vs. Erythropoietin [200]. In addition, cancer patients frequently have unique requirements that further increase the cost of blood transfusion. These may include the requirement for blood irradiation to prevent graft vs. host disease, leukocyte reduction to prevent alloimmunization to leukocyte antigens, provision of blood from CMV seronegative donors to prevent CMV infection, provision of selective phenotype-matched rbc or plt to patiens who are alloimmunized to foreign rbc or plt-associated antigens, or provision of granulocytes to treat infection in some severely neutropenic patients. Frequently transfused cancer patients who become alloimmunized to leukocyte, red cell, or platelet antigens may also require the expensive services of reference labs to identify the antibody specificity, then to identify adequate donors and finally to provide antigen matched red cells or HLA matched platelets. In view of the above, the national economic impact of the hematologic support of patients with malignancy is considerable. In the USA, approximately 12 million units of blood are collected yearly and 11.5 million units of rbc, 9 million units of plt and 3.3 million units of FFP are transfused yearly [88, 89, 214]. Extrapolating mean reported data from two studies regarding the average use of blood by cancer patients, approximately 4 million units of rbc, 5.8 million units of platelets and 0.8 million units of FFP are expected to be used by cancer patients yearly in the USA [129, 139]. The direct costs of blood vary by location,

T.A. Lane

but assuming conservatively that a unit of rbc costs $250/U, a unit of apheresis plt costs $650 and a unit of FFP costs $45, then the aggregate yearly direct cost of blood for cancer patients in the USA would be approximately 4.8 billion. As previously noted, the direct unit costs of blood represent less than half of the total cost of blood transfusion.

22.2 Blood Component Therapy in Patients with Cancer 22.2.1 Red Cell Transfusion in Patients with Cancer Introduction: As noted above, both anemia and red cell transfusion are common in patients with malignancy and increase due to the effects of intensive chemo-radiotherapy. Transfusion requirements in patients treated for malignancy have been reported to vary by the type of disease, and within disease categories, by the type of chemotherapy administered [93]. Transfusion prevalence and requirements are highest in patients with myeloid malignancy [136], especially in marrow transplant patients [143], followed by patients with lymphoma, lung cancer, ovarian cancer and genitourinary malignancy [93]. In one report of cancer patients treated by a large group practice, 31% of all cancer patients required rbc transfusion, with an average of 5.1 units per patient [74]. In another report on transfusion requirements of solid tumor patients who were treated prior to availability of Erythropoietin, 3.7 units of rbc were used per patient [148]. The approach to an anemic patient with cancer is similar to that for non-cancer patients in that treatable sources and causes of blood loss, hemolysis, and marrow dysfunction should be considered, identified, and treated accordingly. Guidelines for Treatment of Anemia: Guidelines for treatment of anemia have been published [88, 89, 119]. In general, rbc transfusion are reserved for patients who have symptomatic anemia that is not due to B12, folate, or iron deficiency and for emergencies. The need for transfusion in an individual patient is typically based on the presence of symptoms, e.g. fatigue (the commonest symptom reported by cancer patients), weakness, dizziness, the hemoglobin value itself, and the context, ie anticipation of a chronic requirement vs.

22 Hematologic Support of the Patient with Malignancy

acute, self-limited anemia. Patients are typically transfused at hemoglobin levels of 7–8 gm/dl, but this may vary depending on the presence of significant cardiovascular or cerebrovascular disease, other significant organ dysfunction, and on predictions regarding the course of the disease and the effect of its treatment on symptomatic anemia., Hemoglobin levels lower than 12 gm/dl in cancer patients have been reported to play a role in cancer-related symptoms such as fatigue [43, 86, 208, 210, 240]. Likewise, improvements in quality of life have been reported in patients treated to a hemoglobin level higher than 9–10 gm/dl [42, 51, 59, 84, 130–132, 174] and recent ASCO guidelines support the use of Erythropoietin or rbc transfusion in carefully selected patients to achieve this goal [183]. The risk/benefit ratio of maintaining a hemoglobin > 10 gm/dl, < 12 gm/dl by the use of Erythropoietin and/or rbc transfusion should be evaluated in each individual patient. In contrast, more restrictive transfusion thresholds have also been proposed in surgical patients and in those who are unlikely to respond to Erythropoietin as a means of diminishing treatment risk and excess cost [62, 111]. Evaluation of the hemoglobin level at which to treat cancer patients by transfusion or Erythropoietin has been the focus of recent investigation, in part because, in addition to fatigue, anemia in cancer patients has been linked to other possible important adverse outcomes. A host of retrospective reports suggested an association between anemia in cancer patients and both poor tumor response and decreased survival after radiation therapy [92, 123, 221, 237]. Studies in animal models provided the scientific basis for an association between tumor oxygenation and radiation effectiveness at tumor sites [203, 220]. Limited retrospective studies in humans suggested that maintaining a higher hemoglobin by transfusion or EPO improved outcome after radiation therapy [83, 92], but not all studies supported an association between hemoglobin and response to treatment [46, 64]. Moreover, recent reports of prospective randomized trials suggest that cancer patients treated with EPO fared less well than placebo-treated patients [101, 127]. A randomized multicenter, double-blind trial including 351 anemic patients with oral-laryngeal cancer who received either placebo or Erythropoietin prior to and during curative radiation therapy, investigated the effect of EPO therapy on the primary endpoint of time to local-regional progression [101]. In this trial patients in the group

383

that received EPO unexpectedly had a statistically significant decrease in the time to progression, despite an increase in hemoglobin, compared with the control patients who did not receive EPO [101]. More recently, a multinational prospective randomized trial in which patients with breast cancer and normal hemoglobin who were receiving first line therapy and who were randomized to receive either placebo or EPO to maintain hemoglobin > 12 gm/dl was terminated early due to an apparent increase in early disease progression and thrombotic events in the group that received EPO [127]. In retrospect, there were unexplained anomalies in randomization and disease course of the control group in this study despite the randomization, and follow-up of the patients was incomplete. However, the study group concluded that the use of EPO in the above manner should be undertaken only in the context of a clinical trial with appropriate safeguards. In addition, a retrospective case-controlled study suggested an increased incidence of thrombotic events in cervical cancer patients who were treated with EPO to correct anemia in the setting of chemo-radiotherapy [247]. In summary, it appears that in persons with a wide range of malignancies, as reviewed above [118], either rbc transfusion or administration of EPO may significantly diminish symptoms of anemia and improve quality of life by increasing the hemoglobin to at least 10 gm/dl. In addition, EPO therapy spares rbc transfusions in those who respond, although perhaps at increased cost. However, currently available information is insufficient to support a policy to maintain hemoglobin above 10 gm/dl as a rationale to improve upon response to radiotherapy or to increase overall survival in patients with oral-laryngeal or breast cancer. Whether these findings can be extended to patients with other types of malignancy and with other treatment remains an open question, however a recent meta-analysis of clinical trials of EPO in cancer patients reported both an increase in the incidence of venous thrombo-embolism (VTE) and mortality in a wide variety of cancer patients [13]. In any event, as a result of these and other studies, on November 8, 2007 the FDA issued a warning regarding the use of EPO in patients with Hb values > 10 gm/dl and CMS has indicated that it would not cover the cost of EPO that is administered outside of the FDA guidelines. These events have resulted in considerable controversy within the medical community, and ultimately in significant changes in patient management. In addition, relevant to this review, it has been

384

predicted that the FDA & CMS decisions will result in a significant increase in the rate of blood transfusion in patients who would otherwise have been treated with EPO to a higher level of Hb [231].

22.2.1.1 Transfusion of Red Cell Components Whole blood: A variety of red blood cell (rbc) containing components are available for transfusion to patients in whom this therapy is indicated. The sole indication for administration of whole blood (500 mL volume; Hct approximately 45%) is replacement of combined deficits of oxygen carrying capacity and blood volume such as occurs in acute hemorrhage. In practice, whole blood is rarely available, primarily because of (a) the difficulty in maintaining a ready supply of this component for all blood types, (b) the compelling need for blood suppliers to generate other components (plasma, platelets, cryoprecipitate) from whole blood, and (c) because there are alternatives that are acceptable or in some cases superior to whole blood. In this author’s institution, which includes active services in trauma, cardiac surgery, liver transplant and burns, whole blood is not used except in neonatal transfusion. Packed red blood cells: Packed rbc consist of a volume of approximately 250 ml of blood with a Hematocrit of 65–75% depending on the preservative solution used. Different preservative solutions maintain acceptable rbc viability for 35 (CPDA1) or 42 days (AS1, AS3, AS5). In adult transfusion, there is little or no clinical difference between rbc preserved in one anticoagulant/preservative solution vs. another since the storage life of rbc in all solutions is dictated by a requirement to maintain the 24-h post transfusion recovery of rbc at the date of unit expiration to greater than 75%. Because of a lower content of donor plasma (10 ml vs. 70) units preserved in AS may have a reduced probability of causing plasma-associated adverse effects compared with units preserved with CPD (see Section 22.3). Administration of a single unit of rbc to a 70 kg person with a normal blood volume is expected to increase the Hemoglobin by approximately 1 gm/dl or the Hematocrit by approximately 3%. A patient whose marrow is making no rbc is expected to require approximately 1 unit of rbc per week to maintain a steady Hemoglobin level. Leukocyte-reduced blood: Patients who are transfused with standard (non-leukocyte-reduced) rbc and

T.A. Lane

platelets and multiparous women may develop antibodies to leukocyte-specific, platelet specific, and HLA antigens. Blood recipients who have developed alloimmune antibodies to foreign leukocyte antigens, and principally alloimmune antibodies to human leukocyte antigens (HLA) may suffer febrile nonhemolytic transfusion reactions when non-leukocyte reduced rbc or platelets are administered. In addition, alloimmune antibodies to foreign HLA antigens are also responsible for immune-mediated refractoriness to platelet transfusion (discussed below). Between 15 and 50% of leukemia patients develop anti-HLA antibodies during induction therapy [5, 206]. When transfusion is indicated, administration of leukocytereduced rbc are indicated in patients who will require multiple transfusions of cellular blood components in order to: (1) diminish or prevent febrile-non-hemolytic transfusion reactions due to anti-leukocyte antibodies and (2) to diminish the probability of alloimmune reactions (sensitization) to leukocyte antigens [5, 206, 219]. While the early studies that demonstrated the effectiveness of leukocyte-reduced blood in preventing alloimmunization were principally focused on patients with leukemia, more recent retrospective studies indicate that patients with a variety of hematologic and non-hematologic malignancy may also benefit from use of leukocyte-reduced blood [96, 117, 161, 198]. (3) Leukocyte-reduced blood is also effective in preventing cytomegalovirus transmission (discussed below) from rbc transfusion. Leukocyte-reduced rbc are produced by processing of red blood cells through special “3rd generation” filters that remove greater than 99.9% of leukocytes, leaving the rbc with less than 5 × 106 leukocytes per unit. Filter efficiency has improved to the point that the mean level of residual leukocytes per unit is almost always considerably below this level [6, 249]. Leukocyte-reduction is performed most reliably by the blood-collecting facility or in the laboratory prior to blood administration [6], and is referred to as “pre-storage leukocyte-reduction” however there are filters available that permit leukocyte-reduction of blood at the time of blood administration, albeit somewhat less reliably. Transfusion is clearly associated with immune modulation, but it is unclear whether transfusion associated immune modulation is ameliorated or prevented by administration of leukocyte-reduced blood. It has long been appreciated that blood transfusion has immunomodulatory effects, as evidenced by prolonged

22 Hematologic Support of the Patient with Malignancy

renal allograft survival [159]. These findings led to the hypothesis that transfusion-associated diminished immune responsiveness might impair host response to malignancy [21]. More specifically, investigators focused on the possibility that passive transmission of “passenger” blood leukocytes in cellular blood components during surgery in cancer patients might be responsible for diminished anti-cancer immunity and hence an increased rate of tumor recurrence [21, 25]. This topic has generated considerable controversy over the past decade, however at this time there is insufficient evidence to conclude that passenger leukocytes in blood impair the response to cancer treatment or cause increased tumor recurrence. A host of retrospective studies suggested a link between cancer recurrence and transfusion, presumably due to the immunosuppressive effect of passenger leukocytes, however, a meta-analysis of the retrospective studies failed to identify an independent association between cancer recurrence and transfusion or the use of leukocytereduced blood. Instead, the meta-analysis suggested that the association of transfusion with cancer recurrence was due to the fact that patients who have extensive disease require extensive resection and therefore increased transfusion and such patients would also be expected to have a higher rate of cancer recurrence [24, 25, 217, 225, 226]. During the previous decade, considerable attention has been specifically directed toward investigating a potential deleterious effect of blood transfusion on the survival and freedom from recurrence of patients undergoing curative surgical treatment for colorectal cancer. Both retrospective and prospective studies failed to identify a relationship between blood transfusion and colorectal cancer metastasis, but confirmed that patients who required transfusion had poorer survival, presumably as a result of more extensive disease [35, 36, 97]. In one randomized study of similar stage colorectal surgery patients who were scheduled for curative surgery, patients who did not require transfusion had improved disease-free survival compared with patients who were transfused, but the incidence of cancer recurrence was equal in patients who received allogeneic transfusions compared with those who received autologous transfusion or a mix of the two [35]. Another study compared tumor free survival and metastases in similar stage colorectal cancer patients who were scheduled for curative surgery and were randomized to receive either allogeneic or autologous blood [99]. This study found

385

no significant difference in disease-free survival or metastasis in the two groups. Patients transfused with allogeneic blood had a higher rate of tumor recurrence than untransfused patients, but this difference disappeared after adjustment for disease stage [99]. A recent prospective investigation reported the outcomes of 697 patients with similar stage colorectal cancer who were scheduled for curative resection and were randomized to receive leukocyte-reduced or standard (buffy coat poor) blood [229]. The study failed to detect a difference in cancer recurrence between patients who were transfused vs. those who were not transfused or between patients who were administered leukocytereduced blood compared with non-leukocyte-reduced blood. Compared with non-transfused patients, those who received any transfusion had lower overall survival and increased local tumor recurrence, but these associations were not independent of tumor stage. In addition to colorectal cancer, observational studies in patients who underwent surgery for non-small cell lung cancer reported a difference in survival between transfused and non-transfused patients and either identified or failed to identify an association between transfusion and disease recurrence [155, 188]. A recent report of an observational study in patients receiving curative resection for gastric cancer concluded that, while transfused patients had poorer overall survival, this finding was associated with the presence of more extensive disease in the transfused patients [26]. Thus, in the types of malignancies studied to date, the weight of evidence does not support an indication for the use of autologous or leukocyte-reduced blood for the purpose of diminishing the probability of tumor recurrence or metastasis after curative surgery. Washed blood: Washed rbc are indicated for patients who have had significant allergic reactions during blood transfusion (anaphylaxis or moderate to severe bronchospasm) or repeated moderate allergic reactions that are unresponsive to pretransfusion administration of antihistamine. Such patients have antibodies to foreign plasma proteins (for example, anti-IgA) and washing rbc eliminates allergic reactions by reducing the amount of plasma protein to <1% of the original content. Washed rbc are not indicated in patients who have had a single mild allergic reaction or those who are responsive to antihistamine administration. Washed rbc are generated by repeated suspension of packed rbc in saline followed by centrifugation and removal of the supernatant fluid. Since this process

386

requires several hours and occurs in an “open” system, washed rbc should be ordered well in advance of the scheduled transfusion and the unit outdates 24 h after preparation. Washed rbc are suspended in saline at a variable Hematocrit (typically 45–65%) in 0.9% sterile saline and contain about 80% of the original rbc and 10% of the leukocytes present in prbc. The transfusion requirement may increase when employing washed rbc due to their reduced content of rbc. Washed rbc are not an acceptable source of leukocytereduced blood since washing removes only 90–95% of leukocytes, hence washed rbc are not preferred over leukocyte-reduced blood in preventing either febrile non-hemolytic reactions, or alloimmunization to the leukocyte antigens that cause such reactions, or in preventing cytomegalovirus transmission. Frozen blood: Frozen-deglycerolized rbc are indicated chiefly to supply rare or unusual antigen-negative units of rbc for patients who have complex rbc alloantibodies. In patients with complex antibodies, autologous blood may be stored frozen in anticipation of a medical or surgical procedure, but this is an expensive and cumbersome undertaking that is rarely indicated or feasible in patients with malignancy. Frozen-deglycerolized rbc are prepared by addition of glycerol to prbc as a cryoprotectant, storage of the product at minus 80◦ C for up to 10 years, then thawing, serial washing to remove glycerol and resuspension of the rbc at a variable Hematocrit (typically 45–65%) in 0.9% sterile saline. When employing frozen-deglycerolized rbc, the transfusion requirement may increase, since each unit supplies approximately 20% fewer packed rbc than units of liquid packed rbc. Since obtaining frozen-deglycerolized rbc requires several hours, this product should be ordered at least a day in advance of the scheduled transfusion. Unit thawing and deglycerolization commonly occurs in an “open” system; consequently the unit outdates 24 h after preparation, due to the risk of bacterial contamination. The recent approval of a “closed” system for post-thaw preparation of frozen rbc permits post-thaw storage for up to 14 days in AS3 preservative solution at 4 C, but the instruments required to process frozen rbc in this manner are not widely available. Allo-immunization to red blood cells: In a retrospective study of 564 transfused patients with hematologic malignancy, lymphoma and myelodysplasia [196], patients who received a total of 15,287 units

T.A. Lane

of rbc in 6182 transfusion episodes (mean of 16 units of rbc per patient), alloimmunization to rbc antigens occurred in 9% of patients (a prevalence similar to other studies in cancer patients [148]) and was a function of the number of units transfused (0.5% per unit or 1% per transfusion episode), but was not a function of diagnosis, age or gender [196]. Patients who received plt in addition to rbc had a lower prevalence of alloimmunization to rbc than those who did not. In this study, the first rbc antibody occurred relatively early during a course of transfusion (generally after 12 units) and patients who formed one antibody had a higher likelihood of forming another. Finally, both the antibody specificities encountered and the persistence of the antibodies were similar to that reported in the general population of transfused patients. The authors concluded that patients with malignancy who are transfused have approximately the same risk of forming anti-rbc antibody as patients without cancer, but cancer patients who are administered platelets may have a lower rate of anti-rbc antibody formation, presumably due to the immunosuppressive effects of cancer therapy. Also, in this study 3 of 33 Rh-negative patients who received 244 Rh-positive plt transfusions and were not treated with anti-RhIg prophylaxis made anti-Rh (D). Other similar studies in cancer patients have reported rates of anti-D formation varying from zero to 19% [8, 144, 149]. Given the very low rate of immunization and the progressive decrease in the rbc contamination of platelets it is increasingly common for institutions disregard the Rh type of platelets when transfusing cancer and in many cases even non-malignancy patients [9, 47]. Artificial oxygen carriers: Several human hemoglobin oxygen carrier (HBOC) solutions have been studied in clinical trials and have shown efficacy in oxygen transport as a cell free oxygen carrier for short-term use, typically in emergencies or in patients for whom compatible blood cannot be found [90]. Advantages of HBOC include ready availability and a reduced risk of infectious disease transmission and alloimmunization to blood elements [90, 179]. However, HBOCs generally have a short intravascular survival (12–24 h) and are not likely to become a replacement for rbc transfusion in patients who require long-term transfusion support [209, 244]. Moreover, none of the more promising candidates have won US FDA approval, due to adverse effects such as myocardial damage, hypertension, or abdominal pain

22 Hematologic Support of the Patient with Malignancy

that are presumably due to the binding of nitric oxide by free hemoglobin [152].

22.2.2 Platelet Transfusion in Patients with Cancer Thrombocytopenia in cancer patients: Thrombocytopenia is common in cancer patients and has multiple etiologies, including the patient’s underlying disease, disease complications, marrow invasion, and cancer therapy. Thrombocytopenia occurs almost universally at presentation of acute myeloid leukemia and in more than 70% of patients with acute lymphocytic leukemia [180], but is somewhat less common in other malignancies. Dutcher et al. reported that thrombocytopenia occurred in 301 of 1274 patients with solid tumors (breast, lung, melanoma, sarcoma, primary brain, testicular, hypernephroma and others) and was principally associated with chemotherapy [66]. Elting et al. reported that 217 of 300 cycles of chemotherapy in 75 patients with solid tumors and lymphoma were accompanied by thrombocytopenia and that during the 40% of chemotherapy cycles that were associated with thrombocytopenia and required platelet transfusion, the cost of treatment was increased by > $1000 (in 1999 dollars) [69]. These authors subsequently reported on the clinical implications of thrombocytopenia in 609 lymphoma and solid tumor (sarcoma, breast, GU, melanoma, lung, et al.) patients during 1262 treatment cycles. Bleeding occurred in 9% of cycles and the occurrence of major bleeding and was associated with febrile neutropenia and failure to respond to platelet transfusion (which occurred in a surprisingly high 19% of all patients). The clinical implications of major bleeding were significant since such episodes frequently required hospitalization, led to delays in chemotherapy administration, and patients who suffered a major bleeding episode had significantly shorter survival [71]. Goldberg et al reported on the implications of thrombocytopenia in 501 patients with GYN malignancy who were being treated with dose-intensive chemotherapy [87]. They found that 808 of 1546 (36%) of chemotherapy cycles in 186 patients were associated with thrombocytopenia and that 76% of thrombocytopenic patients had no bleeding, while major bleeding occurred in 5%. There were no life-threatening bleeding episodes. These investigators,

387

like Elting, found that 27% of platelet transfusions failed to result in the expected post transfusion platelet count increment and that neither single donor nor HLA matched platelets improved transfusion responses in refractory patients. Calhoun, et al reported that the additional direct cost associated with the occurrence of thrombocytopenia during the chemotherapy of patients for ovarian cancer patients was $3268 per episode [38]. Models have been developed to predict both the risk of thrombocytopenia and the need for platelet transfusion in solid tumor patients [23, 70]. These investigators found that a combination prior bleeding history, low platelet count, performance status, type of chemotherapy administered, administration of drugs that interfere with platelet function, the disease, and a number of other parameters prior to chemotherapy enabled prediction of thrombocytopenia and the need for platelet transfusion. Guidelines for platelet transfusion: Platelet Transfusion guidelines for oncology patients have been published and, in general differ little from platelet transfusion guidelines for patients without malignancy [94, 195]. Platelet transfusion is indicated to treat bleeding due to thrombocytopenia or platelet dysfunction. Platelet transfusion is indicated to maintain the platelet count greater than 40,000–50,000 × 106 /L in order to prevent bleeding during an invasive procedure, although simple bone marrow aspiration may be undertaken with a lower count. A post transfusion platelet count should be measured to ensure a satisfactory response to the transfusion. Platelet transfusion is also indicated to prevent bleeding in severely thrombocytopenic patients who are not scheduled for an invasive procedure. The transfusion trigger for prophylactic platelet transfusion support in patients who are not scheduled for an invasive procedure has been the subject of considerable investigation and recent controversy. Early studies indicated an increased bleeding risk in leukemia patients who had platelet counts less than 20,000 per microliter [80] and this finding resulted in the use of a transfusion trigger of 20,000 × 106 /L to prevent bleeding. However the excess bleeding risk in leukemia patients in the past may have been due in part to a lack of appreciation of the relationship between aspirin use and platelet dysfunction [7]. Recent randomized studies in stable patients with acute leukemia indicate that the frequency of bleeding is similar if a 10,000 or a 20,000 trigger is employed [177, 235, 236]. Patients

388

with febrile neutropenia appear to be at higher risk of bleeding. Recent ASCO guidelines suggest that prophylactic platelet transfusion support for leukemia patients should be individualized, that a threshold of 10,000 per microliter is equivalent to 20,000 per microliter in most patients, but that platelet transfusion at higher platelet levels may be necessary in patients with a high risk of bleeding or if platelets are not readily available in emergencies. High-risk leukemia patients include newborns, patients with signs of hemorrhage, high fever, hyperleukocytosis, rapid fall of platelet count, or coagulation abnormalities (e.g. acute promyelocytic leukemia) [195]. These guidelines also apply to marrow transplant patients. The ASCO guidelines suggest that cancer patients who are undergoing high dose chemotherapy receive prophylactic platelet transfusion when the platelet count falls to a level of 10,000 per microliter, except for patients with bladder cancer, for whom a platelet count of 20,000 per microliter is suggested. The ASCO guidelines do not support prophylactic platelet transfusion for other non-bleeding patients who have chronic stable thrombocytopenia, e.g. those with myelodysplasia or aplastic anemia. Recent clinical trials comparing the use of standard vs. low doses of platelets disagree on whether the low dose regimen is equally effective in preventing bleeding, but do indicate that low dose platelets is associated with more frequent platelet administration [97, 204]. Thus, while the introduction of low-dose platelets may be beneficial for the blood center, their use may be more cumbersome for patients, especially outpatients, who will require more frequent transfusions, and the overall effect on costs is unclear. Platelet components: Platelet concentrates for transfusion may be obtained by centrifugation of individual units of fresh whole blood. Four to six of these platelet concentrates (PC), each of which should contain at least 5.5 × 1010 platelets suspended in approximately 50 ml of citrated plasma are typically transfused as a single dose for an adult. Alternatively an equivalent number of platelets (at least 3 × 1011 , typically suspended in 200–300 ml citrated plasma) may be obtained from a single blood donor at one time by apheresis (apheresis platelets). These two platelet sources are equally effective in transfusion support of thrombocytopenic patients. By reducing the number of donor exposures per transfusion, apheresis platelets may diminish the likelihood of alloimmunization to

T.A. Lane

plasma proteins and leukocyte antigens, and may carry a lower risk of disease transmission, but in some areas apheresis platelets are more expensive and may not be as readily available as PC. Platelets are stored at room temperature, with gentle agitation for up to 5 days. Partially as a result of room temperature storage, platelets have been associated with a relatively high rate of bacterial growth, ie bacteria can be grown from as many as 1 in 2000 units of platelets. In an effort to decrease transfusion-associated sepsis, accrediting agencies (AABB, CAP) now require blood centers and transfusion services to test platelets for bacterial contamination prior to transfusion. This has reduced the rate of platelet-associated sepsis to less than 1 in 75,000 transfusions. It is optimal to administer ABO/Rh-type specific platelets, but given the short shelf-life of platelets, this is not always possible or consistent with optimal inventory management. Donor-recipient ABO incompatibility may reduce the response to platelet transfusion and administration of ABO-incompatible plasma may rarely cause hemolysis of recipient rbc. Apheresis platelets and PC contain a small amount of rbc (generally less than 0.1 ml for the former) consequently, if it is necessary to transfuse platelets from Rh-positive donors to Rh-negative patients (especially children and females with childbearing potential) Rh-immunization to Rh can be prevented by administration of Rh-immune globulin (RhIg), preferably using an IV preparation to avoid intramuscular injection in a thrombocytopenic patient. However, as noted above, the frequency of alloimmunization to Rh is extremely low in cancer patients and reports suggest that RhIg prophylaxis is unnecessary in Rh-negative cancer patients who receive Rh-positive platelets. Leukocyte-reduced platelets: Apheresis platelets may be rendered leukocyte-reduced (<5 × 106 leukocytes per unit) at the time of collection and these or PC may also be rendered leukocyte-reduced either in the laboratory or at the bedside by passage through platelet-specific “3rd generation” filters that remove leukocytes by their adhesion to the filter matrix. Similar to leukocyte-reduced red cells, use of leukocyte-reduced platelets will diminish or prevent febrile non-hemolytic reactions due to recipient anti-leukocyte antibodies. Such antibodies arise due to immunization of the patient to foreign leukocytes through transfusion or pregnancy. However, such antibodies also typically cause refractoriness to platelets;

22 Hematologic Support of the Patient with Malignancy

consequently preventing febrile reactions will not restore responsiveness to platelets. Hence the occurrence of febrile non-hemolytic transfusion reactions in response to platelet or rbc transfusion almost always indicates a need for HLA matched and/or crossmatched platelets. By preventing leukocyte release of inflammatory cytokines that accumulate during platelet storage, the use of pre-storage leukocytereduced platelets may also prevent mild, but frequent transfusion reactions that are associated with the passive administration of cytokines in stored platelets [73, 76, 98]. In addition to preventing febrile reactions, leukocyte-reduced platelets appear also to be indicated to prevent or diminish alloimmunization to leukocyte antigens in cancer patients who are destined to require more than one episode of platelet transfusion support. Since formation of anti-leukocyte antibodies, and principally antibodies to human leukocyte antigens (HLA), is the principal cause of immune-mediated platelet refractoriness, the use of leukocyte-reduced platelets (and rbc) has been shown to diminish the incidence of both alloimmunization to leukocyte antigens and of platelet refractoriness in acute leukemia patients who were receiving induction therapy [157, 158, 219]. Since these patients usually also require rbc transfusion, the rbc should also be leukocyte-reduced. The extent to which the prevention of alloimmunization to HLA by leukocyte-reduction of platelets and rbc may be applicable to other cancer patients who require frequent platelet transfusion is unclear. For example, leukemia patients may be more immunocompromized than other cancer patients and it may thus be less difficult to suppress an immune response in these patients to foreign HLA or platelet antigens. However, given the absence of prospective trials of leukocyte-reduced blood in other types of cancer patients and encouraging results from reports of retrospective studies, it has been widely assumed that the benefits of prophylactic leukocyte-reduction of platelets and rbc will extend to non-leukemia patients [117, 161, 189, 195, 198]. Leukocyte-reduced platelets are also indicated to prevent the transmission of cytomegalovirus during platelet administration [29, 30, 185]. Refractoriness to platelets: The extent to which the platelet count increases in number after transfusion is a function of the patient’s blood volume, the initial platelet count, the dose of platelets, the ABO compatibility of the platelets and the patient’s underlying condition. Administration of platelets is typically required

389

every 3 days to maintain the platelet count above the minimal threshold in patients with stable thrombocytopenia. Refractoriness to platelets is defined by the repeated failure of platelet transfusion to achieve a satisfactory increment in platelet count [194]. A single dose of platelets should increase the platelet count in an adult by 30,000–60,000 × 106 /L, when measured 10 min to 1 h after transfusion. Alternatively, the adequacy of the response to platelets may be more accurately measured by use of a formula that requires knowledge of the dose of platelets administered [19]. The objective definition of the platelet refractory state requires at least 2 transfusion failures and may be documented by calculation of the Corrected Count Increment (CCI) as follows:

CCI =

(post trf plt ct) − (pre trf plt ct) #platelets transfused (×1011 )

× BSA

where, BSA = body surface area in m2 . Since the number of platelets transfused per unit of platelet concentrate or apheresis platelets is rarely known, one may estimate the number transfused by multiplying the number of individual platelet concentrates given by 0.6 × 1011 or for apheresis platelets, or by assuming 3.5 × 1011 platelets/transfusion, if the actual count of each unit is not available. A CCI of < 7.5 × 109 /L based on the results of a blood sample drawn 10–60 min post transfusion, or a CCI < 4.5 × 109 /L based a blood sample drawn 18–24 h post transfusion are considered indicative of refractoriness. The causes of refractoriness to platelet transfusion may be conveniently divided into immune or non-immune mechanisms, the latter including splenomegaly, bleeding, infection, consumptiive coagulopathy, receipt of a bone marrow transplant and veno-occlusive disease of the liver [18, 20]. Non-immune refractoriness to platelet transfusion (other than splenomegaly) typically results in a satisfactory increment in platelets when measured 1-h post transfusion but not after 24 h, while immune refractoriness and splenomegaly typically results in a poor immediate and delayed response to platelet transfusion. Refractoriness to platelet transfusion results not only in a poor increment in platelet count after transfusion, but also in failure to control bleeding and may also result in a febrile non-hemolytic transfusion reaction. Febrile reactions, but not the associated poor increment in platelet count in such patients may be

390

prevented by transfusion of leukocyte-reduced platelets. Immunologic causes of platelet refractoriness typically include antibodies to foreign HLA antigens (85–90% of immune refractory patients) and less commonly to platelet-specific antigens (10–20%) or to ABO incompatibility (<5%). Immune thrombocytopenic purpura (ITP) and the less common post-transfusion purpura (PTP) also cause platelet refractoriness. Because of the many clinical factors that may influence the response to platelet transfusion, a poor response to a single platelet transfusion is insufficient to diagnose platelet refractoriness. Thus, per ASCO guidelines, platelet refractoriness should be considered after failure to respond to at least 2 transfusions of ABO compatible platelets that have been stored less than 72 h. It is increasingly difficult to obtain such fresh platelets since the implementation of platelet microbial culturing by the major blood suppliers. Platelet refractoriness is a common problem in patients with leukemia (incidence from 13% to 50% [157, 206, 219, 230]) and in solid tumor patients who require platelet transfusion (20% of all patients; 69% of patients with widely disseminated disease, 45% of patients with lymphoma, 14–15% of patients with GU malignancy or sarcoma [71]) and has serious implications. In one study, bleeding occurred after 9% of chemotherapy cycles (major bleeding in 3%), was frequently associated with a failure to achieve adequate response to platelet transfusion, and was associated with death on 4 of 111 cycles of chemotherapy associated with thrombocytopenia [70]. Management of platelet refractoriness: Patients with non-immune refractoriness are managed by treatment of the underlying condition and judicious platelet transfusion as required to prevent or treat bleeding. Patients with immune refractoriness are optimally managed by selection of platelets that are compatible with the antibodies in their plasma [56, 116, 176, 195]. This is most readily accomplished by selection of HLA matched donors. Identification of the HLA antibodies involved may increase the pool of available donors whose platelets will provide acceptable platelet increments [164]. Platelet crossmatching is an alternative method that identifies most but not all HLA antibodies and nearly all platelet-specific antibodies. Thus, for patients who are unresponsive to HLA-matched platelets or in whom an adequate match cannot be identified, platelet crossmatching may also be employed to identify compatible platelets, and this technique

T.A. Lane

may be required for patients who have both HLA and platelet-specific antibodies. Crossmatching is also required for the small minority of patients who have only platelet-specific antibodies [150]. Administration of random platelets to patients who are alloimmunized is likely to be of little benefit. All platelets are incompatible with patients who have ITP; consequently platelet transfusion is unsuccessful in such patients and is generally employed only in the event of serious bleeding. Finally, as noted above, the incidence of refractoriness can be diminished in leukemia patients by employment of leukocyte-reduced rbc and platelets, and increasing evidence suggests that other cancer patients who are destined to require long term red cell and/or platelet support may also benefit from leukocyte-reduced blood components. Thrombopoietin and Platelet substitutes: The administration of cytokines, including IL-11 and a previously investigational thrombopoietin have been reported to diminish the requirement for platelet transfusion, however the efficacy of agents studied to date has been modest [10, 27, 115, 120, 224]. Two artificial thrombopoietins have recently been approved for the exclusive use in chronic ITP, but studies of one agent in myelodysplastic sydromes were associated with progression of disease, consequently it remains to be seen whether they can be effectively employed in other thrombocytopenic states [37, 81]. A variety of approaches are currently under investigation to create a ready supply of artificial platelets, including lyophilized platelets, platelet membranes, liposomes, RGD-coated rbc, fibrinogen-coated albumin microcapsules, and latex beads, however all are investigational at this time. [22, 79, 122, 216].

22.2.3 Granulocyte Transfusion in Patients with Cancer Neutropenic infection in cancer patients: Febrile neutropenia and infection is common in cancer patients, either due to the underlying disease, e.g. leukemia or to anti-neoplastic therapy that temporarily impairs marrow function. Neutropenia is the most frequent cause of treatment delay [202], and in one study occurred in approximately half the patients who received therapy for breast cancer [44]. Administration of hematopoietic growth factors may diminish the duration of

22 Hematologic Support of the Patient with Malignancy

neutropenia and hospitalization after chemotherapy (Ozer et al., 2000; Dale, 2002) [48, 52, 85, 202]. Predictive models for neutropenia have been reported that may facilitate the targeting of growth factor therapy to patients who are more likely to benefit from it [134]. Febrile neutropenia is frequently associated with microbial infection. Most patients with febrile neutropenia respond to adequate antibiotic or increasingly effective antifungal therapy and eventually recover marrow function [106, 233]. However some patients may have prolonged neutropenia and fail to respond to antimicrobial therapy or growth factor administration, which carries a high risk of mortality. Studies in the 1970s and 1980s have demonstrated that some infections in patients with prolonged neutropenia may respond to an intensive course of allogeneic granulocyte transfusion therapy [211]. Clinical trials of granulocyte transfusion have been largely limited to patients with bacterial sepsis, but anecdotal reports indicate that certain fungal infections may also respond to granulocyte transfusion [16, 190, 193, 211, 248]. Guidelines for granulocyte transfusion in cancer patients: The clinical utility of granulocyte transfusion is still controversial, despite the availability of seven controlled trials performed in febrile neutropenic patients. Three of the seven controlled trials of granulocyte transfusion demonstrated efficacy in clearing infection [102, 103, 234] and two trials showed partial efficacy in subgroups of patients who received at least 4 transfusions and/or had prolonged neutropenia [2, 91]. Two other controlled trials failed to demonstrate efficacy, but their study designs have been criticized on the basis that they employed a low dose of granulocytes [77, 227, 245]. Currently, granulocyte transfusion is typically employed in patients who have severe, prolonged neutropenia (usually less than 500– 1,000 neutrophils per microliter), documented bacterial or fungal infection, and have failed to respond to appropriate antimicrobials, and in whom recovery of neutrophil production is eventually expected [105, 106]. Anecdotal reports also describe successful outcomes after granulocyte transfusion therapy for patients who have congenital or acquired neutrophil dysfunction and who have infections that are unresponsive to antimicrobial and/or antifungal therapy [33, 165, 199, 248]. Enthusiasm for granulocyte transfusion waned during the past 20 years due to these inconsistent reports of the controlled trials, the difficulty in obtaining granulocytes, and to improvements

391

in antibiotic therapy. The advent of G-CSF treatment of donors to increase donor granulocyte counts has resulted in a resurgence in interest in this therapy [172]. Granulocyte components and administration: Granulocytes are harvested from single donors by leukapheresis and each bag or “unit” of apheresis granulocytes should contain at least 1 × 1010 neutrophils; however the product is not FDA licensed and there are no firm product or dose requirements. Apheresis Granulocytes that have been collected from donors who have received G-CSF may contain several-fold more granulocytes per unit compared with unstimulated donors [14, 128, 171, 172]. Apheresis Granulocytes may contain a therapeutic dose of platelets and are heavily contaminated with rbc (Hct from 10 to 25%) and therefore must be ABO compatible [212]. The CMV status of the donor is a consideration for CMV seronegative patients since administration of granulocytes is associated with a high incidence of CMV transmission. Likewise, patients who are alloimmunized to HLA antigens may have severe febrile reactions to granulocytes and the function of the transfused granulocytes may be impaired; consequently granulocytes from HLA matched donors may be indicated in such patients [1, 141, 212, 213]. Since granulocytes are typically administered to severely immunocompromized patients and have been implicated in cases of transfusion-associated graft vs. host disease, they are irradiated prior to transfusion [239]. Granulocytes are stored at room temperature and have a short life span. They should be transfused as soon as possible, and within 24 h after collection. For this reason they are generally administered prior to the completion of donor testing; consequently it is reasonable to employ donors who have recently been acceptable platelet donors. Given the short life span of granulocytes, they are collected on demand and may require 24–48 h to obtain. Donors are typically administered a single dose of corticosteroids (0.5–1 ml per kg of Prednisone or equivalent) 6–12 h prior to collection to increase their circulating granulocyte count and hence the number of granulocytes collected. The circulating and collected number of granulocytes, and their ex- and in-vivo life span are further increased 4 fold by administration of a single dose of granulocyte colony-stimulating factor (G-CSF, 5 micrograms per kg) to the donor 6–12 h prior to collection [171, 172]. Transfusion reactions are common in the recipient during granulocyte

392

administration and may be diminished by premedication of the patient with non-steroidal anti-inflammatory drugs (NSAIDs), Demerol, or steroids. Co-administration of granulocytes with amphotericin-B has been associated with severe pulmonary reactions in some reports, but not others [57, 65, 246]. Granulocytes are typically administered daily until at least 72 h after the infection is cleared, or the neutrophil count recovers, or it becomes clear that the patient is not responsive or will not recover marrow function [67, 171, 212]. Granulocyte administration typically does not result in an increase in the circulating granulocyte count of the recipient unless the granulocytes are obtained in high dose, e.g. from G-CSF stimulated donors [67, 105, 171]. While it seems intuitive that G-CSF stimulation of granulocyte donors, which results in the administration of a higher dose of granulocytes that have improved function and a longer circulating half-life should improve the outcome of granulocyte transfusion, there have been no controlled studies addressing this point [171]. An NIH-sponsored clinical trial that is currently in progress should answer this question.

22.2.4 Transfusion of Plasma and Coagulation Factor Concentrates in Patients with Cancer Hemostasis in cancer patients: Cancer has been characterized as a pre-thrombotic state [17]. Patients with both solid tumors and hematologic malignancy are subject to increased rates of deep vein thrombosis (DVT; approximately 8% vs. 2% in non cancer patients [191]), pulmonary embolism (up to a 6 fold higher incidence than patients without cancer [100, 168]), and disseminated intravascular coagulation (DIC) [17, 113, 125, 133, 181, 182, 191, 192]. Cancer patients comprise up to 20% of all patients with DVT, which is a frequent harbinger of malignancy [11, 133]. In addition, the treatment of malignancy may play a role in the pathogenesis of thromboembolism [133]. DVT has been reported to occur with increased frequency following chemotherapy, such as thalidomide therapy for multiple myeloma [17, 250, 251]. Hemostatic abnormalities are reported to be common in patients following allogeneic BMT and are associated with a poor prognosis [140, 166]. Specifically, veno-occulsive

T.A. Lane

disease of the liver occurs after BMT with a reported incidence ranging from 1 to 54% (presumably due to variable diagnostic criteria, patient selection, type of transplant, and conditioning regimen) and is associated with significant hemostatic abnormalities [12, 40, 114]. Thrombotic thrombocytopenic purpura (TTP) may occur in up to 6.8% of patients following allogeneic marrow transplantation (0.25% after autotransplant) and following drug therapy for malignancy [68, 78, 82, 107, 109, 162, 163, 187]. Associations between TTP and BMT include extensive prior therapy, female gender, use of an unrelated donor, use of cyclosporine or Tacrolimus, and GVHD, and a recent report suggested an association with colonization by H. pylori, presumably due to elevated levels of IL-8 and IL-12 [68, 187, 215]. In addition, disseminated intravascular coagulation (DIC) occurs with an increased frequency in cancer patients, approximately 7% in patients with solid tumors such as prostate and breast cancer [192], and in the majority of patients who present with acute promyelocytic leukemia [75, 113, 125, 192]. Guidelines for treatment of coagulopathy in cancer patients: Treatment of thrombocytopenia is discussed above. Treatment of a defined coagulopathy in cancer patients is guided by the same general principles that apply to non-cancer patients [156, 167]. Treatment or control of the underlying disorder is a major goal. Coagulation factor replacement therapy is indicated in bleeding patients or those who are scheduled for an invasive procedure who have a significant coagulopathy. A significant coagulopathy is typically defined by a prothrombin time or partial thromboplastin time at least 1.5 times the control value, or fibrinogen <150 mg/deciliter, or individual factor levels <25%. Mild DIC may be managed by institution of effective therapy for the neoplasm alone. If coagulation factor replacement therapy is indicated in DIC, fresh frozen plasma (FFP) may be employed to replace significant deficits of multiple coagulation factors [113, 125, 126, 192]. Cryoprecipitate (Cryo) may also be employed to replace combined severe deficits of fibrinogen and factor VIII, or commercially prepared virus-inactivated factor VIII concentrates may be employed to replace disproportionately severe deficits of factor VIII. There is no evidence to suggest that coagulation factor replacement in DIC may be harmful by “adding fuel to the fire” [126]. As in non-cancer patients, if DIC is due to sepsis, evidence suggests that the outcome of DIC may be improved by administration of activated

22 Hematologic Support of the Patient with Malignancy

protein C [15, 72, 192, 232]. Patients who have developed TTP after marrow transplantation or cancer chemotherapy are generally treated by plasmapheresis and volume replacement with FFP, however few patients respond or achieve sustained responses and the outcome of TTP after BMT is generally poor [78, 82, 107, 109, 163, 187]. While anecdotal reports suggest that Cryo-poor supernatant improves upon the therapy of TTP compared with FFP, a small controlled trial failed to demonstrate any advantage to the use of Cryopoor supernatant in TTP therapy compared with use of FFP [252]. The poor response of BMT-associated TTP to standard therapy may be due in part to the fact that TTP after BMT does not appear to be associated with an autoantibody to ADAMTS-13; consequently the rationale for replacing this enzyme is less well established, and the etiology of TTP following BMT remains unclear [15, 68, 253]. Plasma Components: FFP is prepared in 220 ml bags of fresh citrated plasma that is frozen within 8 h of collection and contains approximately 1 unit/ml of each coagulation factor and 400–600 mg of fibrinogen. Administration of single bag of FFP typically increases the plasma level of each coagulation factor by 7% and the dose is typically 15–20 ml per kg. However, correction of a PT that is prolonged due to factor VII deficiency will be short lived, due to the brief halflife of factor VII in circulation (approximately 6 h). Frozen plasma (FP) is increasingly supplied instead of FFP and differs only in that it must be frozen within 8–24 h of collection and contains about 15–25% less factor VIII compared with FFP. Thawed plasma (TP) is FFP or FP that has been thawed and maintained at 4ºC for up to 5 days. TP contains about 15–25% less factor V and 25–35% less Factor VIII than FFP. Widespread experience shows that FFP, FP, and TP may be used interchangeably for the vast majority of clinical indications for plasma. TP has the advantage in surgery of being immediately available. FP and TP are not indicated to replace Factor VIII, but even FFP is not the preferred product for that indication, which calls for a commercial Factor VIII concentrate. Some institutions also prohibit the use of TP for neonates. Cryoprecipitate (Cryo) is made by slowly thawing a unit of FFP, reserving the precipitate that remains in a volume of 20 ml plasma, and refreezing it. Thus, each bag or “unit” of Cryo contains 200– 300 mg fibrinogen, 80–100 U of Factor VIII, 80 U of von Willebrand’s Factor, and 40–60 U of Factor

393

XIII. Commercially available coagulation factor concentrates that have been treated to be non-infectious for HIV and hepatitis are available to treat VIII deficiency, and some contain effective quantities of von Willebrand’s Factor (Humate P and Alphanate), and are therefore the drugs of choice for these conditions. Cryo contains insignificant amounts of other coagulation factors. Cryoprecipitate is supplied in a volume of 15–20 ml/bags. One bag of Cryo may be expected to increase the fibrinogen in an adult by 20 mg/dL. Since the critical level of fibrinogen for hemostasis is approximately 100 mg/dL, then a reasonable starting dose of Cryo to treat fibrinogen deficiency would be 10–15 bags of Cryo, or 1 bag/5 kg. Commercial factor concentrates are supplied in a wide variety of doses that must be reconstituted immediately prior to use. Administration of Antithrombin III patients with sepsis, who frequently have evidence of intravascular coagulation, was recently demonstrated to be ineffective in improving survival in a large randomized trial, however administration of Activated Protein C was recently reported to improve survival in this setting, suggesting the possibility that it may be effective treating DIC [95, 238].

22.3 Transfusion Risks Unique to Cancer Patients 22.3.1 Introduction Transfusion may be associated with a variety of adverse effects. It has been estimated that one in 3000 blood recipients will suffer a serious or fatal adverse effect after blood transfusion, in contrast to one in 167 hospitalized patients who are not transfused and will suffer a serious or fatal iatrogenic event [61]. Adverse effects that occur during or shortly after transfusion, i.e. “transfusion reactions” include allergic, febrile, hemolytic, and septic reactions, and also circulatory overload, and transfusion-related acute lung injury. Transfusion rate-related reactions include circulatory overload and rarely hypocalcemia or hyperkalemia. Adverse effects may be delayed for days, months, or years and include delayed hemolytic reactions, Graft vs. Host disease, viral infection, iron overload, immune suppression. An estimate of current transfusion risks is given on Table 22.1. A full description and discussion

394

T.A. Lane

Table 22.1 Estimates of the frequency of some adverse effects of blood transfusion (A) Infectious Risks Infection Viral hepatitis: HAV HBV HCV HDV HGV HIV-1/2 HTLV-I/II CMV

Epstein-Barr virus Bacterial sepsis Malaria, Chagas and other parasitic diseases Lyme disease Syphilis B 19 parvovirus West Nile Virus ∗ For

Risk per unit

Blood donor testing

rare 1 in 220,000 1 in 1.6 million rare 1 in 100 1 in 1.8 million 1 in 2.9 million ∼ 7 in 100 all donors 1–2 in 100 (leukocyte-reduced or blood from CMV seronegative donor) 1 in 200 (seroconversion) RBC – 1 in 30,000 PLT – 1 in 75,000∗ Rare (<1 in 1,000,000)

Donors screened for recent HAV by history HBV surface antigen, core antibody and soon, NAT HCV antibody and nucleic acid test (NAT) HDV not tested HGV not tested HIV-1 and 2 antibody and NAT HTLV-I and II antibody Untested for CMV CMV serology tested on demand; Leukocyte-reduced blood is considered CMV-safe

Rare Rare Unknown Unknown

Donors not tested RPR or VDRL Donors not tested NAT testing

EBV not tested RBC not tested PLT cultured or tested by other means Donors not tested (Chagas testing is investigational)

an adult, one transfusion consists of 1 unit of apheresis platelets or 6 platelet concentrate (∼1 U/kg)

(B). Non infectious risks Adverse effect

Risk/unit

Comments

Acute hemolytic reaction

1 in 25,000–50,000

Delayed hemolytic reaction

1 in 2,500 clincal 1 in 200 subclinical 1 in 10 transfusions (non-leukocyte reduced)

Majority of cases due to patient identification error in drawing patient’s blood specimen or giving blood. Most involve ABO mismatch; 10–20% are fatal. Occurs 4–14 days after transfusion. Usually clinically silent, evident from dropping Hct and serological findings. Refractory state to platelet transfusion; usually due to anti-HLA antibodies. Minimize or prevent by leukocyte-reduced platelets. Leukocytes are major cause; previous donor history of multiple transfusions or pregnancy. Minimize and/or prevent by leukocyte-reduced blood components. Non-cardiogenic pulmonary edema due to high-titer leukocyte antibody in donor (or rarely recipient) plasma. 5–10% are fatal. Urticaria, usually with plasma containing components. Classically in IgA deficient patient (1 in 600) who has formed anti-IgA reacting with IgA in blood products, but most cases are not IgA deficient. Use washed RBC; pre-Rx with steroid. Problem in multiple RBC recipient, Sickle-cell anemia, thalassemia, etc. Problem in patients with severe immunodeficiency, marrow transplant, and recipients of blood from family members (not reported in HIV). Prevent by blood irradiation Infants and patients over 60 usually involved. Prevention depends on clinical judgment. Use PRC and controlled rates of infusion. Premature hyperkalemic newborns and anhepatic phase of liver transplant surgery Premature newborns and occasionally other massively transfused patients. Use blood warmer. Massive transfusion, e.g. more than 1 unit q 5 min.

Platelet alloimmunization to HLA Febrile, non-hemolytic reaction

1 in 200

Transfusion Related Acute lung injury (TRALI)

1 in 5,000–10,000

Allergic reactions Anaphylactic hypotensive reaction

1 in 200 1 in 50,000–150,000

Red cell alloimmunization

1 in 100

Graft vs. Host disease

Rare

Circulatory overload

1 in 1,000–10,000

Hyperkalemia

Unknown

Hypothermia

Unknown

Citrate toxicity

Unknown

22 Hematologic Support of the Patient with Malignancy

of all transfusion reactions is beyond the scope of this chapter and has been the subject of recent reviews [34, 104, 110, 242, 228]. However, patients with hematologic malignancy and less commonly lymphoma and solid tumors are uniquely susceptible to infection with cytomegalovirus and to transfusion-transmitted graft vs. host disease and will be discussed in more detail below.

22.3.2 Cytomegalovirus Infection Cytomegalovirus (CMV) is transmissible through transfusion of cellular blood components such as red blood cells, whole blood, red cells, platelets, and especially granulocytes, but not through acellular blood components such as FFP or Cryo, presumably due to latent CMV infection in leukocytes that are present in cellular components [28]. The risk of transmission of CMV infection by transfusion of randomly selected non-leukocyte-reduced units of blood and/or platelets to CMV seronegative medical and surgical patients has been reported to range from 16 to 67% of blood recipients [169, 218]. This variability is in part due to the wide range of CMV infection in blood donors in different areas. CMV infection is either asymptomatic or causes a mild mononucleosis-like syndrome in persons with normal immune status. Severe CMV disease is rare in patients treated for hematologic malignancy or solid tumors in the absence of marrow transplantation or severe immune suppression [31, 135, 170, 222]. However, allogeneic marrow transplant patients are at risk for serious CMV infection, principally pneumonitis, hepatitis, gastroenteritis, and marrow suppression. The risk of CMV infection after allogeneic bone marrow transplant prior to the use of pre-emptive therapy with gancyclovir was reported to be between 28 and 57% in CMV seronegative patients with seronegative donors who received CMV unscreened blood and was associated with severe pulmonary, hepatic, or gastrointestinal disease in up to 30% of patients [142, 146]. Administration of blood from CMVseropositive donors is a risk factor for CMV infection in CMV-seronegative marrow transplant patients, but not those who are CMV-seropositive or have a CMVseropositive donor [30, 147]. The incidence of CMV infection after autologous BMT is reported to be similar to that after allogeneic BMT, but infection leads to less severe outcomes [243]. In view of the above,

395

allogeneic marrow transplant patients who are CMVseronegative and have CMV-seronegative donors, and CMV-seronegative autologous transplant patients are deemed to be at risk for transfusion-transmitted CMV infection and efforts are made to prevent this occurrence. In randomized studies, the administration of cellular blood products from CMV-seronegative blood donors and/or the use of leukocyte-reduced blood have been reported to decrease the incidence of transfusionassociated CMV infection to 1–4% in CMV seronegative allogeneic transplant recipients who have CMVseronegative donors [29, 30]. The landmark studies by Bowden, et al and a host of similar retrospective studies led to the widespread use of leukocyte-reduced blood as equivalent to blood from CMV-seronegative donors to prevent CMV disease (the former referred to as “CMV-safe” blood) [173, 178]. This practice has recently been questioned by the publication of a retrospective study whose results suggested that the use of leukocyte-reduced blood was less effective in preventing CMV infection and disease than blood from CMV-seronegative donors, however neither strategy was 100% effective, perhaps due to transient CMV viremia in blood donors [63, 153]. It appears that additional studies may be necessary to resolve the issue of the equivalency of blood from CMV-seronegative donors vs. random, leukocyte-reduced blood, but are unlikely to be performed. These considerations support the continued monitoring of allogeneic marrow transplant patients for CMV infection or activation. The routine use of CMV-safe blood in other patients with malignancy is less compelling, since CMV infection results in mild symptoms.

22.3.3 Transfusion Associated Graft vs. Host Disease (TA-GVHD) TA-GVHD is a rare disease, but certain individuals are uniquely susceptible to it. Freshly collected cellular blood products (red cells, platelets, granulocytes) contain up to 5 × 109 leukocytes of which a proportion corresponding to that in the donor are lymphocytes and granulocyte concentrates may contain 10-fold more. The viability of lymphocytes decreases steadily during liquid storage at 4 degrees Centigrade and random donor leukocytes typically have a brief intravascular life span after transfusion to normal

396

individuals. However, donor lymphocytes may survive and proliferate and may give rise to TA-GVHD in immunocompromized patients (e.g. patients with leukemia, lymphoma, marrow transplant, congenital immune deficiency, and fetuses and premature newborns), in patients who receive blood from family members or HLA-matched donors, and in recipients of fludarabine, clofarabine and rarely after other highly immunosuppressive chemotherapy regimens [3, 4, 14, 124, 154, 197, 201]. HIV infection is not a risk factor for TA-GVHD, presumably due to the destruction of donor lymphocytes by HIV. There is no clear threshold dose of lymphocytes required to initiate TA-GVHD and this complication has been reported in association with the administration of leukocyte-reduced blood. The clinical features of TA-GVHD are generally similar to those of GVHD in the setting of allogeneic marrow transplantation with some important exceptions. First, TA-GVHD is associated with acute, severe, refractory aplastic anemia in addition to skin, gut, and hepatic involvement. Second, perhaps in part due to severe aplastic anemia, TA-GVHD is an almost uniformly rapidly fatal disease [108]. The onset of TA-GVHD is also somewhat earlier (as early as 4 days after transfusion), with a median of 10 days. Fortunately TA-GVHD is readily preventable through the irradiation of all cellular blood components with 2500 cGy of gamma irradiation [151]. The duration of susceptibility to TA-GVHD in patients with the above diseases (except newborns) is unknown and is commonly deemed to be indefinite, along with the need to irradiate blood components. Therapy for TA-GVHD has been almost uniformly dismal, with single case reports of success due to the fortuitous availability of and autologous hematopoietic stem cell graft and after combined cyclosporine and anti-CD3 monoclonal antibody (OKT3) or combined antithymocyte globulin and steroids [108, 197].

22.3.4 The Physician’s Role in Transfusion Safety Whether or not they are aware of it, physicians directly influence the level of transfusion safety experienced by their patients, firstly by employing appropriate transfusion therapy. For example, patients who are destined to receive prolonged transfusion support may directly

T.A. Lane

benefit from the uniform use of leukocyte-reduced blood, both through prevention of CMV infection and by diminishing the likelihood of alloimmunization to leukocytes, which may eliminate transfusion reactions and platelet refractoriness. Likewise the judicious use of platelet transfusion and the employment of leukocyte-reduced apheresis platelets may diminish donor exposures and minimize alloimmunization to leukocytes. Similarly, the appropriate diagnosis and management of coagulopathies will minimize the exposure to FFP and/or Cryo. Next, the use of transfusion alternatives, such as recombinant human erythropoietin, colony stimulating factors, and DDAVP has been demonstrated to achieve therapeutic goals and diminish transfusion requirements. Finally, most serious or fatal transfusion reactions are due to failure to identify the patient at the time a blood specimen is obtained for blood typing and at the time blood is administered. Physicians play a vital role in supporting the uniform adherence to patient care safety standards and setting an example of in their own practice.

22.4 Future Directions Current investigation will lead to additional opportunities to improve the safety and efficacy of hematological support for cancer patients. First, improvements in targeted therapy for an increasing array of malignancies may serve to diminish marrow toxicity by circumventing the need for classical cytotoxic chemotherapy that impairs marrow function. Second, while recent progress has been limited, the eventual approval of artificial blood substitutes will diminish short term (e.g. intra-operative or emergency) requirements for red cell transfusion. Platelet substitutes are also under investigation. Continuing investigation of human recombinant proteins that ameliorate blood loss with suboptimal platelet counts, e.g. human recombinant factor VIIa may define specific indications. Agents or growth factors that alter the procoagulant state in cancer patients, or protect vascular endothelium or promote its regrowth may diminish the likelihood of DIC, VOD and diminish platelet destruction. The development of culture methods to artificially grow pharmacologic doses of immune cells and perhaps also red cells and platelets, is under active investigation. Third, the development of an indication for recently approved

22 Hematologic Support of the Patient with Malignancy

thrombopoietic agents in post-chemotherapy patients may further limit the need for platelet transfusion after chemotherapy. Fourth the safety of blood components will be improved by the development of improved methods to screen blood donors or their donated components for infectious diseases. Examples include the recent initiation of testing donors for West Nile virus, the successful initiative to diminish transfusionassociated sepsis by testing of platelets and the more recent initiative to reduce transfusion-related acute lung injury by restricting plasma donations by highrisk donors. In the near future, an improved method to screen blood donors for hepatitis B, which is currently the highest risk serious transfusion-transmitted viral infection, will be implemented. Additional tests for new infectious threats can likewise be anticipated. Fifth, continuing investigation of methods to inactivate microbes, first in FFP and platelets, and later in red cells will also limit transfusion risks in the future and such methods have already been approved for use in Europe. Importantly, the increasing employment of automated methods to positively identify patients during blood specimen acquisition and blood administration, and improved methods of laboratory testing for alloantibodies will improve overall transfusion safety. Finally, the AABB, in association with the CDC is implementing a nationwide “hemovigilance” program in the USA, similar to that in the UK and France, that will provide essential information regarding the risks of transfusion. This information will provide a basis to prioritize both nationals goal and research toward improving the safety of blood transfusion. Thus, the hematologic support of patients with malignancy with donor-derived, perishable, and to some extent risky blood components will be required for the foreseeable future, but should become increasingly efficacious and safe through continued research and development efforts.

References 1. Adkins DR, Goodnough LT, Shenoy S, Brown R, Moellering J, Khoury H et al (2000) Effect of leukocyte compatibility on neutrophil increment after transfusion of granulocyte colony-stimulating factor-mobilized prophylactic granulocyte transfusions and on clinical outcomes after stem cell transplantation. Blood 95:3605–3612 2. Alavi JB, Root RK, Djerassi I, Evans AE, Gluckman SJ, MacGregor RR et al (1977) A randomized clinical trial of

397

3. 4.

5.

6.

7.

8.

9.

10. 11. 12.

13.

14.

15.

16.

17. 18.

19.

20.

granulocyte transfusions for infection in acute leukemia. N Engl J Med 296:706–711 Anderson KC, Braine HG (1990) Specialized cell component therapy. Semin Oncol Nurs 6:140–149 Anderson K (2003) Broadening the spectrum of patient groups at risk for transfusion-associated GVHD: implications for universal irradiation of cellular blood components. Transfusion 43:1652–1654 Andreu G, Dewailly J, Leberre C, Quarre MC, Bidet ML, Tardivel R et al (1988) Prevention of HLA immunization with leukocyte-poor packed red cells and platelet concentrates obtained by filtration. Blood 72:964–969 AuBuchon JP, Elfath MD, Popovsky MA, Stromberg RR, Pickard C, Herschel L et al (1997) Evaluation of a new prestorage leukoreduction filter for red blood cell units. Vox Sanguinis 72:101–106 Avvisati G, Tirindelli MC, Annibali O (2003) Thrombocytopenia and hemorrhagic risk in cancer patients. Crit Rev Oncol/Hematol 48, S13–S16 Baldwin ML, Ness PM, Scott D, Braine H, Kickler TS (1988) Alloimmunization to D antigen and HLA in D-negative immunosuppressed oncology patients. Transfusion 28:330–333 Bartley AN, Carpenter JB, Berg MP (2009) D+ platelet transfusions in D- patients: cause for concern? Immunohematology 25(1):5–8 Basser R (2002) The impact of thrombopoietin on clinical practice. Curr Pharm Des 8:369–377 Bates SM, Ginsberg JS (2004) Treatment of deep-vein thrombosis. N Engl J Med 351:268–277 Bearman SI (1995) The syndrome of hepatic venoocclusive disease after marrow transplantation. Blood 85:3005–3020 Bennett CL, Silver SM, Djulbegovic B et al (2008) Venous thromboembolism and mortality associated with recombinant erythropoietin and darbepoetin administration for the treatment of cancer-associated anemia. JAMA 299(8):914–924 Benson K, Marks AR, Marshall MJ, Goldstein JD (1994) Fatal graft-versus-host disease associated with transfusions of HLA-matched, HLA-homozygous platelets from unrelated donors. Transfusion 34:432–437 Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A et al (2001) Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 344:699–709 Bhatia S, McCullough J, Perry EH, Clay M, Ramsay NK, Neglia JP (1994) Granulocyte transfusions: efficacy in treating fungal infections in neutropenic patients following bone marrow transplantation. Transfusion 34: 226–232 Bick RL (2003) Cancer-associated thrombosis. N Engl J Med 349:109–111 Bishop JF, Matthews JP, McGrath K, Yuen K, Wolf MM, Szer J (1991) Factors influencing 20-hour increments after platelet transfusion. Transfusion 31:392–396 Bishop JF, Matthews JP, Yuen K, McGrath K, Wolf MM, Szer J (1992) The definition of refractoriness to platelet transfusions. Transfus Med 2:35–41 Bishop JF, McGrath K, Wolf MM, Matthews JP, De Luise T, Holdsworth R et al (1988) Clinical factors

398

21. 22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32. 33.

34.

35.

36.

T.A. Lane influencing the efficacy of pooled platelet transfusions. Blood 71:383–387 Blajchman MA (2002) Immunomodulation and blood transfusion. Am J Ther 9:389–395 Blajchman MA (2003) Substitutes and alternatives to platelet transfusions in thrombocytopenic patients. J Thromb Haemost 1:1637–1641 Blay JY, Le Cesne A, Mermet C, Maugard C, Ravaud A, Chevreau C et al (1998) A risk model for thrombocytopenia requiring platelet transfusion after cytotoxic chemotherapy. Blood 92:405–410 Blumberg N (1998) Perioperative allogeneic blood transfusion does not cause adverse sequelae in patients with cancer: a meta-analysis of unconfounded studies. Br J Surg 85:1163–1164 Blumberg N, Heal JM (1994) Perioperative blood transfusion and colorectal cancer recurrence. Transfusion 34:450–452 Bortul M, Calligaris L, Roseano M, Leggeri A (2003) Blood transfusions and results after curative resection for gastric cancer. Suppl Tumori 2:S27–S30 Bosanquet N, Tolley K (2003) Treatment of anaemia in cancer patients: implications for supportive care in the national health service cancer plan. Curr Med Res Opin 19:643–650 Bowden R, Sayers M (1990) The risk of transmitting cytomegalovirus infection by fresh frozen plasma. Transfusion 30:762–763 Bowden RA, Slichter SJ, Sayers M, Weisdorf D, Cays M, Schoch G et al (1995) A comparison of filtered leukocyte-reduced and cytomegalovirus (CMV) seronegative blood products for the prevention of transfusionassociated CMV infection after marrow transplant. Blood 86:3598–3603 Bowden RA, Slichter SJ, Sayers MH, Mori M, Cays MJ, Meyers JD (1991) Use of leukocyte-depleted platelets and cytomegalovirus-seronegative red blood cells for prevention of primary cytomegalovirus infection after marrow transplant. Blood 78:246–250 Breathnach O, Donnellan P, Collins D, McNicholas W, Crown J (1999) Cytomegalovirus pneumonia in a patient with breast cancer on chemotherapy: case report and review of the literature. Ann Oncol 10: 461–465 Bron D, Meuleman N, Mascaux C (2001) Biological basis of anemia. Semin Oncol 28:1–6 Brzica SM Jr, Pineda AA, Taswell HF, Rhodes KH (1977) Chronic granulomatous disease and the Mcleod phenotype. Successful treatment of infection with granulocyte transfusions resulting in subsequent hemolytic transfusion reaction. Mayo Clin Proc 52:153–156 Busch MP (2001) Insights into the epidemiology, natural history and pathogenesis of hepatitis C virus infection from studies of infected donors and blood product recipients. Transfus Clin Biol 8:200–206 Busch OR, Hop WC, Marquet RL, Jeekel J (1993) Prognostic impact of blood transfusions on disease-free survival in colorectal carcinoma. Scand J Gastroenterol Suppl 200:21–23 Busch OR, Hop WC, Marquet RL, Jeekel J (1994) Blood transfusions and local tumor recurrence in colorectal

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50. 51.

52.

cancer. Evidence of a noncausal relationship. Ann Surg 220:791–797 Bussel J, Kuter D, Pullarkat V, Lyons R, Guo M, Nichol J (2009) Safety and efficacy of long-term treatment with romiplostim in thrombocytopenic patients with chronic ITP. Blood 113:2161–2171 Calhoun EA, Chang CH, Welshman EE, Fishman DA, Lurain JR, Bennett CL (2001) Evaluating the total costs of chemotherapy-induced toxicity: results from a pilot study with ovarian cancer patients. Oncologist 6:441–445 Cantor SB, Hudson DV Jr, Lichtiger B, Rubenstein EB (1998) Costs of blood transfusion: a process-flow analysis. J Clin Oncol 16:2364–2370 Carreras E (2000) Veno-occlusive disease of the liver after hemopoietic cell transplantation. Eur J Haematol 64: 281–291 Caspar CB, Seger RA, Burger J, Gmur J (1993) Effective stimulation of donors for granulocyte transfusions with recombinant methionyl granulocyte colony-stimulating factor. Blood 81:2866–2871 Cella D, Bron D (1999) The effect of Epoetin alfa on quality of life in anemic cancer patients. Cancer Pract 7:177–182 Cella D, Viswanathan H, Hays R et al (2008) Development of a fatigue and functional impact scale (FFIS) in anemic cancer patients receiving chemotherapy. Cancer 113(6):1480–1488 Chang J (2000) Chemotherapy dose reduction and delay in clinical practice: evaluating the risk to patient outcome in adjuvant chemotherapy for breast cancer. Eur J Cancer 36:11–14 Chiavetta JA, Herst R, Freedman J, Axcell TJ, Wall AJ, Rooy SC (1996) A survey of red cell use in 45 hospitals in central Ontario, Canada. Transfusion 36:699–706 Chow E, Danjoux CE, Pataki I, Franssen E, Jenkin RD (1999) Effect of hemoglobin on radiotherapy response in children with medulloblastoma: should patients with a low hemoglobin be transfused? Med Pediatr Oncol 32:395–397 Cid J, Ortin X, Elies E, Castella D, Panades M, MartinVega C (2002) Absence of anti-D alloimmunization in hematologic patients after D-incompatible platelet transfusions. Transfusion 42:173–6 Clark OA, Lyman G, Castro AA, Clark LG, Djulbegovic B (2003) Colony stimulating factors for chemotherapy induced febrile neutropenia. Cochrane Database Syst Rev CD003039 Coiffier B, Guastalla JP, Pujade-Lauraine E, Bastit P (2001) Predicting cancer-associated anaemia in patients receiving non-platinum chemotherapy: results of a retrospective survey. Eur J Cancer 37:1617–1623 Cole PD, Adam HM (2009) Hematopoietic growth factors in pediatric patients. Pediatr Rev 30(1):30–31 Crawford J, Cella D, Cleeland CS, Cremieux PY, Demetri GD, Sarokhan BJ et al (2002) Relationship between changes in hemoglobin level and quality of life during chemotherapy in anemic cancer patients receiving epoetin alfa therapy. Cancer 95:888–895 Crawford J, Dale DC, Lyman GH (2004) Chemotherapyinduced neutropenia: risks, consequences, and new directions for its management. Cancer 100:228–237

22 Hematologic Support of the Patient with Malignancy 53. Cremieux PY, Barrett B, Anderson K, Slavin MB (2000) Cost of outpatient blood transfusion in cancer patients. J Clin Oncol 18:2755–2761 54. Cullis JO, Duncombe AS, Dudley JM, Lumley HS, Apperley JF, Smith AG (1998) Acute leukaemia in Jehovah’s Witnesses. Br J Haematol 100:664–668 55. Dale DC (2002) Colony-stimulating factors for the management of neutropenia in cancer patients. Drugs 62(1):1–15 56. Dan ME, Schiffer CA (2003) Strategies for managing refractoriness to platelet transfusions. Curr Hematol Rep 2:158–164 57. Dana BW, Durie BG, White RF, Huestis DW (1981) Concomitant administration of granulocyte transfusions and amphotericin B in neutropenic patients: absence of significant pulmonary toxicity. Blood 57:90–94 58. Demetri GD (2001) Targeted approaches for the treatment of thrombocytopenia. Oncologist 6:15–23 59. Demetri GD, Kris M, Wade J, Degos L, Cella D (1998) Quality-of-life benefit in chemotherapy patients treated with epoetin alfa is independent of disease response or tumor type: results from a prospective community oncology study. Procrit Study Group. J Clin Oncol 16: 3412–3425 60. Dicato M (2003) Anemia in cancer: some pathophysiological aspects. Oncologist 8:19–21 61. Dodd RY (1992) The risk of transfusion-transmitted infection. N Engl J Med 327:419–421 62. Dougenis D, Patrinou V, Filos KS, Theodori E, Vagianos K, Maniati A (2001) Blood use in lung resection for carcinoma: perioperative elective anaemia does not compromise the early outcome. Eur J Cardiothorac Surg 20:372–377 63. Drew WL, Tegtmeier G, Alter HJ, Laycock ME, Miner RC, Busch MP (2003) Frequency and duration of plasma CMV viremia in seroconverting blood donors and recipients. Transfusion 43:309–313 64. Dunphy EP, Petersen IA, Cox RS, Bagshaw MA (1989) The influence of initial hemoglobin and blood pressure levels on results of radiation therapy for carcinoma of the prostate. Int J Radiat Oncol Biol Phys 16: 1173–1178 65. Dutcher JP, Kendall J, Norris D, Schiffer C, Aisner J, Wiernik PH (1989) Granulocyte transfusion therapy and amphotericin B: adverse reactions? Am J Hematol 31:102–108 66. Dutcher JP, Schiffer CA, Aisner J, O’Connell BA, Levy C, Kendall JA et al (1984) Incidence of thrombocytopenia and serious hemorrhage among patients with solid tumors. Cancer 53:557–562 67. Einsele H, Northoff H, Neumeister B (2004) Granulocyte transfusion. Vox Sanguinis 87:205–208 68. Elliott MA, Nichols WL Jr, Plumhoff EA, Ansell SM, Dispenzieri A, Gastineau DA et al (2003) Posttransplantation thrombotic thrombocytopenic purpura: a single-center experience and a contemporary review. Mayo Clin Proc 78:421–430 69. Elting LS, Cantor SB, Martin CG, Hamblin L, Kurtin D, Rivera E et al (2003) Cost of chemotherapy-induced thrombocytopenia among patients with lymphoma or solid tumors. Cancer 97:1541–1550

399 70. Elting LS, Martin CG, Kurtin DJ, Cantor SB, Rubenstein EB, Rodriguez S et al (2002) The Bleeding Risk Index: a clinical prediction rule to guide the prophylactic use of platelet transfusions in patients with lymphoma or solid tumors. Cancer 94:3252–3262 71. Elting LS, Rubenstein EB, Martin CG, Kurtin D, Rodriguez S, Laiho E et al (2001) Incidence, cost, and outcomes of bleeding and chemotherapy dose modification among solid tumor patients with chemotherapy-induced thrombocytopenia. J Clin Oncol 19:1137–1146 72. Ely EW, Laterre PF, Angus DC, Helterbrand JD, Levy H, Dhainaut JF et al (2003) Drotrecogin alfa (activated) administration across clinically important subgroups of patients with severe sepsis. Crit Care Med 31:12–19 73. Enright H, Davis K, Gernsheimer T, McCullough JJ, Woodson R, Slichter SJ (2003) Factors influencing moderate to severe reactions to PLT transfusions: experience of the TRAP multicenter clinical trial. Transfusion 43: 1545–1552 74. Estrin JT, Schocket L, Kregenow R, Henry DH (1999) A retrospective review of blood transfusions in cancer patients with anemia. Oncologist 4:318–324 75. Falanga A, Rickles FR (2003) Pathogenesis and management of the bleeding diathesis in acute promyelocytic leukaemia. Best Pract Res Clin Haematol 16:463–482 76. Ferrara JL (1995) The febrile platelet transfusion reaction: a cytokine shower. Transfusion 35:89–90 77. Fortuny IE, Bloomfield CD, Hadlock DC, Goldman A, Kennedy BJ, McCullough JJ (1975) Granylocyte transfusion: a controlled study in patients with acuute nonlymphocytic leukemia. Transfusion 15:548–558 78. Fuge R, Bird JM, Fraser A, Hart D, Hunt L, Cornish JM et al (2001) The clinical features, risk factors and outcome of thrombotic thrombocytopenic purpura occurring after bone marrow transplantation. Br J Haematol 113:58–64 79. Galan AM, Casals E, Estelrich J, Hernandez MR, Bozzo J, Reverter J et al (2002) Possible hemostatic effect of synthetic liposomes in experimental studies under flow conditions. Haematologica 87:615–623 80. Gaydos LA, Freireich EJ, Mantel N (1962) The quantitative relation between platelet count and hemorrhage in patients with acute leukemia. N Engl J Med 266:905–909 81. George J, Terrell D (2008) Novel thrombopoietic agents: a new era for management of patients with thrombocytopenia. Haematologica 93(10):1445–1449 82. Gharpure VS, Devine SM, Holland HK, Geller RB, O’Toole K, Wingard JR (1995) Thrombotic thrombocytopenic purpura associated with FK506 following bone marrow transplantation. Bone Marrow Transplant 16: 715–716 83. Glaser CM, Millesi W, Kornek GV, Lang S, Schull B, Watzinger F et al (2001) Impact of hemoglobin level and use of recombinant erythropoietin on efficacy of preoperative chemoradiation therapy for squamous cell carcinoma of the oral cavity and oropharynx. Int J Radiat Oncol Biol Phys 50:705–715 84. Glaspy J, Bukowski R, Steinberg D, Taylor C, Tchekmedyian S, Vadhan-Raj S (1997) Impact of therapy with epoetin alfa on clinical outcomes in patients with nonmyeloid malignancies during cancer chemotherapy in community oncology practice. Procrit study group. J Clin Oncol 15:1218–1234

400 85. Glaspy JA (2003) Hematopoietic management in oncology practice. Part 1. Myeloid growth factors. Oncology (Huntingt) 17:1593–1603 86. Glaspy JA (2003) Hematopoietic management in oncology practice. Part 2. Erythropoietic factors. Oncology (Huntingt) 17:1724–1730 87. Goldberg GL, Gibbon DG, Smith HO, DeVictoria C, Runowicz CD, Burns ER (1994) Clinical impact of chemotherapy-induced thrombocytopenia in patients with gynecologic cancer. J Clin Oncol 12:2317–2320 88. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP (1999) Transfusion medicine. First of two parts – blood transfusion. N Engl J Med 340:438–447 89. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP (1999) Transfusion medicine. Second of two parts – blood conservation. N Engl J Med 340:525–533 90. Gould SA, Moore EE, Hoyt DB, Burch JM, Haenel JB, Garcia J et al (1998) The first randomized trial of human polymerized hemoglobin as a blood substitute in acute trauma and emergent surgery. J Am Coll Surg 187: 113–120 91. Graw RG Jr, Herzig G, Perry S, Henderson ES (1972) Normal granulocyte transfusion therapy: treatment of septicemia due to gram-negative bacteria. N Engl J Med 287:367–371 92. Grogan M, Thomas GM, Melamed I, Wong FL, Pearcey RG, Joseph PK et al (1999) The importance of hemoglobin levels during radiotherapy for carcinoma of the cervix. Cancer 86:1528–1536 93. Groopman JE, Itri LM (1999) Chemotherapy-induced anemia in adults: incidence and treatment. J Natl Cancer Inst 91:1616–1634 94. Haem BJ (ed) (2003) Guidelines for the use of platelet transfusions. Br J Haematol 122:10–23 95. Hambleton J, Leung LL, Levi M (2002) Coagulation: consultative hemostasis. Hematology (Am Soc Hematol Educ Program) 335–352 96. Heddle NM (2004) Universal leukoreduction and acute transfusion reactions: putting the puzzle together. Transfusion 44:1–4 97. Heddle N, Cook R, Tinmouth A et al (2009) A randomized controlled trial comparing standard- and low-dose strategies for transfusion of platelets (SToP) to patients with thrombocytopenia. Blood 113:1564–1573 98. Heddle NM, Klama L, Singer J, Richards C, Fedak P, Walker I et al (1994) The role of the plasma from platelet concentrates in transfusion reactions. N Engl J Med 331:625–628 99. Heiss MM, Mempel W, Delanoff C, Jauch KW, Gabka C, Mempel M et al (1994) Blood transfusion-modulated tumor recurrence: first results of a randomized study of autologous versus allogeneic blood transfusion in colorectal cancer surgery. J Clin Oncol 12:1859–1867 100. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ III (2000) Risk factors for deep vein thrombosis and pulmonary embolism: a populationbased case-control study. Archiv Intern Med 160: 809–815 101. Henke M, Laszig R, Rube C, Schafer U, Haase KD, Schilcher B et al (2003) Erythropoietin to treat head and neck cancer patients with anaemia undergoing

T.A. Lane

102.

103.

104.

105.

106.

107.

108.

109.

110. 111.

112.

113.

114.

115. 116.

radiotherapy: randomised, double-blind, placebocontrolled trial. Lancet 362:1255–1260 Herzig RH, Herzig GP, Graw RG Jr, Bull MI, Ray KK (1977) Successful granulocyte transfusion therapy for gram-negative septicemia. A prospectively randomized controlled study. N Engl J Med 296:701–705 Higby DJ, Yates JW, Henderson ES, Holland JF (1975) Filtration leukapheresis for granulocyte transfusion therapy. Clinical and laboratory studies. N Engl J Med 292:761–766 Hillyer CD, Josephson CD, Blajchman MA, Vostal JG, Epstein JS, Goodman JL (2003) Bacterial contamination of blood components: risks, strategies, and regulation: joint ASH and AABB educational session in transfusion medicine. Hematology 575–589 Hubel K, Dale DC, Engert A, Liles WC (2001) Current status of granulocyte (neutrophil) transfusion therapy for infectious diseases. J Infect Dis 183:321–328 Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE, Calandra T et al (2002) 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 34:730–751 Humphreys BD, Sharman JP, Henderson JM, Clark JW, Marks PW, Rennke HG et al (2004) Gemcitabineassociated thrombotic microangiopathy. Cancer 100:2664–2670 Hutchinson K, Kopko PM, Muto KN, Tuscano J, O’Donnell RT, Holland PV et al (2002) Early diagnosis and successful treatment of a patient with transfusionassociated GVHD with autologous peripheral blood progenitor cell-transplantation. Transfusion 42:1567–1572 Ichihashi T, Naoe T, Yoshida H, Kiyoi H, Fukutani H, Kubo K et al (1992) Haemolytic uraemic syndrome during FK506 therapy. Lancet 340:60–61 Janatpour K, Holland PV (2002) Noninfectious serious hazards of transfusion. Curr Hematol Rep 1:149–155 Jansen AJ G, Caljouw MA A, Hop WC J, van Rhenen DJ, Schipperus MR (2004) Feasibility of a restrictive redcell transfusion policy for patients treated with intensive chemotherapy for acute myeloid leukaemia. Transfus Med 14:33–38 Jefferies LC, Sachais BS, Young DS (2001) Blood transfusion costs by diagnosis-related groupsin 60 university hospitals in 1995. Transfusion 41:522–529 Kampel LJ (2003) Challenging problems in advanced malignancy: CASE 2. disseminated intravascular coagulation in metastatic hormone-refractory prostate cancer. J Clin Oncol 21:3170–3171 Kashyap A, Wingard J, Cagnoni P, Jones R, Tarantolo S, Hu W et al (2002) Intravenous versus oral busulfan as part of a busulfan/cyclophosphamide preparative regimen for allogeneic hematopoietic stem cell transplantation: Decreased incidence of hepatic venoocclusive disease (HVOD), HVOD-related mortality, and overall 100-day mortality. Biol Blood Marrow Transplant 8:493–500 Kaushansky K (2000) Use of thrombopoietic growth factors in acute leukemia. Leukemia 14:505–508 Kekomaki S, Volin L, Koistinen P, Koivunen E, Koskimies S, Ruutu T et al (1998) Successful treatment of platelet transfusion refractoriness: the use of platelet transfusions matched for both human leucocyte antigens (HLA)

22 Hematologic Support of the Patient with Malignancy

117.

118.

119.

120.

121.

122.

123.

124.

125. 126.

127. 128.

129.

130.

131. 132.

133.

and human platelet alloantigens (HPA) in alloimmunized patients with leukaemia. Eur J Haematol 60:112–118 King KE, Shirey RS, Thoman SK, Bensen-Kennedy D, Tanz WS, Ness PM (2004) Universal leukoreduction decreases the incidence of febrile nonhemolytic transfusion reactions to RBCs. Transfusion 44:25–29 Knight K, Wade S, Balducci L (2004) Prevalence and outcomes of anemia in cancer: a systematic review of the literature. Am J Med 116(Suppl 7A):11S–26S Koeller JM (1998) Clinical guidelines for the treatment of cancer-related anemia. Pharmacotherapy 18: 156–169 Kuter DJ, Begley CG (2002) Recombinant human thrombopoietin: basic biology and evaluation of clinical studies. Blood 100:3457–3469 Laszlo D, Agazzi A, Goldhirsch A, Cinieri S, Bertolini F, Rabascio C et al (2004) Tailored therapy of adult acute leukaemia in Jehovah’s Witnesses: unjustified reluctance to treat. Eur J Haematol 72:264–267 Lee DH, Blajchman MA (2000) Platelet substitutes and novel platelet products. Exp Opin Investig Drugs 9: 457–469 Lee WR, Berkey B, Marcial V, Fu KK, Cooper JS, Vikram B et al (1998) Anemia is associated with decreased survival and increased locoregional failure in patients with locally advanced head and neck carcinoma: a secondary analysis of RTOG 85–27. Int J Radiat Oncol Biol Phys 42:1069–1075 Leitman SF, Tisdale JF, Bolan CD, Popovsky MA, Klippel JH, Balow JE et al (2003) Transfusion-associated GVHD after fludarabine therapy in a patient with systemic lupus erythematosus. Transfusion 43:1667–1671 Levi M (2001) Cancer and DIC. Haemostasis 31(Suppl 1): 47–48 Levi M (2004) Current understanding of disseminated intravascular coagulation. Br J Haematol 124: 567–576 Leyland-Jones B (2003) Breast cancer trial with erythropoietin terminated unexpectedly. Lancet Oncol 4:459–460 Liles WC, Rodger E, Dale DC (2000) Combined administration of G-CSF and dexamethasone for the mobilization of granulocytes in normal donors: optimization of dosing. Transfusion 40:642–644 Lim YA, Lee WG, Cho SR, Hyun BH, Sc D (2004) A study of blood usage by diagnoses in a Korean university hospital. Vox Sanguinis 86:54–61 Littlewood TJ, Bajetta E, Nortier JW, Vercammen E, Rapoport B (2001) Effects of epoetin alfa on hematologic parameters and quality of life in cancer patients receiving nonplatinum chemotherapy: results of a randomized, double-blind, placebo-controlled trial. J Clin Oncol 19:2865–2874 Littlewood TJ, Cella D, Nortier JW (2002) Erythropoietin improves quality of life. Lancet Oncol 3:459–460 Littlewood TJ, Nortier J, Rapoport B, Pawlicki M, de Wasch G, Vercammen E et al (2003) Epoetin alfa corrects anemia and improves quality of life in patients with hematologic malignancies receiving non-platinum chemotherapy. Hematol Oncol 21:169–180 Lopez JA, Kearon C, Lee AY Y (2004) Deep venous thrombosis. Hematology 2004:439–456

401 134. Lyman GH (2000) A predictive model for neutropenia associated with cancer chemotherapy. Pharmacotherapy 20:104S–111S 135. Manna A, Cordani S, Canessa P, Pronzato P (2003) CMV infection and pneumonia in hematological malignancies. J Infect Chemother 9:265–267 136. Marec-Berard P, Blay JY, Schell M, Buclon M, Demaret C, Ray-Coquard I (2003) Risk model predictive of severe anemia requiring RBC transfusion after chemotherapy in pediatric solid tumor patients. J Clin Oncol 21:4235–4238 137. Marsh JCW, Bevan DH (2002) Haematological care of the jehovah’s witness patient. Br J Haematol 119:25–37 138. Marsh J, Ganser A, Stadler M (2009) Hematopoietic growth factors in the treatment of acquired bone marrow failure states. Semin Hematol 44:138–147 139. Mathoulin-Pelissier S, Salmi LR, Verret C, Demoures B (2000) Blood transfusion in a random sample of hospitals in France. Transfusion 40:1140–1146 140. Matsumoto T, Wada H, Nishiyama H, Hirano T, Sakakura M, Nishii K et al (2004) Hemostatic abnormalities and changes following bone marrow transplantation. Clin Appl Thromb Hemost 10:341–350 141. McCullough J, Weiblen BJ, Clay ME, Forstrom L (1981) Effect of leukocyte antibodies on the fate in vivo of indium-111-labeled granulocytes. Blood 58:164–170 142. McGavin JK, Goa KL (2001) Ganciclovir: an update of its use in the prevention of cytomegalovirus infection and disease in transplant recipients. Drugs 61:1153–1183 143. Mehta J, Powles R, Singhal S, Horton C, Hamblin M, Zomas A et al (1996) Transfusion requirements after bone marrow transplantation from HLA-identical siblings: effects of donor-recipient ABO incompatibility. Bone Marrow Transplant 18:151–156 144. Menitove JE (2002) Immunoprophylaxis for Dpatients receiving platelet transfusions from D-donors? Transfusion. 2002;42:136–138. Transfusion 42:1618 145. Mercadante S, Gebbia V, Marrazzo A, Filosto S (2000) Anaemia in cancer: pathophysiology and treatment. Cancer Treat Rev 26:303–311 146. Meyers JD, Flournoy N, Thomas ED (1986) Risk factors for cytomegalovirus infection after human marrow transplantation. J Infect Dis 153:478–488 147. Miller WJ et al (1991) Prevention of CMV infection following BMT: a RCT of blood product screening Bone Marrow Transplant 7:227–234 148. Mohandas K, Aledort L (1995) Transfusion requirements, risks, and costs for patients with malignancy. Transfusion 35:427–430 149. Molnar R, Johnson R, Sweat LT, Geiger TL (2002) Absence of D alloimmunization in D- pediatric oncology patients receiving D-incompatible single-donor platelets. Transfusion 42:177–182 150. Moroff G, Garratty G, Heal JM, MacPherson BR, Stroncek D, Huang ST et al (1992) Selection of platelets for refractory patients by HLA matching and prospective crossmatching. Transfusion 32:633–640 151. Moroff G, Leitman SF, Luban NL (1997) Principles of blood irradiation, dose validation, and quality control. Transfusion 37:1084–1092 152. Natanson C, Kern SJ, Lurie P, Banks SM, Wolfe SM (2008) Cell-free hemoglobin-based blood substitutes and

402

153.

154.

155.

156.

157.

158.

159.

160.

161.

162.

163.

164.

165.

166.

167.

T.A. Lane risk of myocardial infarction and death: a meta-analysis. JAMA. 299(19):2304–2312 Nichols WG, Price TH, Gooley T, Corey L, Boeckh M (2003) Transfusion-transmitted cytomegalovirus infection after receipt of leukoreduced blood products. Blood 101:4195–4200 Nollet KE, Holland PV (2003) Toward a coalition against transfusion-associated GVHD. Transfusion 43: 1655–1657 Nosotti M, Rebulla P, Riccardi D, Baisi A, Bellaviti N, Rosso L et al (2003) Correlation between perioperative blood transfusion and prognosis of patients subjected to surgery for stage I lung cancer. Chest 124:102–107 O’Shaughnessy DF, Atterbury C, Bolton Maggs P, Murphy M, Thomas D, Yates S et al (2004) Guidelines for the use of fresh-frozen plasma, cryoprecipitate and cryosupernatant. Br J Haematol 126:11–28 Oksanen K (1994) Leukocyte-depleted blood components prevent platelet refractoriness in patients with acute myeloid leukemia. Eur J Haematol 53:100–107 Oksanen K, Kekomaki R, Ruutu T, Koskimies S, Myllyla G (1991) Prevention of alloimmunization in patients with acute leukemia by use of white cell-reduced blood components – a randomized trial. Transfusion 31:588–594 Opelz G, Terasaki PI (1976) Prolongation effect of blood transfusions on kidney graft survival. Transplantation 22:380–383 Ozer H, Armitage JO, Bennett CL, Crawford J, Demetri GD, Pizzo PA et al (2000) 2000 Update of recommendations for the use of hematopoietic colony-stimulating factors: evidence-based, clinical practice guidelines. J Clin Oncol 18:3558–3585 Paglino JC, Pomper GJ, Fisch GS, Champion MH, Snyder EL (2004) Reduction of febrile but not allergic reactions to RBCs and platelets after conversion to universal prestorage leukoreduction. Transfusion 44:16–24 Petersen SL, Madsen HO, Ryder LP, Svejgaard A, Jakobsen BK, Sengelov H et al (2004) Haematopoietic stem cell transplantation with non-myeloablative conditioning in the outpatient setting: results, complications and admission requirements in a single institution. Br J Haematol 125:225–231 Pettitt AR, Clark RE (1994) Thrombotic microangiopathy following bone marrow transplantation. Bone Marrow Transplant 14:495–504 Petz LD, Garratty G, Calhoun L, Clark BD, Terasaki PI, Gresens C et al (2000) Selecting donors of platelets for refractory patients on the basis of HLA antibody specificity. Transfusion 40:1446–1456 Pflieger H, Arnold R, Bhaduri S, Bultmann B, Goldmann SF, Haghou F et al (1979) Beneficial effect of granulocyte transfusions in patients with defects in granulocyte function and severe infections. Scand J Haematol 22: 33–41 Pihusch R, Salat C, Schmidt E, Gohring P, Pihusch M, Hiller E et al (2002) Hemostatic complications in bone marrow transplantation: a retrospective analysis of 447 patients. Transplantation 74:1303–1309 Practice Guidelines Development Task Force of the College of American Pathologists (1994) Practice parameter for the use of fresh-frozen plasma, cryoprecipitate,

168.

169.

170.

171. 172.

173.

174.

175.

176. 177.

178.

179. 180.

181.

182.

183.

and platelets. Fresh-frozen plasma, cryoprecipitate, and platelets administration. JAMA 271:777–781 Prandoni P (2002) Cancer and thromboembolic disease: how important is the risk of thrombosis? Cancer Treat Rev 28:133–136 Preiksaitis JK, Brown L, McKenzie M (1988) The risk of cytomegalovirus infection in seronegative transfusion recipients not receiving exogenous immunosuppression. J Infect Dis 157:523–529 Preiksaitis JK, Desai S, Vaudry W, Roberts S, Akabutu J, Grundy P et al (1997) Transfusion- and communityacquired cytomegalovirus infection in children with malignant disease: a prospective study. Transfusion 37:941–946 Price TH (2002) Granulocyte transfusion in the G-CSF era. Int J Hematol 76(Suppl 2):77–80 Price TH, Bowden RA, Boeckh M, Bux J, Nelson K, Liles WC et al (2000) Phase I/II trial of neutrophil transfusions from donors stimulated with G-CSF and dexamethasone for treatment of patients with infections in hematopoietic stem cell transplantation. Blood 95:3302–3309 Przepiorka D, Leparc GF, Werch J, Lichtiger B (1996) Prevention of transfusion-associated cytomegalovirus infection. Practice parameter. American society of clinical pathologists. Am J Clin Pathol 106:163–169 Quirt I, Robeson C, Lau CY, Kovacs M, BurdetteRadoux S, Dolan S et al (2001) Epoetin alfa therapy increases hemoglobin levels and improves quality of life in patients with cancer-related anemia who are not receiving chemotherapy and patients with anemia who are receiving chemotherapy. J Clin Oncol 19:4126–4134 Ray-Coquard I, Le Cesne A, Rubio MT, Mermet J, Maugard C, Ravaud A et al (1999) Risk model for severe anemia requiring red blood cell transfusion after cytotoxic conventional chemotherapy regimens. J Clin Oncol 17:2840 Rebulla P (2002) Refractoriness to platelet transfusion. Curr Opin Hematol 9:516–520 Rebulla P, Finazzi G, Marangoni F, Avvisati G, Gugliotta L, Tognoni G et al (1997) The threshold for prophylactic platelet transfusions in adults with acute myeloid leukemia. N Engl J Med 337:1870–1875 Reesink HW, Engelfriet CP, Tegtmeier GE, O’Riordan J, Eglin R, Barbara JA et al (2002) Prevention of posttransfusion cytomegalovirus: leucoreduction or screening? Vox Sang 83:72–87 Reid TJ (2003) Hb-based oxygen carriers: are we there yet? Transfusion 43:280–287 Reiter A, Schrappe M, Ludwig WD, Hiddemann W, Sauter S, Henze G et al (1994) Chemotherapy in 998 unselected childhood acute lymphoblastic leukemia patients. Results and conclusions of the multicenter trial ALL-BFM 86. Blood 84:3122–3133 Rickles FR, Levine M, Edwards RL (1992) Hemostatic alterations in cancer patients. Cancer Metastasis Rev 11:237–248 Rickles FR, Falanga A (2001) Molecular basis for the relationship between thrombosis and cancer. Thrombosis Res 102:V215–V224 Rizzo JD, Lichtin AE, Woolf SH, Seidenfeld J, Bennett CL, Cella D et al (2002) Use of epoetin in patients with

22 Hematologic Support of the Patient with Malignancy

184.

185.

186. 187.

188.

189.

190.

191.

192.

193.

194. 195.

196.

197. 198.

cancer: evidence-based clinical practice guidelines of the American society of clinical oncology and the American society of hematology. J Clin Oncol 20:4083–4107 Rizzo JD, Somerfield MR, Hagerty KL et al (2008) Use of epoetin and darbepoetin in patients with cancer: 2007 American society of hematology/American society of clinical oncology clinical practice guideline update. Blood 111(1):25–41 Ronghe MD, Foot AB, Cornish JM, Steward CG, Carrington D, Goulden N et al (2002) The impact of transfusion of leucodepleted platelet concentrates on cytomegalovirus disease after allogeneic stem cell transplantation. Br J Haematol 118:1124–1127 Ruggiero A, Riccardi R (2002) Interventions for anemia in pediatric cancer patients. Med Pediatr Oncol 39:451–454 Ruutu T, Hermans J, Niederwieser D, Gratwohl A, Kiehl M, Volin L et al (2002) Thrombotic thrombocytopenic purpura after allogeneic stem cell transplantation: a survey of the European group for blood and marrow transplantation (EBMT). Br J Haematol 118:1112–1119 Rzyman W, Dziadziuszko R, Skokowski J, Wilimski R, Raiter A, Szymanowska A et al (2003) The influence of blood transfusion on survival in operated non-small cell lung cancer patients. J Thorac Cardiovasc Surg 126: 755–760 Saarinen UM, Kekomaki R, Siimes MA, Myllyla G (1990) Effective prophylaxis against platelet refractoriness in multitransfused patients by use of leukocyte-free blood components. Blood 75:512–517 Safdar A, Hanna HA, Boktour M, Kontoyiannis DP, Hachem R, Lichtiger B et al (2004) Impact of highdose granulocyte transfusions in patients with cancer with candidemia. Cancer 101:2859–2865 Sallah S, Wan JY, Nguyen NP (2002) Venous thrombosis in patients with solid tumors: determination of frequency and characteristics. Thromb Haemost 87:575–579 Sallah S, Wan JY, Nguyen NP, Hanrahan LR, Sigounas G (2004) Disseminated intravascular coagulation in solid tumors: clinical and pathological study. Thromb Haemost 86(3):828–833 Samadi DS, Goldberg AN, Orlandi RR (2001) Granulocyte transfusion in the management of fulminant invasive fungal rhinosinusitis. Am J Rhinol 15:263–265 Schiffer CA (2001) Diagnosis and management of refractoriness to platelet transfusion. Blood Rev 15:175–180 Schiffer CA, Anderson KC, Bennett CL, Bernstein S, Elting LS, Goldsmith M et al (2001) Platelet transfusion for patients with cancer: clinical practice guidelines of the American society of clinical oncology. J Clin Oncol 19:1519–1538 Schonewille H, Haak HL, van Zijl AM (1999) Alloimmunization after blood transfusion in patients with hematologic and oncologic diseases. Transfusion 39:763–771 Schroeder M (2002) Transfusion-associated graft-versushost disease. Br J Haematol 117:275–287 Seftel MD, Growe GH, Petraszko T, Benny WB, Le A, Lee CY et al (2004) Universal prestorage leukoreduction in Canada decreases platelet alloimmunization and refractoriness. Blood 103:333–339

403 199. Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM (2000) Genetic, biochemical, and clinical features of chronic granulomatous disease. Medicine (Baltimore) 79:170–200 200. Sheffield R, Sullivan SD, Saltiel E, Nishimura L (1997) Cost comparison of recombinant human erythropoietin and blood transfusion in cancer chemotherapy-induced anemia. Ann Pharmacother 31:15–22 201. Shivdasani RA, Haluska FG, Dock NL, Dover JS, Kineke EJ, Anderson KC (1993) Brief report: graft-versus-host disease associated with transfusion of blood from unrelated HLA-homozygous donors. N Engl J Med 328: 766–770 202. Siena S, Secondino S, Giannetta L, Carminati O, Pedrazzoli P (2003) Optimising management of neutropenia and anaemia in cancer chemotherapy-advances in cytokine therapy. Crit Rev Oncol Hematol 48:S39–S47 203. Silver DF, Piver MS (1999) Effects of recombinant human erythropoietin on the antitumor effect of cisplatin in SCID mice bearing human ovarian cancer: a possible oxygen effect 1. Gynecol Oncol 73:280–284 204. Slichter SJ, Kaufman RM, Assmann SF et al (2010) dose of prophylactic platelet transfusions and prevention of hemorrhage. N Engl J Med 362:600–613 205. Smith TJ, Khatcheressian J, Lyman GH, Ozer H et al (2006) 2006 update of recommendations for the use of white blood cell growth factors: an evidencebased clinical practice guideline. J Clin Oncol 24(19): 3187–3205 206. Sniecinski I, O’Donnell MR, Nowicki B, Hill LR (1988) Prevention of refractoriness and HLA-alloimmunization using filtered blood products. Blood 71:1402–1407 207. Spivak JL (1994) Cancer-related anemia: its causes and characteristics. Semin Oncol 21:3–8 208. Stasi R, Abriani L, Beccaglia P, Terzoli E, Amadori S (2003) Cancer-related fatigue: evolving concepts in evaluation and treatment. Cancer 98:1786–1801 209. Stowell CP (2002) Hemoglobin-based oxygen carriers. Curr Opin Hematol 9:537–543 210. Straus DJ (2003) Epoetin alfa therapy for patients with hematologic malignancies and mild anemia. Clin Lymphoma 4(Suppl 1):S13–S17 211. Strauss RG (1993) Therapeutic granulocyte transfusions in 1993. Blood 81:1675–1678 212. Strauss RG (1994) Granulocyte transfusion therapy. Hematol Oncol Clin North Am 8:1159–1166 213. Stroncek DF, Leonard K, Eiber G, Malech HL, Gallin JI, Leitman SF (1996) Alloimmunization after granulocyte transfusions. Transfusion 36:1009–1015 214. Sullivan MT, McCullough J, Schreiber GB, Wallace EL (2002) Blood collection and transfusion in the United States in 1997. Transfusion 42:1253–1260 215. Takatsuka H, Wakae T, Toda A, Itoi H, Okada M, Misawa M et al (2004) Association of Helicobacter pylori> with thrombotic thrombocytopenic purpura and hemolytic uremic syndrome after bone marrow transplantation. Clin Transplant 18:547–551 216. Takeoka S, Okamura Y, Teramura Y, Watanabe N, Suzuki H, Tsuchida E et al (2003) Function of fibrinogen gammachain dodecapeptide-conjugated latex beads under flow. Biochem Biophys Res Commun 312:773–779

404 217. Tartter PI (1992) The association of perioperative blood transfusion with colorectal cancer recurrence. Ann Surg 216:633–638 218. Tegtmeier GE (1989) Posttransfusion cytomegalovirus infections. Arch Pathol Lab Med 113:236–245 219. The Trial to Reduce Alloimmunization to Platelets (TRAP) Study Group (1997) Leukocyte reduction and ultraviolet B irradiation of platelets to prevent alloimmunization and refractoriness to platelet transfusions. N Engl J Med 337:1861–1870 220. Thews O, Koenig R, Kelleher DK, Kutzner J, Vaupel P (1998) Enhanced radiosensitivity in experimental tumours following erythropoietin treatment of chemotherapyinduced anaemia. Br J Cancer 78:752–756 221. Thomas GM (2002) Raising hemoglobin: an opportunity for increasing survival? Oncology 63(Suppl 2): 19–28 222. Thomas M, Laurent K, Damien W, Anne-Marie K, PierreYves D (2002) Cytomegalovirus colitis – a severe complication after standard chemotherapy. Acta Oncologica 41:704–706 223. Titlestad K, Georgsen J, Jorgensen J, Kristensen T (2001) Monitoring transfusion practices at two university hospitals. Vox Sanguinis 80:40–47 224. Vadhan-Raj S, Verschraegen CF, Bueso-Ramos C, Broxmeyer HE, Kudelka AP, Freedman RS et al (2000) Recombinant human thrombopoietin attenuates carboplatin-induced severe thrombocytopenia and the need for platelet transfusions in patients with gynecologic cancer. Ann Intern Med 132:364–368 225. Vamvakas EC (1995) Perioperative blood transfusion and cancer recurrence: meta-analysis for explanation. Transfusion 35:760–768 226. Vamvakas EC, Carven JH, Hibberd PL (1996) Blood transfusion and infection after colorectal cancer surgery. Transfusion 36:1000–1008 227. Vamvakas EC, Pineda AA (1997) Determinants of the efficacy of prophylactic granulocyte transfusions: a metaanalysis. J Clin Apheresis 12:74–81 228. Vamvakas E, Blajchman M (2009) Transfusion-related mortality: the ongoing risks of allogeneic blood transfusionand the available strategies for their prevention. Blood 113:3406–3417 229. van de Watering LM, Brand A, Houbiers JG, Klein Kranenbarg WM, Hermans J, van de Velde C (2001) Perioperative blood transfusions, with or without allogeneic leucocytes, relate to survival, not to cancer recurrence. Br J Surg 88:267–272 230. van Marwijk KM, van Prooijen HC, Moes M, BosmaStants I, Akkerman JW (1991) Use of leukocyte-depleted platelet concentrates for the prevention of refractoriness and primary HLA alloimmunization: a prospective, randomized trial. Blood 77:201–205 231. Vansteenkiste J, Hedenus M, Gascon P., (2009) Darbepoetin alfa for treating chemotherapy-induced anemia in patients with a baseline hemoglobin level < 10 g/dL versus > or = 10 g/dL: an exploratory analysis from a randomized, double-blind, active-controlled trial. BMC Cancer 3(9):311–322 232. Vincent JL, Angus DC, Artigas A, Kalil A, Basson BR, Jamal HH et al (2003) Effects of drotrecogin alfa

T.A. Lane

233. 234.

235.

236.

237.

238.

239.

240.

241.

242.

243.

244. 245.

246.

247.

(activated) on organ dysfunction in the PROWESS trial. Crit Care Med 31:834–840 Viscoli C, Castagnola E (2002) Treatment of febrile neutropenia: what is new? Curr Opin Infect Dis 15:377–382 Vogler WR, Winton EF (1977) A controlled study of the efficacy of granulocyte transfusions in patients with neutropenia. Am J Med 63:548–555 Wandt H, Ehninger G, Gallmeier WM (2001) New strategies for prophylactic platelet transfusion in patients with hematologic diseases. Oncologist 6:446–450 Wandt H, Frank M, Ehninger G, Schneider C, Brack N, Daoud A et al (1998) Safety and cost effectiveness of a 10 + 109/L trigger for prophylactic platelet transfusions compared with the traditional 20 + 109/L trigger: a prospective comparative trial in 105 patients with acute myeloid leukemia. Blood 91:3601–3606 Warde P, O’Sullivan B, Bristow RG, Panzarella T, Keane TJ, Gullane PJ et al (1998) T1/T2 glottic cancer managed by external beam radiotherapy: the influence of pretreatment hemoglobin on local control. Int J Radiat Oncol Biol Phys 41:347–353 Warren BL, Eid A, Singer P, Pillay SS, Carl P, Novak I et al (2001) Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: a randomized controlled trial. JAMA 286:1869–1878 Weiden PL, Zuckerman N, Hansen JA, Sale GE, Remlinger K, Beck TM et al (1981) Fatal graft-versushost disease in a patient with lymphoblastic leukemia following normal granulocyte transfusion. Blood 57: 328–332 Weiss MJ (2003) New insights into erythropoietin and epoetin alfa: mechanisms of action, target tissues, and clinical applications. Oncologist 8(Suppl 3):18–29 Wells AW, Mounter PJ, Chapman CE, Stainsby D, Wallis JP (2002) Where does blood go? Prospective observational study of red cell transfusion in north England. BMJ 325:803 Williamson LM, Lowe S, Love EM, Cohen H, Soldan K, McClelland DB L et al (1999) Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports. BMJ 319:16–19 Wingard JR, Chen DY, Burns WH, Fuller DJ, Braine HG, Yeager AM et al (1988) Cytomegalovirus infection after autologous bone marrow transplantation with comparison to infection after allogeneic bone marrow transplantation. Blood 71:1432–1437 Winslow RM (2002) Blood substitutes. Curr Opin Hematol 9:146–151 Winston DJ, Ho WG, Gale RP (1982) Therapeutic granulocyte transfusions for documented infections. A controlled trial in ninety-five infectious granulocytopenic episodes. Ann Intern Med 97:509–515 Wright DG, Robichaud KJ, Pizzo PA, Deisseroth AB (1981) Lethal pulmonary reactions associated with the combined use of amphotericin B and leukocyte transfusions. N Engl J Med 304:1185–1189 Wun T, Law L, Harvey D, Sieracki B, Scudder SA, Ryu JK (2003) Increased incidence of symptomatic venous thrombosis in patients with cervical carcinoma treated with concurrent chemotherapy, radiation, and erythropoietin. Cancer 98:1514–1520

22 Hematologic Support of the Patient with Malignancy 248. Yomtovian R, Abramson J, Quie P, McCullough J (1981) Granulocyte transfusion therapy in chronic granulomatous disease. Report of a patient and review of the literature. Transfusion 21:739–743 249. Yomtovian R, Gernsheimer T, Assmann SF, Mohandas K, Lee TH, Kalish LA et al (2001) WBC reduction in RBC concentrates by prestorage filtration: multicenter experience. Transfusion 41:1030–1036 250. Zangari M, Anaissie E, Barlogie B, Badros A, Desikan R, Gopal AV et al (2001) Increased risk of deep-vein thrombosis in patients with multiple myeloma receiving thalidomide and chemotherapy. Blood 98:1614–1615 251. Zangari M, Barlogie B, Anaissie E, Saghafifar F, Eddlemon P, Jacobson J et al (2004) Deep vein thrombosis in patients with multiple myeloma treated with thalidomide and chemotherapy: effects of prophylactic

405 and therapeutic anticoagulation. Br J Haematol 126: 715–721 252. Zeigler ZR, Shadduck RK, Gryn JF, Rintels PB, George JN, Besa EC et al (2001) Cryoprecipitate poor plasma does not improve early response in primary adult thrombotic thrombocytopenic purpura (TTP). J Clin Apheresis 16:19–22 253. Zheng XL, Kaufman RM, Goodnough LT, Sadler JE (2004) Effect of plasma exchange on plasma ADAMTS13 metalloprotease activity, inhibitor level, and clinical outcome in patients with idiopathic and nonidiopathic thrombotic thrombocytopenic purpura. Blood 103:4043–4049 254. Zimmermann R, Buscher M, Linhardt C, Handtrack D, Zingsem J, Weisbach V et al (1997) A survey of blood component use in a German university hospital. Transfusion 37:1075–1083

Chapter 23

Current Status of Bone Marrow Transplantation for Treatment of Cancer Edward D. Ball, Asad Bashey, Ewa Carrier, Januario E. Castro, Peter Holman, and Thomas A. Lane

23.1 Introduction Cancer treatment is evolving and improving through a better understanding of molecular biology and the identification of specific cancer-associated targets. However, most cancer therapies depend on cytotoxic chemicals that are marginally more toxic to neoplastic cells than normal cells. Thus, cancer therapy is imperfect, toxic, and curative in only a small percentage of patients. Several decades ago, the idea of treating cancer and, in particular, leukemia patients by giving higher doses of chemotherapeutic agents or radiation began clinical testing. Higher doses of chemotherapy (CT) or radiation clearly worked against leukemia cells in vitro, but toxicity, primarily to the bone marrow, limited its application to patients. Hematopoietic stem cell transplant (HSCT) offered the possibility of escalating doses of cancer-killing agents by rescuing the patient from the effects of the toxic chemicals. This was achieved by infusions of healthy hematopoietic stem cells. Recently, it has been recognized that the efficacy of HSCT is partially dependent on immunological reactions of donor cells against cancer-related antigens. HSCT has evolved into a standard-of-care for many types of hematologic neoplasms and selected solid tumors. Currently, over fifty thousand patients are transplanted annually around the world.

E.D. Ball () Department of Medicine and Moores UCSD Cancer Center, La Jolla, CA 92093-0960, USA e-mail: [email protected]

Many obstacles were encountered in the early efforts in HSCT. Many of these obstacles have been either eliminated or made less relevant, yet many remain as the subject of basic and clinical research. HSCT has emerged as curative therapy for many disease indications. This chapter reviews the concepts and principles of HSCT, and focuses on its current application to specific disease states.

23.2 Autologous Stem Cell Transplantation Auto-HSCT allows the administration of higher doses of effective but myelotoxic CT by facilitating rapid restoration of hematopoiesis. If patients with malignancies affecting the bone marrow can achieve remission with CT, normal hematopoietic stem cells can be removed from the bone marrow or blood, and stored prior to treating the patient with high-dose CT. Initially, hematopoietic stem cells (HSC) were obtained from the bone marrow and cryopreserved. Recently, it has been discovered that hematopoietic stem cells characterized by cell surface expression of the sialo-protein CD34 circulate in the blood at physiologically low levels. By giving hematopoietic growth factors, such as granulocyte-colony stimulating factor (G-CSF) to patients, “mobilized” peripheral blood stem cells (PBSC) are enriched in CD34+ stem/progenitor cells. They generate rapid recovery of PB cell counts following the use of high-dose CT. An underlying assumption based on experimental evidence was that the HSC must be free of contaminating tumor cells. In the 1980s and 1990s, large efforts were made to develop methods of purging

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_23, © Springer Science+Business Media B.V. 2011

407

408

occult cancer cells in bone marrow products. Many patients with leukemia and lymphoma treated in noncontrolled studies with purged bone marrow stem cell products showed impressive long-term diseasefree survival (DSF) [79]. Yet relapses in lymphomas usually occur in sites of previous disease, suggesting that optimizing treatment was the principal concern. When PBSC became more common, the ability to purge the larger numbers of cells became cumbersome and expensive. In addition, the lack of FDA-approved agents for purging reduced enthusiasm for this practice. Thus, current practice is to achieve the best quality remission by repetitive CT and then sample the bone marrow to determine whether residual disease exists. Then patients are treated with a growth factor such as G-CSF, in concert with CT, to mobilize PBSC. These cells are collected by apheresis, and viably frozen. This therapy has demonstrated impressive results in patients with acute leukemia, non-Hodgkin’s lymphoma, Hodgkin’s disease, and multiple myeloma (see below for disease-specific discussions). Auto-HSCT is preferred for many forms of leukemia and lymphoma, especially those over 60 years. It is often the only type of stem cell transplantation available for patients who lack a suitable related or unrelated HLAmatched donor. Specific application of auto-HSCT will be discussed below under each disease heading.

23.3 Stem Cell Mobilization and Collection 23.3.1 Definition Stem cell mobilization is the process by which hematopoietic stem and progenitor cells (HPC) are released from bone marrow (BM) into the peripheral blood (PB), to allow collection of sufficient HPC by hemapheresis to perform BM transplantation (BMT). There are few HPC in steady-state (unmobilized) blood, but administration of CT sufficient to result in neutropenia or administration of hematopoietic growth factors (HGF), e.g. G-CSF, GM-CSF or Plerixafor (Mozobil), increases HPC levels in PB by 10- to 50-fold. Apheresis enables the collection of a much higher targeted dose of PBSC, typically measured by the content of CD34+ cells, than is obtained by marrow aspiration. Retrospective studies in patients

E.D. Ball et al.

receiving auto-BMT indicated that engraftment was reliably achieved with a dose of 2 × 106 CD34+ cells/kg patient weight [15, 193]. CD34+ cell doses, up to 5 × 106 CD34+ cells/kg were associated with progressively shorter times to platelet engraftment. The T cell content of PBSC is 7–10 fold higher than a typical BM graft. Compared with BM, autologous and allogeneic PBSC results in faster engraftment of platelets and neutrophils, and is better tolerated by most normal donors [16, 159, 198]. After allo-BMT, the higher T cell content of PBSC is associated with more rapid immune reconstitution and lower infection, but a higher incidence of chronic GVHD than after transplantation using BM [64, 182].

23.3.2 Mechanism of HPC Mobilization Adherence and motility are fundamental properties of HPC; thus during ontogeny primitive HPC migrate from para-aortic sites to the yolk-sac, liver and spleen, and finally into the marrow. The mechanism of HPC mobilization has been extensively investigated, but is not completely understood. Evidence suggests that mobilizing agents alter the number and/or function of HPC adherence molecules and their ligands, releasing HPC from marrow stroma, which facilitates migration toward vessels and marrow egress. Mobilizing agents may also activate BM stromal cells, causing the release of HGF and cytokines that in turn increase HPC motility and induce HPC proliferation. VLA-4 and CXCR4 adhesion molecules on CD34+ cells mediate HPC adherence to the respective ligands, VCAM1 and SDF-1 on marrow stroma. Administration of Cyclophosphamide or G-CSF releases proteolytic enzymes, Cathepsin G (CG), elastase (EL), and proteinase 3 from marrow neutrophils [46]. CG and EL may directly cleave CXCR4 on CD34+ cells and VCAM-1 on stroma, resulting in disruption of HPC adherence interactions. G-CSF activates BM mesenchymal cells (osteoblasts) that release SDF-1. SDF1 induces release of the proteolytic enzymes MMP-2 and MMP-9 from CD34+ cells and activates osteoclasts to release IL-8 and MMP-9. MMP-9 cleaves c-kit from CD34+ cells, resulting in the release of Stem Cell Factor (SCF). Both IL-8 and SCF are potent mobilizing agents, and SCF also induces proliferation of marrow stem cells. SDF-1 and other cytokines increase

23 Current Status of Bone Marrow Transplantation

409

the motility of CD34+ cells, promoting marrow egress. G-CSF or SCF associated mobilization peaks after 4–6 daily injections, while mobilization after IL-8 administration or novel agents that directly alter HPC adhesion occurs in minutes–hours. Plerixafor, which blocks CXCR4 receptor is an example of the latter, and is FDA-approved for use in patients with NHL and MM but not leukemia or in normals.

higher levels of HPC than either CT or HGF alone [129]. An ideal CT regimen will also have activity against the patient’s disease. A well studied regimen that predictably results in excellent mobilization with few side effects uses a single dose of cyclophosphamide 2 gm/m2 on day 1, followed by GCSF at 10 mcg/kg starting on day 6, until the completion of collection, and apheresis starting on day 11 [126].

23.3.3 Mobilization Regimens

23.3.4 HPC Collection

G-CSF is the standard mobilizing agent for normal related or unrelated donors. Mobilization by G-CSF is both dose and schedule dependent. Typically, 5–16 mcg/kg/day either as a single or divided dose is administered subcutaneously (SC) for 3–5 days prior to apheresis. CD34+ cells peak approximately 4–6 hours after injection; divided dosing may result in higher overall CD34+ cell counts. Side effects are also dose-dependent, typically including headache, bone pain, myalgia, insomnia, and anorexia, and occur less with divided dosing. They usually respond to symptomatic therapy and uncommonly require dose adjustment. Leukocytosis is typically less than 75,000 microL. Asymptomatic splenomegaly is common and rare cases of splenic rupture have been reported in normal donors. G-CSF should also be used with caution in patients with coronary artery disease and sickle cell disease; safety in pregnancy is unknown. The potential for long term adverse marrow effects of HGF is a consideration in normal donors [77, 118]. GM-CSF in dosages of 5–10 mcg/kg/day SC for 4–6 days is less effective than G-CSF in mobilizing HPC, causing similar but somewhat more severe side effects, as well as rare cases of pulmonary dysfunction. GM-CSF has been used effectively in combination with G-CSF for allogeneic donors [110]. G-CSF alone or combined with GM-CSF, has been employed in HPC mobilization for auto-BMT. Plerixafor is approximately equally effective as G-CSF but mobilizes HPC within 8–12h. Its effects are additive with G-CSF when the two are used in combination and comined G-CSF + Plerixafor has proven to be an effective regimen to mobilize HPC in most heavily pretreated patients who mobilize poorly (see below). In addition to HGF, a host of CT regimens, with or without growth factors, have been employed to mobilize HPC for autologous BMT, potentially resulting in

Mobilization using G-CSF (+/− Plerixafor) is sufficiently reliable that HPC harvesting can begin 4–6 days after the initial injection. CT induced mobilization generally requires more careful monitoring and may use a biological threshold for initiating HPC collection, e.g. leukocyte count > 1,000–10,000 or blood CD34+ cells > 8–20/microL. In practice, HPC collection is difficult with leukocyte counts < 3,000 to 5,000; regardless of the WBC, which correlates with blood CD34+ cells, few CD34+ cells are collected unless there are > 10 CD34+ cells/microL in pre-apheresis peripheral blood. HPC are collected by a variety of hemapheresis instruments that separate a mononuclear cell rich fraction of WBC from whole blood by centrifugation, taking advantage of the different sedimentation properties of red cells, platelets and leukocytes. Modern instruments employ a two-needle technique in which blood is continuously drawn from the donor, anti-coagulated with citrate, processed in a sterile disposable fluid path; the remainder returned to the donor. Excellent venous access is required, and may necessitate surgical placement of a large bore IV line. Donors may experience citrate-induced hypocalcemia, treated or prevented by infusion of calcium salts. Typically 2 donor blood volumes are processed during a 2–3 h procedure, however, “large-volume” apheresis (4 or more volumes) are increasingly collected, subject to donor tolerance. Product volumes range from 50 to 350 mL. After repeated aphereses, the development of anemia and thrombocytopenia may require transfusion. The CD34+ cell collection efficiency ranges from 30 to 40%, not changing appreciably during collection presumably due to ongoing recruitment of CD34+ cells from the marrow. Consequently, the preapheresis blood level of CD34+ cells may be a general guide to the volume blood required to be processed [46]. Most normal donors require one or two apheresis

410

procedures to obtain an adequate collection. To increase the efficiency of stem cell collection, the CD34+ content of the HPC product may be directly measured on a mid-collection sample [109]. In patients with malignant disease, 10–25% do not mobilize sufficiently well to yield a transplant dose (2 × 106 CD34+ cells/kg) [24]. Mobilization capacity is a continuous function of age with no discrete threshold; there is weak correlation with sex and obesity. Factors associated with poor mobilization include receipt of >12 months of myelotoxic therapy, recent myelotoxic therapy, age > 70, and platelet count < 200,000 microL. The SDF-1 inhibitor has recently been associated with good mobilization [50]. Approximately 50% of poor mobilizers produce sufficient cells for transplant after a brief period of rest (10–14 days), along with the administration of a more dose-intensive or combined growth factor regimen [14, 24, 114]. Approximately 2/3 of MM or NHL patients who fail to mibilize well after a first attempt will do so after a second regimen using G-CSF and Plerixafor. Alternatively, BM may be harvested from such patients, with or without HGF administration, and used to successfully support BMT, although engraftment rates are slower [113]. Also, failure to administer 2 × 106 CD34/kg does not necessarily preclude a favorable BMT outcome in individual patients [174].

23.3.5 Future Directions Long acting G-CSF preparations may enable CD34+ collection after a single dose. Novel pharmacologic agents that interfere with stem cell adhesion via the CXCR4 receptor have recently been developed. The SDF-1 inhibitor, plerixifor, has been approved for use in stem cell mobilization in patients with non-Hodgkin lymphoma and multiple myeloma and is in routine clinical use [173].

23.4 Myeloablative and Non-myeloablative Allogeneic Stem Cell Transplantation (NST) Over the past 50 years, the role of BMT has changed from an experimental treatment with a high mortality rate to a curative treatment modality for

E.D. Ball et al.

thousands of patients with hematologic diseases. Presently, cure rates with matched sibling donors exceed 85% for some otherwise lethal diseases, such as chronic myelogenous leukemic (CML), aplastic anemic (AA), or βthalassemia. The recent development of non-myeloablative conditioning followed by stem cell transplantation allows this therapy for an older patient population who otherwise suffer unacceptable treatment-related toxicity. This section discusses different aspects of myeloablative and NST with an emphasis on clinical outcomes, complications, and future perspectives.

23.4.1 Clinical Experience with Ablative Allogeneic Transplant (allo-HSCT) is now an established curative treatment for numerous hematologic diseases, such as acute and chronic leukemias. This therapy eliminates malignant cells and generates graft-vs.-leukemia or graft-vs.-tumor (GVL/GVT) effects mediated by donor-derived T-lymphocytes. The IBMTR assessed 2,254 patients with early leukemia who underwent HSCT from an HLA-identical sibling, demonstrating the favorable impact of GVHD on relapse rates [89]. More direct evidence for the existence of potent GVL/GVT effects is seen in studies of donor leukocyte infusions (DLI) [43, 70, 104, 105, 142]. Of these patients, 70–90% enter CR after DLI without further CT [43, 70, 105]. Complete and less durable responses are less frequent in patients with transformed phase CML, AML, and ALL. Despite its curative potential, allo-HSCT has been feasible in only a proportion of patients with malignant hematologic and lymphoid disorders. The limitations are treatment related mortality and the availability of a donor. In the pediatric population, umbilical cord blood has enabled transplants for children without sibling donors. Cord blood stem cells require less stringent matching, and have as much as a 3/6 antigen mismatch, and still yield similar results in terms of engraftment and the incidence of GVHD. Elderly patients and heavily pretreated patients cannot tolerate a fully myeloablative regimen; so the use of standard allogeneic transplant is limited [23, 103, 151]. The development of NST allows older patients to benefit from this modality.

23 Current Status of Bone Marrow Transplantation

23.4.2 Allogeneic Transplantation Using Unrelated Donors Only about 25% of patients in need of HST have an HLA-matched related sibling donor. Therefore, this treatment is not an option for the majority of patients. Advances in molecular tissue typing techniques have made it possible to identify suitable unrelated donors. There are now more than 5 million HLAtyped potential volunteer donors in national registries. The clinical results of unrelated donor transplants are similar in younger patients to sibling related transplants [80].

23.4.3 Graft-Vs.-Host Disease (GVHD) As predicted by dog models of transplantation, even with HLA-matched donors, approximately 50% of patients developed GVHD despite use of post-grafting immunosuppression [32, 190]. The severity of GVHD in humans was not fully appreciated until longterm engraftment of donor marrow was achieved. Better control of GVHD was achieved by combining methotrexate with cyclosporine (CSA) or tacrolimus (FK506) [132, 176–178].

23.4.4 Non-Myeloablative Stem Cell Transplants (NST) The NST is a recently developed procedure that applies the principle of immunotherapy in a variety of malignant disorders. Studies in murine and canine models demonstrated that a state of stable-mixed chimerism can be successfully established using reduced intensity CT or radiation. Storb and colleagues established that the pre-transplant use of cyclosporine (CSA), mycophenylate mofetil (MMF) and reduced dosing of total body radiation [TBI] (2 Gy) allows stable mixed chimerism [179–181]. Studies in humans were primarily initiated for older patients who could not tolerate ablative allo-HSCT, and heavily pre-treated patients who would suffer excessive mortality and morbidity. Storb et al developed human clinical protocols based on their experience in the canine model [175, 200].

411

Transplants following 2 Gy TBI, CSA and MMF were performed using PB mononuclear cells from matched sibling donors. Patients experienced no alopecia and minimal nausea and diarrhea. All 28 patients in the first cohort showed donor cell engraftment with mixed donor chimerism. Over the past 6 years, NST has been widely used in patients and the kinetics of engraftment and mechanisms of GVHD are now better understood. NST does not initially eliminate all host hematopoiesis and commonly leads to a state of mixed donor chimerism. Mixed chimerism defines persistence of donor cells with either benign host hematopoietic cells and /or cells of the underlying malignancy. The initial nonmyeloablative treatment is expected to produce only transient suppression of the underlying malignancy, but it allows time for the graft-vs.-tumor (GVT) effect to develop. Patients with mixed donor chimerism after NST may respond to additional immunotherapeutic approaches, such as withdrawal of immunosuppressive therapy, DLI, or a second NST. These immune manipulations can potentially eliminate residual disease and host-hematopoiesis, and produce full-donor chimerism.

23.4.5 Comparison of NST with Fully Myeloablative HSCT A. Infections: Several studies compared NST to historical control populations of patients who received full myeloablative transplant. Factors such as transfusion requirement, incidence of infections and GVHD were analyzed. The incidence of bacterial infections during the first 100 days in these two groups was compared [94]. The 30 and 100 day incidence of bacteremia were 9% and 27% in the NST group vs. 27% and 41% in the control group (p = 0.07) respectively. Invasive aspergillosis occurred in 15% of NST group vs. 9% in control group (not statistically significant). The CMV infection incidence rate was reported in 56 NST recipients and compared to controls. Each NST recipient was matched to 2 controls who received full myeloablative transplants at the same time, and matching criteria included CMV risk group, HSC source, donor type, age, and underlying disease. The 100-day incidence of CMV

412

E.D. Ball et al.

infection was 9% vs. 19% in the control group (p = 0.08). The onset of CMV disease was significantly delayed compared to the control group (130 days vs. 52 days, p = 0.02). These studies suggest that CMV surveillance should be carried out beyond day 100, and pre-emptive gancyclovir given when CMV is detected. B. Transfusion requirement: Another study reviewed transfusion requirements (platelets and red blood cells) in 40 NST patients compared to 67 patients who received myeloablative transplant during the same time period [199]. The incidence of transfusion requirement were 23% and 63% in the NST group vs. 96% in the conventional group respectively, (p<0.001). The median number of platelet and red cells transfused was 0 and 2 in the NST group vs. 24 and 6 in the control group respectively (p<0.001). C. Incidence of GVHD: Another study compared the incidence of GVHD in NST (n = 44) with conventional transplants (n = 52) [128]. Transplants were done with related and unrelated donors who were serologically matched HLA-A, HLA-B, HLA-C and allele level matched for HLA-DRB1 and HLADQB1. The post-transplant GVHD prophylaxis consisted of MMF in NST group and CSA with MTX (n = 48) or CSA and MMF (n = 4) in the control group. Only 1 patient in the NST group received DLI. The cumulative 100-day incidence of grade II-IV GVHD was 62% in NST group and 77% in control group (p = 0.02). The incidence of chronic GVHD was comparable in both groups (73% in NST group vs. 71% in control

group). The skin and gastrointestinal symptoms (GI) peaked between 6–12 months in the NST group, and the first 30 days in the control group. Overall, patients who received NST required less systemic immunosuppression, and glucocorticoid treatment was initiated later.

23.5 Specific Disease Indications HSCT is primarily used in the treatment of malignant diseases of the hematopoietic system. Indications change over time due to results of clinical trials, and introduction of new medical treatments. Figure 23.1 below illustrates recent indications for blood and marrow transplantation in North America. The numbers of transplants performed reflect the relative incidence of the disease as well as the efficacy of HSCT for the disease. We will discuss below the current status of HSCT for diseases most commonly treated with HSCT.

23.5.1 Hematological Malignancy 23.5.1.1 Acute Lymphoblastic Leukemia in Adults Acute lymphoblastic leukemia (ALL) accounts for 20% of all acute leukemias in adults, with an incidence of two persons per 100,000 in the USA annually [145]. Major progress in therapy has occurred in the last

INDICATIONS FOR BLOOD AND MARROW TRANSPLANTATION IN NORTH AMERICA 2002 4,500 Allogeneic (Total N = 7,200) Autologous (Total N = 10,500)

4,000

Fig. 23.1 International statistics of transplants as reported to the Center for International Blood and Bone Marrow Transplantation Research (used with permission)

TRANSPLANTS

3,500 3,000 2,500 2,000 1,500 1,000 500 0 Multiple NHL Myeloma

AML Hodgkin Disease

ALL

MDS / CML CLL Neuroblastoma Other Leukemia

Breast Other NonCancer Cancer Ma ignant Disease

7

23 Current Status of Bone Marrow Transplantation

20 years; currently the complete response (CR) rate for adult patients is in the range of 75–90%. Despite this progress, the ability to cure adult ALL patients is limited mainly because of the high risk of relapse. AlloHSCT has been shown to decrease the relapse rate of adult ALL patients, and provide longer remissions and cures than intensive CT. However, wider application of allo-HSCT is limited by the risk of complications and TRM that can be as high as 40% [58]. Appropriate risk stratification based on clinical and laboratory parameters along with timing of the transplant are critical for successful intervention. Cytogenetic abnormalities are independent predictors of treatment outcome. Patients with abnormalities including clonal translocations such as the Philadelphia chromosome, t(9;22) or t(4; 11), t(1; 19) or t(8;14) have a higher risk of relapse after CT, exhibiting a worse clinical prognosis. In addition, patients in whom transplant is performed after CR1 or patients not in remission or with refractory disease have worse outcomes [51, 97]. Other important prognostic factors include an elevated white blood cell count (WBC) >30,000, age > 30 years, non-T cell phenotype, and time to achieve CR [87]. Burkitts type leukemia (identified as L3) is recognized as a poor prognostic indicator, yet the prognosis of this subgroup has improved with the advent of combination CT treatments including high-dose methotrexate (MTX) and fractionated higher doses of cyclophosphamide (CY) or ifosfamide [88].

23.5.1.2 HSCT in ALL Allo-HSCT can induce long-term remission and cure in ALL patients. Initial attempts to use this approach were undertaken in the late 1950s [191], and evolved rapidly over the last 40 years. The important role of allo-HSCT for the treatment of ALL patients has evolved from its early applications as a salvage regimen for end-stage patients to its current use in highrisk patients in first CR [145, 189]. Large clinical trials have reported DFS of 30–60%, long term survivors of more than 10 years and overall relapse rates of 15–20%, most in the first 5 years after transplant [97, 192]. It is now recognized that remission status is a major determinant of the transplant outcome since patients in remission at the time of transplant had improved survival, a lower incidence of recurrent

413

leukemia, and lower death rates from non-leukemic causes [189]. The use of HSCT in cases of refractory or relapsed ALL still provides better outcomes than CT alone with DFS of 20–40%. Therefore, allo-HSCT should be considered as the best therapeutic option for these patients [111, 145]. If a matched related donor is not available, then efforts should be undertaken to look for an unrelated donor. Recent improvements in post-transplant patient support and high resolution typing provides a better outcome for patients transplanted with unrelated donor cells. Several recent studies have shown that the gap between matched related and unrelated donor HSCT is decreasing, with patients having similar outcomes including 5-year overall DFS of 30–45% [45]. Allo-HSCT produces better outcomes in ALL patients when compared with auto-HSCT or CT. Large randomized trials have been performed comparing Allo-HSCT, auto-HSCT and CT alone. The French Group on Therapy for Adult ALL analyzed the data from 572 ALL patients who achieved remission and were treated with either allo-HSCT, auto-HSCT or CT [8]. Patients were randomized to the allo-HSCT arm if a sibling donor was available. Remaining patients were randomized to receive treatment with auto-HSCT or CT. The 5-year overall DFS was significantly higher for the allogeneic transplant group compared to the other two groups (46% vs. 31%; p = 0.04). There was no significant difference between CT and autoHSCT. The greatest benefit was seen in those with high-risk features, in which the 10-year survival was 44% following allo-HSCT vs. 11% for CT or autoHSCT (p = 0.009). The international MRC–ECOG trial reported similar results; this study has registered over 1,400 patients, and was recently reported [74]. The investigators found that the overall EFS for the subset of patients with standard risk disease who underwent allo-HSCT was 53% vs. 45% for the patients who did not have an HLA-matched sibling donor.

23.5.1.3 Significance of Graft Vs. Leukemia Effect in ALL Clinical trials have shown a correlation between GVHD and relapse rates in ALL [51, 137]. Allo-HSCT promotes a potent and clinically relevant graft vs. leukemia (GVL) effect, reflected by the fact that ALL

414

patients have higher relapse risks after auto-HSCT or syngeneic HSCT compared to allo-HSCT, lower incidence of relapse in those who develop GVHD, and increased relapse rates in recipients of T-cell-depleted marrow grafts. In one study [51], the probability of relapse was higher in patients without GVHD compared to patients with GVHD grade II or more (80% vs. 40%). Similar results were found in a larger study involving more that 1,000 patients. In this clinical trial, patients with either acute or chronic GVHD had a decreased relapse risk; this protective effect was observed in both T and B cell lineage ALL [137]. Despite this strong association between GVHD and low risk of relapse, it is still uncertain why ALL patients respond poorly to DLI compared to patients with CML or AML [85, 140, 158]. This limited beneficial effect of DLIs in ALL patients could be due to deficiencies in antigen presentation by the leukemia cells as well as defects in leukemia-reactive T cells, either to be generated or to promote active immune responses. Studies aimed at enhancing cellular responses against leukemia cells in ALL constitute a very active and promising area of research [5].

23.5.1.4 Different Sources of Hematopoietic Cells for Transplants in ALL Recently, mobilized PBSC have become the preferred source of hematopoietic cells in transplantation. Separate studies have previously reported that G-CSF mobilized PBSC leads to rapid engraftment without an apparent increase in GVHD [17, 107]. A large randomized trial confirmed that the use of growth factor mobilized PBSC led to improved survival, a similar incidence of acute GVHD and faster engraftment compared to BM [16]. Another study in patients with different hematological malignancies showed that PBSC transplants had better outcomes. This effect was most obvious in patients with high risk of relapse and complications [17]. There is less available data concerning the use of mobilized PBSC vs. BM in the unrelated donor setting. The use of cryopreserved unrelated cord blood has become a real alternative source of stem cells for patients lacking either a related or unrelated donor [108, 160]. Cord blood hematopoietic cells offer several advantages, particularly a reduced incidence of GVHD even in the setting of HLA mismatch. While

E.D. Ball et al.

clinical results are encouraging, long-term follow-up is required to analyze results concerning DFS and OS. Donors with one fully mismatched HLA haplotype (haploidentical donors) are another potential source of hematopoietic cells for transplants. This approach relies upon the use of manipulated grafts in which T cell depletion and a larger number of hematopoietic cells per kilogram are essential to ensure engraftment and control of severe GVHD [11, 86].

23.5.1.5 Conclusions Significant improvements in the treatment of adult ALL have been made during the last 40 years. Significant progress has been made is the development of HCT. Current data supports the use of this matched related donor HCT in CR1 in patients with standard risk features. Patients with high risk features based on age, elevated white blood cell upon presentation, cytogenetic abnormalities, and the subtype of leukemia cells may be offered matched unrelated donor stem cell transplantation. In addition, allo-HSCT should be considered early during the course of treatment for those patients who do not achieve a CR with conventional CT, and in those with refractory disease or in later remissions. Rapid identification of those patient and referral to specialized centers contributes to expedited typing and the search for potential donors.

23.5.2 Acute Myeloid Leukemia Despite recent advances and the use of induction and consolidation CT, the prognosis of adult patients with acute myeloid leukemia (AML) remains poor. Most studies using induction-consolidation therapy report long term DFS <40%, with mortality in most cases due to recurrent leukemia [121]. HSCT offers an additional therapeutic alternative for treatment of this disease. Several randomized trials have shown that allo-HSCT compared to auto-HSCT and conventional CT induces improved long term DFS and in some cases is curative [31, 183, 201]. In addition, biological evidence of a potent GVL in AML and the possibility to reduce the immediate TRM using low intensity conditioning regiments makes this treatment approach more appealing and applicable to a larger number of patients.

23 Current Status of Bone Marrow Transplantation

23.5.2.1 Prognostic Factors in AML Early reports of HSCT for AML in first CR helped identify clinical and laboratory parameters associated with clinical outcome. Among those parameters, age, white blood cell count at diagnosis, and length of time before achieving remission or time from diagnosis to transplant were noted [123, 185]. However, the strongest predictor of clinical outcome in AML is cytogenetics. AML patients can be subdivided into different subgroups depending on the karyotype. Good prognosis cases with long-term DFS exceeding 50% includes patients with t(8;21), t(15;17) or abnormalities of chromosome 16 including inv(16), t(16; 16) or del(16). The intermediate group was composed primarily of patients with normal cytogenetics. All other patients with various abnormalities are considered to have poor prognosis/high risk [22, 96]. This classification has allowed patient stratification and selection of treatment and design of clinical trials. Several large randomized clinical trials have shown that DFS in patients receiving a transplant is determined by the presence of cytogenetic characteristics upon diagnosis [63, 67]. Data from the IBMTR have shown similar leukemia-free survival in patients with good or intermediate prognosis who underwent allo-HSCT (50–56%). This was in contrast to the poor prognosis group which had a significantly worse leukemia-free survival of only 24% due to a higher risk of relapse [67]. Similar results have been obtained by other large collaborative and international trials [63, 67, 76]. Karyotypic analysis of an US Intergroup phase III study of post-remission therapy for adults with AML found that the OS regardless of therapy was 55% for the favorable cytogenetics group, and 38 and 11%, respectively, for the intermediate and poor groups [170]. More importantly, when the data was analyzed based on consolidation received, the 5-year OS estimates were 44% for the allo-HSCT arm, 13% for the auto-HSCT, and 15% for the CT arm. These differences were statistically significant when the analysis combined the autologous and CT arms (p = 0.043). More recently, one study analyzed the prognostic significance of karyotype for outcome after allo-BMT in CR1 [33]. This study included patients receiving both matched related (n = 82) and unrelated donor HSCT (n = 11). The median follow-up was 93 months and the OS, EFS, relapse rate, and TRM were not statistically different between the groups. Patients

415

receiving unrelated donor hematopoietic cells had a worse prognosis, confirmed in multivariate analysis. This study suggested that presentation karyotype has less prognostic significance for outcomes following allo-HSCT than for outcomes following conventional CT. In particular, AML patients with poor prognostic cytogenetic changes in CR1 who are unlikely to be cured with CT alone should be strongly considered for allo-HSCT. The role of allogeneic stem cell transplant for the group of AML patients with normal cytogenetics has been controversial. Recently, it was shown that in this group of patients, those with mutated nucleophosmin and wild type Flt-3 genes had favorable outcomes with chemotherapy and no transplant [165].

23.5.2.2 The Effect of Consolidation Therapy Prior to Transplant Several studies have investigated the need for consolidation CT prior to transplant. The IBMTR has reviewed registry data from patients who received different consolidation treatments. They include: no consolidation CT (n = 62), standard dose cytarabine (n = 222), and high-dose cytarabine (n = 147). The results showed no differences in OS, DFS, or relapse rate among these three groups [186]. Another retrospective study by the European Group for Blood and Marrow Transplantation showed no difference in outcome of patients receiving different consolidation treatments [30].

23.5.2.3 Source of Hematopoietic Cells for Transplants in AML Using PBSC has facilitated the logistics of hematopoietic transplantation, making it the most common source of stem cells. Several studies have demonstrated the equivalence and, in some cases, the superiority of transplants performed using PBSC. One study demonstrated that patients with advanced leukemia had superior survival when receiving PBSCT compared with BM [17]. A recent randomized clinical trial compared different donor cell sources in transplants for various hematological malignancies including AML [47]. All patients were transplanted with matched related donor cells, receiving similar conditioning regimens

416

and GVHD prophylaxis. In this study, there was no difference in the incidence of acute or chronic GVHD or relapse between the two groups, although OS was improved in the group receiving PBSCT. 23.5.2.4 The Use of Unrelated Donor Cells An analysis of 70 AML patients who received unrelated donor BMT demonstrated a 2-year DFS of 45% for patients in first or second remission; 19% for patients with more advanced disease [164]. GVHD and relapse remain significant barriers to long-term survival. The largest experience of outcomes of matchedunrelated donor (MUD) transplants for AML is based on 161 adult and pediatric patients [169]. DFS was 50% for patients transplanted in first CR, and 28% for patients treated in second CR. Patients with more advanced disease, including those with primary induction failure fared worse. Outcomes for DFS were comparable to those reported with matched-sibling donor transplants; rates of acute and chronic GVHD were higher in MUD recipients. These data show the importance of identifying and treating patients with MUD transplants early in the course of their disease, when the outcomes are similar to recipients of matched related donor transplants. Umbilical cord or placental derived hematopoietic cells represent a viable alternative for patients who do not have a donor. Because of the immaturity of the T cells obtained, there is a low incidence of GVHD even in cases with a significant HLA mismatch. The Placental Blood Program at the New York Blood Center reported their experience of 562 unrelated umbilical cord-placental hematopoietic cell transplants [160]. Young AML patients had a relapse rate in the first year of 30%. These results concurred with those of another study in which 19 AML patients receiving umbilical cord-placental hematopoietic cell transplant had DFS at 40 months of 26% [112]. Longterm survival data of these patients is limited; this lack of data creates difficulties interpreting the potential advantages or disadvantages of reduced immunomodulation of the graft, either presenting as GVHD or GVL effect. Ongoing research efforts focus on strategies to expand umbilical cord-placental hematopoietic cells. This strategy could facilitate the use of larger numbers of hematopoietic cells needed to transplant adults of average size (70 kg) or larger.

E.D. Ball et al.

Another alternative for adult patients who lack a potential donor is the use of HLA mismatched hematopoietic cells from haploidentical donors (siblings, parents and children). Preliminary reports indicate that when appropriate immunosupression and T cell depleted grafts are used, the degree of GVHD is not as high as initially expected based on the degree of HLA disparity [11]. Patients with AML (but not ALL) seem to benefit from the protective immunological effect mediated by natural killer cells (NKC) present in the allo-graft [161]. OS and other outcome parameters from haploidentical transplants cannot be assessed yet due to the lack of long term follow-up. Ongoing studies of haploidentical transplants continue to expand our knowledge about immunomodulation of the transplant, especially NKC reactivity, mechanism of immunosupression that can control GVHD and enhance the GVL effect, and new supportive care strategies that can benefit these patients.

23.5.2.5 Considering the Best Consolidation Strategy for AML Patients At least 20 different large randomized trials have addressed this question for AML patients in CR1 [6, 7, 31, 201]. Most studies have shown that if a donor is available, allo-HSCT provides the best long term DFS and the lowest risk of relapse compared to standard CT and auto-HSCT. The largest study reported so far was conducted on behalf of the European Organization for Research and Treatment of Cancer (EORTC) and Gruppo Italiano Malattie Ematologiche Maligne dell’ Adulto (GIMEMA) [201]. They reported a 4-year DFS of 55%, 48% and 30% for patients undergoing alloHSCT, auto-HSCT and CT consolidation, respectively. The DFS results obtained after allo-HSCT were statistically significant, and the risk of relapse was much lower in the allo-HSCT group. There was no significant advantage in OS for allo- or autoPBSC vs. CT. Current available data show better outcome for patients transplanted in first CR vs. second CR, relapse or refractory disease [40, 44]. In addition, patients transplanted in untreated first relapse compared with second CR have similar DFS of 24 and 26%, respectively [29]. The IBMTR and American BMTR reported results of 2 retrospective studies analyzing the outcome

23 Current Status of Bone Marrow Transplantation

of patients undergoing transplant vs. CT in second remission [66]. Both studies showed a more favorable DFS with allo-HSCT vs. auto-HSCT or standard CT. Available data suggest that AML patients benefit from allo-HSCT in CR1, and those in second CR or untreated first relapse can expect a similar outcome following allo-HSCT from a matched-sibling donor.

417

should be considered for some patients [93]. NST reduces TRM and other complications secondary to the conditioning regimen. In most cases, NST is used in patients who would not be candidates for conventional myeloablative transplants due to advanced age or other co-morbid conditions. Long-term follow-up of patients treated in clinical trials will determine how this modality should be incorporated in the treatment schema of AML patients.

23.5.3 Reduced Intensity Regimens for AML 23.5.5 Chronic Lymphocytic Leukemia Results from a large multi-institutional trial using this approach in different hematological malignancies has been reported [125]. Using low-dose TBI in a single 200 cGy dose and, in some cases, the same dose of TBI plus fludarabine, with post-transplant immunosuppression using CSP and mycophenolate mofetil. Forty-five patients were enrolled. Ten were adults with AML (most in CR); 50% were still in CR after 1 year of follow-up. Grade II—III acute GVHD occurred in 47%; nonfatal graft rejection was encountered in 20%. TRM was 6.7% and survival was 73.3% (median follow-up 244 days). A recent follow-up of that study in 18 cases of AML showed a non-relapse mortality (NRM) at day +100 of 0%, with a 1-year estimated NRM of 17% (95% confidence interval [CI] 0–35%). Ten patients died; median follow-up among the 8 survivors was 766 days (188–1,141 days). Seven of the 8 survivors remained in CR. Longer follow-up will be required to analyze data concerning DFS and OS, and the full impact of reduced intensity conditioning on GVL effect.

23.5.4 Conclusions The survival of AML patients has improved mostly due to the recognition of reliable prognostic factors such as cytogenetic abnormalities, the use of consolidation CT, and treatment with allo-HSCT. Patients with intermediate or high-risk features should be considered for allo-HSCT earlier in the disease course. For those patients without an available donor, alternative sources of stem cells for transplant should be considered. These include MUD, umbilical cord-placental cells, haploidentical donors. In addition, autologous stem cell transplantation can result in good outcomes and

Chronic lymphocytic leukemia (CLL) is a B cell leukemia constituted by cells that accumulate in lymphoid organs and the peripheral blood, mainly due to the failure of leukemia cells to die by apoptotic mechanisms [95]. CLL patients have diverse clinical manifestations due to either direct involvement of the lymph nodes and spleen or those related to the cellular and immune deficiency accompanying this disease. Patients with CLL have different outcomes; it is only recently that this biological variability has been better understood. For example patients with more indolent disease (median survival 10 years) have immunoglobulin variable heavy chain genes (Ig VH ) that are mutated, while those with a more aggressive clinical course (median survival 4 years) have unmutated Ig VH genes [59, 91]. Microarray technology has made it possible to differentiate even further the molecular differences of these two subsets of patients, and to propose a group of signature genes characteristics of aggressive-high risk CLL [156]. Among these, the gene ZAP-70 has been most extensively studied because of its strong association with unmutated cases [34, 48]. ZAP-70 encodes a protein kinase normally expressed in T and NK cells, not in normal B cells. The functions of ZAP-70 protein and its involvement in the process of CLL leukemogenesis are currently matters of intense research. Despite these biologic advances, CLL remains incurable by conventional treatments such as CT or irradiation. The observation that patients treated with auto-HSCT or allo-HSCT have better DFS and OS than those treated with conventional CT are encouraging, and have promoted the investigation of this concept further in randomized clinical trials. The fact that patients treated with allo-HSCT can achieve prolonged

418

survival, and even be cured from CLL, has generated great expectations regarding the broader applications of this therapeutic approach.

23.5.5.1 Auto-HSCT in CLL Auto-HSCT using high dose CT plus low dose TBI has been tested in CLL [100, 127, 139, 146, 194]. The major problem is to eliminate residual disease from the BM or PB prior to collection of stem cells. Several authors have found discordant results; for example, reported transient remissions in heavily pretreated patients with a high incidence of relapse [100, 139]. Others describe more encouraging results, focusing on the treatment of patients early in their disease [144, 146]. The long-term follow-up shows that DFS curves do not achieve a plateau due to late relapses; hence it is unlikely that auto-HSCT can cure CLL. Another interesting concept uses sequential highdose therapy (SHDT) including auto-HSCT in CLL [53]. Sixty-six patients underwent treatment with sequential CT, including CHOP followed by fludarabine based CT and auto-HSCT, using BEAM as the preparative regimen. Results were compared with a database of 291 patients treated with CT. Patient groups were well balanced for risk factors including adverse genomic abnormalities and CD38 expression. With a median follow-up of 78 months, survival was significantly longer for SHDT patients than for conventionally treated patients. The benefit for the SHDT group remained significant when the analyses were restricted to those 58 patients with an unmutated variable immunoglobulin heavy chain. Cox regression analysis confirmed SHDT as independent favorable prognostic factor for survival from diagnosis (HR 0.38, p = 0.04), as well as from study entry (HR 0.38, p = 0.03). These data suggest a survival benefit for patients with poor-risk CLL receiving SHDT during the course of their disease.

23.5.5.2 Allo-HSCT in CLL Several studies have explored the use of allo-HSCT in CLL patients at different stages of progression reporting a 5 year DFS of 20–55% [53, 99, 194]. Others reported on 28 cases of advanced stage of CLL patients refractory to fludarabine (median previous

E.D. Ball et al.

treatments – 3) [99]. The conditioning regimen for most was high-dose cyclophosphamide 60 mg/kg daily for 2 days and fractionated TBI. GVHD prophylaxis consisted of cyclosporine-A or tacrolimus and MTX in the majority of patients. Seven patients had a MUD, and the remaining received sibling donor cells. The median follow-up for survivors was 66 months. For chemo-sensitive patients, the OS was 78% vs. 31% for those with refractory disease (p = 0.05). Progression-free survival at 5 years was 78% for the chemo-sensitive, and 26% for those refractory to CT at the time of transplantation (p = 0.03); TRM at 100 days was 11%. The risk of severe or life threatening GVHD was 49%. These data suggested that alloHSCT provides long term DFS, and may be curative for some CLL patients. Because chemosensitivity is an independent predictor of response to allo-HSCT, patients should be considered for this procedure prior to becoming refractory to CT. A similar report highlighting the importance of chemoresponsiveness as a predictor of outcome with allo-HSCT has been published by the EBMT and the IBMTR [127]. Allo-HSCT in CLL offers not only the benefit of strong high dose cytotoxic therapy from the preparative regimen, but also the possibility of inducing GVL. This appears to be responsible for the potent anti-leukemia effect of allo-HSCT. However, this requires time to develop, which is precisely why the outcome of antileukemia immunomodulation in an indolent disease like CLL may prove to be more successful. The use of allo-HSCT is limited mainly by the associated mortality. Several series have reported a TRM of 30–40%, correlating with the performance status of patients, number of prior treatments, and stage of disease [57, 138]. NST or reduced intensity conditioning regimens could potentially decrease TRM while preserving a potent GVL-effect. A number of publications that have reported initial results with this reduced intensity conditioning regimens will be discussed below. The German CLL Study Group has conducted a pilot study using a combination of fludarabine and cyclophosphamide. Seven patients with symptomatic CLL (that meet NCI working group treatment criteria and that were refractory to fludarabine) were treated. GVHD prophylaxis was performed with either CSA and a short-course of methotrexate or CSA – mycophenolate mofetil. Transplants were performed with PBSC from HLA-identical donors. All patients

23 Current Status of Bone Marrow Transplantation

achieved donor chimerism, 2 after DLI [median time to 95% chimerism was 108 (49–202) days]. Five patients experienced acute and/or chronic GVHD; in 4 cases, chronic GVHD was associated with immunologic and molecular clearance of residual disease. At the time of publication, all patients were alive and progressionfree [52]. Similarly promising findings have been observed in other series, with TRM and GVL-effect being favorable features of reduced intensity conditioning regimens [72, 98, 163].

419

for selection of patients who would benefit most from HSCT, i.e. high risk vs. low risk patients and the incorporation of new molecular prognostic factors such as the level of expression of Zap70 in the leukemia cells. In addition, it is important to determine the most appropriate time to perform the transplant, and the precise role of reduced intensity conditioning regimens. Future directions must focus on the study of fundamental basic problems such as separating GVL-effects from GVHD, and the implementation of efficient and well-organized multi-institutional clinical trials.

23.5.5.3 Auto-HSCT Vs. Allo-HSCT in CLL In general, clinical trials have shown that allo-HSCT produces a better outcome than auto-HSCT by reducing the rate of relapse after transplant. In one study, 22 patients with advanced CLL refractory to fludarabine were treated with either auto-HSCT or alloHSCT [141]. Autologous donor cells were purged of leukemia contamination using an immunomagnetic procedure and B cell antibodies. The 3-year DFS rates of allo-HSCT compared with purged ASCT were 57 and 24%.; 3-year survival was 57% vs. 33% respectively. The better outcome of allo-HSCT treated patients is likely secondary to GVL effect. The observation that DLI can induce remission after relapse from allo-HSCT corroborates the importance of GVL in CLL [155, 163].

23.5.6 Conclusions Allo-HSCT has demonstrated its potential curative role in CLL compared to auto-HSCT and conventional CT. The therapeutic effect of allo-HSCT is primarily mediated by its associated GVL-effect. However, the high rate of TRM limits the application of this treatment modality in patients who are elderly, refractory to conventional CT, or those with advanced disease. Unfortunately, patients with similar characteristics are those most frequently referred for transplant after having failed a number of alternative therapies. Hence, early referral of appropriate candidates for transplantation potentially improves the outcome of patients undergoing this procedure. Several questions related to the application of HSCT in CLL remain unanswered. They include the identification of optimal biological and clinical parameters

23.5.7 Chronic Myeloid Leukemia CML results from malignant transformation of a relatively primitive hematopoietic stem cell, which retains the capacity to differentiate along several hematopoietic lineages. The disease is characterized by the presence of the Philadelphia chromosome (t 9; 22–q34; q11) within the malignant cells. If not eradicated, the disease progresses through an initial chronic phase (CP), through an accelerated phase (AP) of variable duration, to an often rapidly fatal terminal blastic phase (BP). Allo-HSCT is a highly effective strategy for eradication of CML. This is suggested by the existence of patients who are alive and free of disease in excess of 20 years following allo-HSCT [4, 68], and the high rate of molecular (PCR-negative) remissions in patients after undergoing allo-HSCT [147]. IBMTR reports that approximately 70% of CP-CML patients achieve long-term survival if transplanted within 1 year of diagnosis from a matched sibling donor. Data from selected single centers are superior to those reported by the IBMTR (3 year survival of 86%; 131 patients) using a targeted busulfan and cyclophosphamide regimen [148]. Patients undergoing allo-HSCT > 1 year following diagnosis have poorer outcomes than those transplanted earlier – even if patients in more advanced phases are excluded [56]. Patients undergoing alloHSCT from a MUD have traditionally had somewhat inferior outcomes to those from matched-sibling donors. However, recent data, improved HLA-typing and better supportive care, suggest that outcomes for MUD transplants may approximate those for sibling transplants in some centers [124]. Eradication of CML through allo-HSCT appears to result from a potent

420

GVL effect as suggested by the major increase in relapse rates following the use of T-cell depleted grafts, and the ability of DLI to effect long-term remissions when performed for cytogenetic and early hematologic relapses. Clinical trials of allo-HSCT have revealed areas of consensus. A randomized trial performed in Seattle demonstrated that the combination of busulfan and cyclophosphamide (BuCy) was better tolerated than Cy +TBI as a preparative regimen; long term OS also appears superior in the BuCy arm [41]. Individualized busulfan (targeted dosing) based upon first-dose pharmacokinetics appears to compensate for individual differences in absorption and metabolism of oral busulfan, and seems to improve outcomes, although no randomized comparisons have been performed [148]. Using IV busulfan may overcome the variability seen with non-targeted oral busulfan; it is not clear whether IV busulfan completely overcomes the need for pharmacokinetic monitoring. Splenectomy or splenic irradiation do not appear to benefit patients prior to allo-HSCT [75]. The role of BM vs. PB as a stem cell source remains controversial in CML. Randomized trials show more rapid engraftment following PB transplants and equivalent GVHD. However, chronic GVHD appears more prevalent in a number of trials. No statistically significant survival advantage has been demonstrated with PB in CML-CP patients. T-cell depletion leads to a severely increased risk of relapse following allo-HSCT for CML [73], and is no longer widely practiced. Patients with advanced phase CML have inferior outcomes to those transplanted in CP with long-term survival in approximately 45% and 15% of patients transplanted in AP and BP respectively using sibling donors. Evidence suggests that patients transplanted in AP defined by cytogenetic evolution only may have superior outcomes to those with AP defined by hematologic parameters [39]. Patients with BP-CML may benefit from attempts to re-instate chronic phase (2nd CP) prior to allo-HSCT [197]. Patients who have undergone allo-HSCT for CML should be monitored using BM karyotyping and/or PB fluorescent–in–situ-hybridization (FISH) since cytogenetic relapse is more successfully treated with DLI than frank hematologic relapse. Molecular monitoring using RT-PCR on PB and/or BM cells becomes predictive of relapse starting 6 months post-transplant [147]. These patients should be monitored by RT-PCR

E.D. Ball et al.

starting at this stage. Persistently positive PCR findings beyond 6 months should be treated with immunologic manipulation or imatinib mesylate (Gleevac). Serial monitoring of quantitative RT-PCR can detect rising malignant transcript levels to more readily identify impending cytogenetic or hematologic relapse. Non-transplant management of CML has been transformed by the advent of therapy with tyrosine kinase inhibitors such as imatinib (Gleevec). This orally bio-available tyrosine kinase inhibitor achieves complete hematologic remission in most patients with CP-CML, and in a significant proportion of patients with advanced phase disease. Furthermore, imatinib achieves complete cytogenetic remission in nearly 80% of CP patients within 18 months when used as first-line therapy [136]. There is now significant evidence that patients achieving cytogenetic remissions obtain a prolongation of the duration of chronic phase and survival. Long-term success of imatinib in suppressing, perhaps eradicating, CP-CML has not been demonstrated (in contrast to the clear demonstration of long term cure potential following allo-HSCT). Its potency in inducing complete cytogenetic remissions with its low toxicity and risk of early death make it an attractive initial alternative to allo-HSCT in many patients with CP-CML. In fact, current practice is to treat all new patients with CML with one of the current tyrosine kinase inhibitors such as imatinib. The majority of patients with CML are not likely to need a stem cell transplant. However, there are potential risks to the strategy of initial imatinib therapy in candidates for allo-HSCT. These include the delay in allo-HSCT in light of the known detrimental effects of delay beyond 1 year from diagnosis to transplant, advanced patient age resulting in a possibly higher-risk transplant later in the course of the disease, and the unknown effects of imatinib on transplant efficacy with known effects. However, the use of imatinib as first-line therapy with allo-HSCT only in patients with an unsatisfactory cytogenetic response to the drug is currently the preferred approach. Patients with AP and BP CML have much poorer outcomes with imatinib than patients treated in CP [162, 187]. Eventual development of molecular resistance to single-agent imatinib and disease recurrence is more likely in this setting. Gleevac is best considered a temporary measure to control/debulk the patient’s disease while a donor is identified for allo-HSCT.

23 Current Status of Bone Marrow Transplantation

23.5.8 Multiple Myeloma Multiple Myeloma (MM) is generally a chemosensitive disease. However, although conventionaldose chemotherapy (CDT) such as the combination of low-dose melphalan and prednisone produced objective responses in > 50% of patients with previously untreated MM, complete responses were rarely achieved and prolongation of survival was relatively small. Two studies assessed very high doses of chemotherapy (HDT) (e.g. melphalan >100 mg/m2 ) in order to improve the response rates and survival seen with CDT [122, 168]. Studies using melphalan 140 mg/m2 without auto-PBSC demonstrated high overall response (OR) rates and CR rates of 25–30% in newly diagnosed patients. However, morbidity and mortality from severe myelosuppression was high. Attempts to ameliorate the myelosuppression caused by HDT with hematopoietic growth factors achieved limited success, most effectively in patients with adequate BM reserve [13, 131]. HDT was better tolerated when accompanied by auto-BM or PB stem cell support (ASCT). When used in primary refractory patients, response rates of 65–88% were reported with an OS up to 42 months [2, 149]. When used in patients who respond to initial CT, non-randomized studies have shown that HDT with autologous PBSC support is safe (<5% TRM), inducing CR in 30–50% of patients. However, claims of superiority of HDT to CDT alone in this setting were difficult to analyze because of potential selection bias in these phase II studies. 23.5.8.1 Single auto Transplant Vs. Conventional Dose Therapy Alone The superiority of HDT to CDT was demonstrated in a prospectively randomized multi-center trial by the Intergroupe Francais du Myelome (IFM) in the IFM 90 trial [10]. Patients received 4–6 cycles of alternating multiagent CDT, and were randomized to receive either 4 additional cycles of multi-agent CDT or HDT (melphalan 140 mg/m2 +TBI with ASCT). On an intent-to-treat analysis, the HDT arm had significantly better CR rate, EFS and OS. Since the publication of the results, other randomized trials comparing HDT + ASCT to CDT have been reported [21, 36, 61]. All trials demonstrated a significantly improved CR rate in

421

the HDT arm. The median reported EFS was higher in the HDT in all studies, and significantly higher in the HDT arm in 3/5 reported randomized trials. OS was significantly higher in the HDT arm in 2 reported trials (IFM 90 and MRC7), and tended to favor the HDT arm in 2 of the 3 remaining studies. These data provide strong support for the use of HDT+ASCT to consolidate the response to CDT in newly diagnosed patients < 65 years old. The ability of some trials to demonstrate statistically significant superiority in the HDT arm may have been compromised by failure to randomize patients prior to starting the CDT component, insufficient follow-up, salvage HDT+ASCT in relapsing patients on the CDT arm, or inadequate trial size. Recently data from SWOG/Intergroup trial (S9321) [13] showed no significant advantage to the HDT arm vs. the “standard therapy” arm for CR rate, EFS and OS. This was affected by a high salvage transplant rate (52%) for patients on the non-HDT arm. This trial was more a study of early vs. late HDT, rather than HDT vs. CDT. Early collection of PB followed by delayed HDTASCT at disease relapse may achieve a similar OS to early HDT-ASCT (immediately following response to initial therapy). However, a randomized French clinical trial demonstrated that the same OS is achieved at a cost of more overall therapy and inferior quality of life in the delayed HDT arm [62].

23.5.8.2 Tandem Vs. Single Auto Transplant A recent IFM trial (IFM-94) compared tandem HDTASCT using melphalan 140 mg/m2 followed by melphalan 140 mg/m2 + TBI 8 Gy to a single transplant using melphalan +TBI alone. Initial results were presented at the 2002 American Society of Hematology meeting; results were updated with the benefit of additional follow-up at the IX International Myeloma Workshop [9]. They show a 7 year EFS of 20% for the tandem arm compared to 10% in the single auto transplant arm. OS was also superior (42% vs. 21%). Subgroup analysis demonstrated that the greatest benefit from the tandem transplant was seen in patients who failed to achieve a CR or very good PR after the first auto-HSCT. Other randomized trials in MM have demonstrated that melphalan 200 mg/m2 is superior to melphalan 140 mg/m2 +TBI in toxicity and OS [130]. CD34

422

+ cell selection using currently available technology does not improve outcomes over unselected stem cells [172], and may be associated with more prolonged immunosuppression and increased risk of opportunistic infections. 23.5.8.3 Allogeneic Transplantation HDC-ASCT is not considered curative in MM. However, long-term survivors following allo-HSCT have been reported [16], suggesting that some patients may be cured. Allo-HSCT allows the administration of a graft free of myeloma contamination and may enable adoptive immunotherapy (graft-vs.-myeloma effect). More direct evidence for the existence of a graft-vs.-myeloma effect has come from reports of remission induced by DLI alone in patients relapsing after allo-HSCT [117]. The use of myeloablative allo-HSCT as a potentially curative strategy in patients with myeloma has been limited by the severe risk of TRM in early studies [16]. Similarly, the allo-HSCT arm of the SWOG/Intergroup trial (S9321) was closed after accrual of only 38 patients because of unacceptably high early TRM [13]. However, a recent update of data from that trial supports the existence of a graft-vs.-myeloma effect. A plateau was apparent on the survival curve of the alloHSCT arm, whereas patients who underwent ASCT demonstrated continuing relapses. Recent data suggest that TRM after allo-HSCT for myeloma may be decreasing; perhaps with better patient selection and improved supportive care (Gahrton, 2003). However, the most significant attempt to reduce TRM during allo-HSCT for myeloma has been the application of reduced-intensity NST regimens. Studies do suggest that the rates of early TRM using NST indeed appear lower than expected following ablative allo-HSCT in a similar population [12]. However, there is a significant risk of relapse or progression of MM following NST, often necessitating additional cellular therapy for disease control. This is particularly the case when patients undergo NST after failing multiple prior therapies, and when T-cell depletion such as in vivo alemtuzumab therapy is used to abrogate GVHD [140]. One approach designed to improve both the tolerability and efficacy of allo-HSCT for MM currently being evaluated is tandem transplantation: a standard auto transplant followed rapidly by NST [119]. A regimen initiated in Seattle involves NST using TBI

E.D. Ball et al.

2 Gy as the preparative regimen. The NST is administered 40–120 days following a standard ASCT using melphalan 200 mg/m2 in patients who have an HLAidentical sibling donor. Cyclosporine and mycophenolate mofetil are used to control both GVHD and graft rejection following the NST. This trial showed very low early TRM in the first 52 patients. Eightythree percent of patients had an objective response (CR+PR) after this approach, and 57% had a CR; OS at 2 years was 75%. However, it is unclear that there is a plateau on the relapse-free survival curve from this trial; longer follow-up is awaited. Meanwhile, this approach is being tested in a randomized comparison in a large trial organized by the Bone Marrow Transplant Clinical Trials Network (BMT-CTN 0102). Patients are genetically randomized based upon the availability of an HLA-identical sibling donor to the approach described above vs. 2 auto transplants using melphalan 200 mg/m2 . Patients in the auto-HSCT only arm are subsequently randomized to receive maintenance therapy (thalidomide/dexamethasone) for one year. The study has completed enrollment but results are not yet known at the time of this report. A similar study from an Italian consortium showed superiority in the allogeneic HSCT arm of the study compared to tandem autologous stem cell transplantation [28]. In addition, a Spanish study has shown promising early results in the reduced intensity allogeneic stem cell transplant arm [157]. In summary, at least 1 ASCT using melphalan 200 mg/m2 has been considered standard of care in patients (age <65) with stage II or III MM who respond to initial cytoreductive therapy. Auto transplant may also be well tolerated and beneficial in older patients who are otherwise healthy. A second auto-HSCT may benefit patients who fail to achieve a CR after one autoHSCT. The use of allo-HSCT, particularly using nonablative conditioning as a tandem procedure following cytoreductive autografting, is a promising and potentially curative strategy. Further follow-up and results of trials currently underway are awaited before the role of this strategy can be adequately defined. Moreover, the introduction of many new active chemotherapy agents and more impressive response rates in newly diagnosed patients with multiple myeloma has made the treatment of myeloma more complicated. Clinical trials will continue to evaluate the role of stem cell transplantation in this era of improved chemotherapy results in multiple myeloma.

23 Current Status of Bone Marrow Transplantation

23.5.9 NHL and Hodgkin Disease The non-Hodgkin’s lymphomas (NHL) are a heterogeneous group of malignant disorders of lymphocytes. The most recent and widely accepted classification from the World Health Organization (WHO) [81] evolved as a refinement of the Revised EuropeanAmerican Classification of Lymphoid Neoplasms (REAL) [82]. The REAL classification attempted to be an all inclusive system utilizing immunological and genetic features in ways not utilized in previous classifications. As a result, better definition of entities not fitting into previous classifications was achieved. The WHO classification takes these features and aspects of clinical behavior into consideration, resulting in a comprehensive list of entities relating lymphoid malignancies to their normal cellular counterparts. The older Working Formulation (WF) classification allowed categorization of specific entities into groups with similar clinical behaviors. Thus, NHL was classified as low, intermediate, or high grade. Low-grade lymphoma, although characterized generally as sensitive to a variety of CT agents or combinations, was incurable; patients generally died from their disease after a median period of 7–10 years. These lymphomas can follow an indolent course, sometimes not requiring active therapy, but eventually progress. Although intermediate and high-grade lymphomas are more rapidly growing, in many cases cure can be achieved with various combinations of CT alone, or combined with radiation. The histologic subtype determines the optimal treatment. Understanding the grading of entities within the WHO classification is necessary for treatment planning. For terminology purposes, entities considered low-grade are now referred to as indolent; intermediate and high-grade lymphomas are considered aggressive. These terms encompass a number of different malignancies; understanding specific entities is required for optimal management. Indolent NHL can be conservatively managed in selected cases with periods of observation alone; “watch and wait” strategy. In other cases, early treatment is required for management of its various manifestations. Options for treatment include radiation alone in highly selected cases of localized disease, CT (single agent or combination), or monoclonal antibody

423

(mAb) therapy. Alternatively, these therapies may be given in combination. Traditional management has been an escalated approach over time, with progressively lower response rates, and shorter periods of remission with subsequent regimens. More recently, mAb has an increasingly significant role. Specifically, anti-CD20 mAbs and next-generation radioimmunoconjugates are in common usage, alone or in combination with CT. For aggressive lymphomas, initial treatment is usually given with curative intent. Standard is CHOP (cyclophosphamide, adriamycin, vincristine, prednisone) given in 21 day cycles. Overall, this is curative in approximately 40% of cases. The monoclonal antibody Rituximab has been shown to increase the response rate and OS in patients over the age of 60 [42]; ongoing studies are evaluating this in other populations. For high-grade lymphomas including lymphoblastic lymphoma, Burkitt’s and Burkitt’s-like NHL, more intense, multi agent CT regimens are administered, also with curative intent.

23.5.9.1 Role of Autologous Transplantation for Indolent Lymphoma Agents known to be active against NHL whose primary toxicity is myelosuppression are included in the HSCT regimen. As noted, indolent lymphoma is not curable following standard CT regimens; this is also generally true following HDT-ASCT. Success has been limited by the failure to completely eradicate minimal residual disease and marrow involvement. However, a number of clinical trials have demonstrated benefit. Initial reports included patients undergoing transplant with BM, whereas more recent reports utilize PBSC. With marrow involvement as an obstacle to improving outcome, purging of the graft, either ex vivo with a cocktail of monoclonal antibodies, or in vivo with CT and/or monoclonal antibodies has been attempted. At the Dana Farber Cancer Institute, 153 patients underwent autologous BM transplants using an anti-B cell monoclonal antibody cocktail. Patients in sensitive relapse or incomplete first remission (median age 43 years) and a median of 3 prior treatment regimens received the Cy/TBI preparative regimen. After median follow-up of 80 months, 63 patients had relapsed, predominantly in sites of previous disease; 34

424

were alive. After median follow-up of 61 months, 79 were alive in CR. Eight years following auto-BMT, the DFS and OS were 42% and 66%, with the suggestion of a plateau in the DFS curve. There was a significantly longer freedom from recurrence in patients who achieved PCR negativity after purging. There was a correlation between continuing PCR negativity and a continuing CR [65]. A recent study from the European Group for Blood and Marrow transplantation (EBMT) sought to determine in a randomized fashion whether HDT-ASCT with or without purging was beneficial. Primary end points were PFS and OS [167]. This study suffered from a number of limitations including slow and incomplete accrual. Later patients were only accrued to the arms evaluating purged vs. unpurged marrow transplant. Overall, only 89 patients were randomly assigned between the groups (only 19 between the 2 transplant arms). With a median follow-up of 69 months, a significant improvement in PFS was noted in favor of HDT. No difference could be demonstrated between purged and unpurged transplants. Determining the role of ASCT for indolent lymphomas continues to be very challenging. The long natural history and the availability of an increasing number of therapeutic agents make such evaluation difficult. Nonetheless, evidence strongly suggests that a real benefit in terms of progression free survival exists, and that there is value to obtaining a state of minimal residual disease. Exploring newer therapeutic strategies to eradicate minimal residual disease post-ASCT setting may well be a fruitful strategy.

23.5.9.2 Role of Allogeneic Transplantation for Indolent Lymphoma Allogeneic transplantation is a promising approach for selected patients with indolent lymphoma. The graft vs. lymphoma effect as demonstrated by a reduced relapse rate in the allogeneic vs. autologous setting [195], and also the observation that the relapse rate is lower in patients experiencing chronic GVHD [38], provides the main rationale for pursuing this approach. Studies evaluating traditional allogeneic transplant approaches with HSCT have reported encouraging results with a significantly higher PFS than alternative approaches. However, the mortality from transplantrelated complications has offset any advantage [150]. The recent introduction of NST, attempting to reduce

E.D. Ball et al.

TRM while maintaining the graft vs. malignancy effect, has increased the pool of patients to potentially benefit from this immunotherapy. Very promising preliminary results have been reported from the M.D. Anderson Cancer Center in 20 patients (median 51 years) who received a NST with fludarabine/cyclophosphamide conditioning. With a median follow-up of 21 months, no relapses were seen [98]. An expanded group of patients from the same group included 20 – indolent NHL, 14 – mantle cell lymphoma and 15 – aggressive NHL was recently reported [102]. The median age was 55 years. At a median follow-up of 19 months, rates of PFS (± SE) were 85% (±8%), 68% (±21%) and 60% (±12%) respectively. One patient died within 100 days of transplant, an additional 7 died at later time points, 4 from relapse and 2 from chronic GVHD. Eight-year experience with allogeneic stem cell transplantation for relapsed follicular lymphoma after nonmyeloablative conditioning with fludarabine, cyclophosphamide, and rituximab. An update of this experience continues to show very promising long-term survival [101].

23.5.9.3 Role of Autologous Transplantation for Aggressive Lymphoma For patients with relapsed aggressive lymphoma (intermediate grade in the WF classification) who remain sensitive to CT, HDT-ASCT is the treatment of choice. This approach is supported by results from a randomized trial comparing a conventional salvage CT regimen to HDT followed by ABMT. Significant improvement in EFS (46 vs. 12% p = 0.001) and OS (53 vs. 32% p = 0.038) favoring the high dose arm was seen at 5 years. This improvement was seen even though some patients allocated to the transplant arm did not actually receive a transplant for a variety of reasons. It was further observed that patients relapsing within 1 year of initial CT were less likely to benefit from high dose therapy [141]. For others, the role of transplantation remains more controversial. The International Prognostic Index has allowed a risk designation to be assigned to patients at diagnosis [143]. Five year survival:73% for low-risk patients, 51%:low-intermediate risk, 43%:high-intermediate risk, and 26%:high risk: Clearly, improved outcomes are required, especially among the higher risk groups. A number of investigators have attempted to determine whether HDT/ASCT

23 Current Status of Bone Marrow Transplantation

in CR1 can provide improved disease control. While the addition of rituximab to anthracycline based therapy has improved response rates and survival [42], the role of HDT-ASCT remains open. One study of curtailed induction therapy followed by HDT/ABMT demonstrated improved results for early transplant [69], while contradictory results have been reported from another group in higher risk patients [71]. In patients responding slowly to CHOP (PR after 3 cycles) who underwent HDT/ABMT, no improvement was seen when compared to continued CHOP [196]. In patients with high/intermediate to high risk disease who achieve a CR with induction therapy, a large randomized trial has demonstrated a significant improvement in survival at 8 years for HDT/ABMT vs. no additional therapy (64% vs. 49% p = 0.04) [78]. These studies were conducted prior to the introduction of mAb, introducing a further confounding factor into their interpretation.

23.5.9.4 Role of Allogeneic Transplant for Aggressive Lymphoma Few studies have examined this issue. Clearly the graft vs. aggressive lymphoma effect is less effective than in indolent lymphoma [20]. The M.D. Anderson report of NST included 49 patients, 15 with transformed or de-novo aggressive lymphoma. With a median followup of 19 months, the PFS was 60%±12%. The role of allo-HSCT for aggressive lymphoma continues to be an open research question.

23.5.10 Hodgkin’s Disease Hodgkin’s disease is a malignant disorder characterized by the presence of Reed-Sternberg cells derived from B cell precursors [120]. Overall, approximately 80% of cases are cured using radiation therapy alone, CT alone (using the ABVD regimen) or a combination of the 2 modalities. Patients with relapsed disease or those who fail to achieve a CR with initial therapy should be considered for HDT-ASCT. Whether patients with high-risk features at diagnosis benefit from HSCT remains controversial. For patients who fail to achieve CR or those who relapse at least 1 year after initial therapy, HDT-ASCT

425

is indicated [115, 166]. PFS is significantly improved but to date differences in OS have not been shown. It is likely that this is a function of study design where most patients in the non-transplant arm subsequently undergo transplant at the time of disease progression. In the study from the European consortium, 161 patients with relapsed Hodgkin’s disease, up to age 60 were randomized between 4 cycles of CT or 2 cycles of CT followed by HDT and HSCT or BMT transplant. After a median follow-up of 39 months, the freedom from treatment failure was 55% for the high dose arm, and only 34% for the conventional dose arm. This study also suggested that patients whose initial remission was longer than 1 year also benefit from HDT-ASCT. Whether consolidating high-risk patients with HDT-ASCT is beneficial remains investigational. Prognostic factors identifying patients at increased risk for relapse have been identified [84]. A recent report from European and Israeli investigators described 163 patients with unfavorable characteristics achieving a CR or PR after 4 cycles of ABVD or another doxorubicin containing regimen. Unfavorable characteristics included at least 2 of the following: high LDH, a large mediastinal mass, more than one extranodal site, a low hematocrit and inguinal involvement. Patients were randomized after 4 cycles of chemotherapy to an additional 4 cycles or HDT-ASCT (BEAM or CEB). At a median follow-up of 48 months, the CR rate (92 v 89%), 5 year failure free survival (75 v 82%) and 5 year OS (88% in both groups) were not significantly different. However, of the 83 patients randomized to the transplant arm, 16 never received the transplant. It is also unclear whether patient selection using the International Prognostic Factors Project on Advanced Hodgkin’s Disease would result in a different outcome [60]. For patients relapsing after ASCT, an allogeneic transplant appears to be beneficial. A reduced rate following allogeneic transplants vs. ASCT provides the main evidence for a graft v Hodgkin’s disease effect [1, 3, 92]. However, the higher TRM indicates the need to carefully select appropriate patients. NST is also being evaluated in HD and a number of early reports have appeared. A large series has been reported by the EBMT. They compared through registry analysis 99 patients receiving a NST and 154 receiving a conventional allogeneic SCT treated between 1997 and 2001. Fifty-five percent of patients receiving the NST had undergone a prior ASCT vs. 37% of those receiving

426

a conventional allogeneic transplant. Although the CR rate and incidence of acute GVHD were similar in both groups, (42% vs. 54% and 44% vs. 56% respectively), patients undergoing NST had a lower risk of TRM and improved survival. Patients with resistant disease at the time of transplant did poorly regardless of type of transplant [184].

23.5.11 Solid Tumors 23.5.11.1 Germ Cell Tumor Germ cell tumor (GCT) is a highly chemo-sensitive disease. Approximately 80% of patients with advanced stage GCT are cured using first-line cisplatin based CT. Of those who relapse after achieving a CR, or fail to achieve a CR with first-line therapy, only 15–30% can be cured using conventional dose (CDT) salvage regimens [83, 116].

E.D. Ball et al.

[55]. Of 184 patients, 116 had complete remission of disease without relapse during a median follow-up of 48 months (range, 14 to 118). Most investigators now use 2 or more cycles of HDT each with ASCT at relatively short intervals, instead of a single cycle HDT. This concept was first developed for GCT through a phase I/II Indiana University trial of tandem administration of carboplatin and etoposide with ASCT in multiply relapsed patients [134]. Phase II studies of multiple cycle HDT-ASCT have been encouraging with respect to tolerability and EFS; results of randomized trials of this approach vs. CDT are pending. Newer approaches are also combining HDT with more effective CDT tumor debulking using agents such as paclitaxel, gemcitabine or oxaliplatin. HDT-ASCT can also be effective in a small proportion of multiply relapsed, heavily pre-treated patients who are considered incurable using CDT. The earliest trials of HDT were performed in this setting; 15–20% long-term survival was achieved [54, 55, 133].

23.5.11.2 High-Dose Chemotherapy (HDT) for Relapsed Refractory Disease HDT with ASCT, used relatively early in patients with relapsed or refractory disease, has produced EFS of 40–60% in several reported phase II studies. These data have implied an improvement in outcome through the use of HDT over historical controls using CDT salvage regimens alone. However, such comparisons are subject to a significant risk of selection bias. In 1996, Beyer et al. developed a prognostic index for outcome following salvage HDT-ASCT in patients with GCT based on a multivariate analysis of 283 patients [18]. Patients were divided into good, intermediate, and poor risk groups, based on the presence/absence of risk factors such as evidence of refractory disease prior to HDT, hCG level prior to HDT, and mediastinal primary site. The respective 2-year EFS for the 3 groups were 51, 27, and 5%. The use of such prognostic markers allows a more meaningful comparison of outcomes across clinical trials and treatment centers. A recent matched-pair analysis demonstrated 12 and 11% absolute improvement in EFS and OS at 2 years using HDT, compared to CDT alone [19]. Einhorn in Indiana reported their retrospective experience with tandem HDT-ASCT in metastatic germ cell tumors

23.5.11.3 HDT for Primary Therapy of High Risk Disease The prognostic classification for germ cell tumors developed by the International Germ Cell Cancer Collaborative Group (IGCCCG) provides a means of predicting likelihood of cure with standard firstline cisplatin based CT [90]. Patients considered to have poor- prognosis GCT are those with nonseminomatous histology with any of the following characteristics: mediastinal primary, non-pulmonary visceral metastases, alpha-fetoprotein > 10,000 ng/mL, human chorionic gonadotrophin level > 50,000 IU/L, LDH 10 × upper limit of normal. Patients in this category have an approximately 50% probability of cure with standard therapy. Several phase II studies of HDT-ASCT (including studies in patients with brain metastases and primary mediastinal GCT) suggest a superior outcome to that expected with CT [26, 49, 106]. A matched pair analysis in 292 patients with poor prognosis GCT compared 3 cycles of sequential highdose etoposide, ifosfamide and cisplatin with CDT. Statistically significant absolute improvements (16%

23 Current Status of Bone Marrow Transplantation

and 11% in DFS and OS respectively) were reported in the HDT treated patients [25]. To date, the only reported phase III randomized trial has been presented solely in abstract form. Patients were randomized to an unusual 4 drug standard dose regimen of cisplatin, etoposide, vinblastine and bleomycin administered for 4 cycles vs. 3 cycles of the same regimen, followed by a single cycle of high-dose cisplatin, etoposide and cyclophosphamide with ASCT. No significant advantage was found for the HDT arm. However, only 114 patients were randomized; approximately 30% of patients randomized to HDT did not receive it [35]. Thus, this trial cannot be considered a definitive answer to the question of early HDT for poor prognosis disease. Three newer randomized phase III trials are being conducted by the US Intergroup, EORTC and NCI Milan. All these trials utilize multiple cycles of HDT. In summary, whereas phase II studies and matchedpair analyses suggest superiority of HDT-ASCT over CDT in both salvage therapy of relapsed GCT and early treatment of poor prognosis GCT by IGCCCG criteria, confirmation of this benefit through well-designed phase III randomized trials is awaited.

23.5.12 Renal Cell Cancer Metastatic renal cell cancer (RCC) that has failed therapy with cytokines has a very poor prognosis, with a median life expectancy of less than 12 months. The ability of cytokine therapy to induce responses in RCC that are sometimes durable implies a susceptibility to immunological activity against the cancer cells in some situations. Childs et al. first demonstrated that adoptive immunotherapy as facilitated by a NST was capable of producing objective disease regressions in some patients with cytokine therapy-refractory RCC [37]. In the initial 19 patients treated, 10 objective regressions occurred including 3 CRs and 7 PRs. The responses occurred relatively late after the allo-HSCT (median 4 months), often after initial tumor progression following the transplant. The responses typically occurred after withdrawal of immunosuppression or DLI. There was a strong correlation between tumor response and the occurrence of GVHD. These data suggest that the responses occurred as a result of adoptive

427

immunotherapy rather than the preparative cytotoxic CT used for the allo-HSCT. Since the original publication by Childs, other groups have demonstrated similar responses following NST in metastatic RCC [27, 152]. The delayed and relatively slow nature of the observed responses seen in the reported series, suggest that patients with relatively non-bulky and slowly progressive disease are the most suited to this therapeutic approach. Patients with widespread malignancy that is rapidly growing are unlikely to survive sufficiently long for a clinically significant graft- vs.-tumor effect to develop.

23.5.13 Breast Cancer The role of HDT-ASCT in breast cancer remains undefined, despite the completion of several randomized trials of HDT-ASCT vs. CDT in both metastatic breast cancer (MBC) and HRPBC. A detailed analysis of the randomized trials is beyond the scope of this chapter; the reader is referred to reviews for further information [135, 188]. At least seven randomized trials have been performed for MBC. Most of the reported studies, with the notable exception of the Philadelphia trial [171], demonstrated a statistically significant improvement in disease-free or progression-free survival in the HDT arm. No studies have demonstrated a significantly superior OS in the HDT arm. Potential reasons for the discrepancy between observed results in DFS and OS are discussed in detail in the published reviews. They include cross-over designs, pursuit of HDT offprotocol by relapsed patients in the SDT arm, higher than expected TRM in the HDT arm in some studies, and small size and inadequate length of follow-up in some of the trials. At least 13 randomized trials of adjuvant HDT vs. SDT in HRPBC have been performed worldwide. Of two trials, the Netherlands NWAST trial (the largest trial with 885 accrued patients) [154], and the PEGASE 01 trial [153] demonstrated a superior DFS in the HDT arm. OS was also superior in the Netherlands trial in the first 284 patients analyzed; yet no statistically significant benefit in OS survival was seen in the remaining trials reported. However, the failure to observe an OS benefit may be related to problems with study design. The reported data suggest that although DFS may be improved in patients undergoing HDT for MBC and

428

perhaps also for HRPBC, OS is not clearly improved. It is possible that, with continued follow-up and results of trials that have recently completed accrual, a benefit to HDT will emerge in some categories of breast cancer. HDT-ASCT may be an important platform on which to evaluate novel therapies for breast cancer such as mAb and vaccine strategies. That said, at the time of this review, autologous transplants for breast cancer have been essentially abandoned for now.

23.6 Summary and Conclusion This is an exciting time in the basic science and clinical application of HSCT. Advances in the understanding of the conditions necessary for engraftment of allogeneic stem cells has allowed the application of this curative therapy to older patients. Since most hematologic malignancies occur more commonly with advancing age, many more patients are now able to benefit from the hope for cure or prolonged survival that a stem cell transplant provides. Alternative donor sources also are allowing more patients to receive stem cell transplants. As the toxicity of stem cell transplants is reduced through better supportive care, prophylaxis and treatment of GVHD, and donor selection, one can envision the use of HSCT continuing to grow robustly in the upcoming years.

References 1. Akpek G, Ambinder RF, Piantadosi S et al (2001) Longterm results of blood and marrow transplantation for Hodgkin’s lymphoma. J Clin Oncol 19:4314–4321 2. Alexanian R, Dimopoulos M (1994) The treatment of multiple myeloma. N Engl J Med 330:484–489 3. Anderson JE, Litzow MR, Appelbaum FR et al (1993) Allogeneic, syngeneic, and autologous marrow transplantation for Hodgkin’s disease: the 21-year Seattle experience. J Clin Oncol 11:2342–2350 4. Appelbaum FR (2004) Allogeneic transplantation for chronic myeloid leukemia. Thomas’ hematopoietic cell transplantation, vol 457, section 5, ch. 73. WileyBlackwell, Hoboken, NJ, pp 1007–1017 5. Appelbaum FR (2001) Haematopoietic cell transplantation as immunotherapy. Nature 411:385–389 6. Appelbaum FR, Dahlberg S, Thomas ED et al (1984) Bone marrow transplantation or chemotherapy after remission induction for adults with acute nonlymphoblastic leukemia. A prospective comparison. Ann Int Med 101:581–588

E.D. Ball et al. 7. Appelbaum FR, Fisher LD, Thomas ED (1988) Chemotherapy v marrow transplantation for adults with acute nonlymphocytic leukemia: a five-year follow-up. Blood 72:179–184 8. Attal M, Blaise D, Marit G et al (1995) Consolidation treatment of adult acute lymphoblastic leukemia: a prospective, randomized trial comparing allogeneic versus autologous bone marrow transplantation and testing the impact of recombinant interleukin-2 after autologous bone marrow transplantation. BGMT Group Blood 86: 1619–1628 9. Attal M, Harousseau JL, Facon T et al (2003) Single versus double autologous stem-cell transplantation for multiple myeloma. N Engl J Med 349:2495–2502 10. Attal M, Harousseau JL, Stoppa AM et al (1996) A prospective, randomized trial of autologous bone marrow transplantation and chemotherapy in multiple myeloma. Intergroupe Francais du Myelome. N Engl J Med 335: 91–97 11. Aversa F, Tabilio A, Velardi A et al (1998) Treatment of high-risk acute leukemia with T-cell-depleted stem cells from related donors with one fully mismatched HLA haplotype. N Engl J Med 339:1186–1193 12. Badros A, Barlogie B, Siegel E et al (2002) Improved outcome of allogeneic transplantation in high-risk multiple myeloma patients after nonmyeloablative conditioning. J Clin Oncol 20:1295–1303 13. Barlogie B, Jagannath S, Dixon DO et al (1990) Highdose melphalan and granulocyte-macrophage colonystimulating factor for refractory multiple myeloma. Blood 76:677–680 14. Bashey A, Corringham S, Gilpin E et al (2000) Simultaneous administration of G-CSF and GM-CSF for re-mobilization in patients with inadequate initial progenitor cell collections for autologous transplantation. Cytotherapy 2:195–200 15. Bender JG, To LB, Williams S et al (1992) Defining a therapeutic dose of peripheral blood stem cells. J Hematother 1:329–341 16. Bensinger WI, Martin PJ, Storer B et al (2001) Transplantation of bone marrow as compared with peripheral-blood cells from HLA-identical relatives in patients with hematologic cancers. N Engl J Med 344: 175–181 17. Bensinger WI, Weaver CH, Appelbaum FR et al (1995) Transplantation of allogeneic peripheral blood stem cells mobilized by recombinant human granulocyte colonystimulating factor. Blood 85:1655–1658 18. Beyer J, Kramar A, Mandanas R et al (1996) High-dose chemotherapy as salvage treatment in germ cell tumors: a multivariate analysis of prognostic variables. J Clin Oncol 14:2638–2645 19. Beyer J, Stenning S, Gerl A et al (2002) High-dose versus conventional-dose chemotherapy as first-salvage treatment in patients with non-seminomatous germ-cell tumors: a matched-pair analysis. Ann Oncol 13:599–605 20. Bierman PJ, Sweetenham JW, Loberiza FR Jr et al (2003) Syngeneic hematopoietic stem-cell transplantation for non-Hodgkin’s lymphoma: a comparison with allogeneic and autologous transplantation – The lymphoma working committee of the international bone marrow transplant

23 Current Status of Bone Marrow Transplantation

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

registry and the European group for blood and marrow transplantation. J Clin Oncol 21:3744–3753 Blade J, San Miguel JF, Fontanillas M et al (2001) Increased conventional chemotherapy does not improve survival in multiple myeloma: long-term results of two PETHEMA trials including 914 patients. Hematol J 2:272–278 Bloomfield CD, Lawrence D, Byrd JC et al (1998) Frequency of prolonged remission duration after highdose cytarabine intensification in acute myeloid leukemia varies by cytogenetic subtype. Cancer Res 58:4173–4179 Blume KG, Forman SJ, Nademanee AP et al (1986) Bone marrow transplantation for hematologic malignancies in patients aged 30 years or older. J Clin Oncol 4:1489–1492 Boeve S, Strupeck J, Creech S et al (2004) Analysis of remobilization success in patients undergoing autologous stem cell transplants who fail an initial mobilization: risk factors, cytokine use and cost. Bone Marrow Transplant 33:997–1003 Bokemeyer C, Kollmannsberger C, Meisner C et al (1999) First-line high-dose chemotherapy compared with standard-dose PEB/VIP chemotherapy in patients with advanced germ cell tumors: a multivariate and matchedpair analysis. J Clin Oncol 17:3450–3456 Bokemeyer C, Schleucher N, Metzner B et al (2003) Firstline sequential high-dose VIP chemotherapy with autologous transplantation for patients with primary mediastinal nonseminomatous germ cell tumours: a prospective trial. Br J Cancer 89:29–35 Bregni M, Dodero A, Peccatori J et al (2002) Nonmyeloablative conditioning followed by hematopoietic cell allografting and donor lymphocyte infusions for patients with metastatic renal and breast cancer. Blood 99:4234–4236 Bruno B, Rotta M, Patriarca F et al (2007) A comparison of allografting with autografting for newly diagnosed myeloma. N Engl J Med 356:1110–1120 Buckner CD, Clift RA, Thomas ED et al (1982) Allogeneic marrow transplantation for patients with acute non-lymphoblastic leukemia in second remission. Leuk Res 6:395–399 Cahn JY, Labopin M, Sierra J et al (2000) No impact of high-dose cytarabine on the outcome of patients transplanted for acute myeloblastic leukaemia in first remission. Acute leukaemia working party of the European Group for Blood and Marrow Transplantation (EBMT). Br J Haematol 110:308–314 Cassileth PA, Harrington DP, Appelbaum FR et al (1998) Chemotherapy compared with autologous or allogeneic bone marrow transplantation in the management of acute myeloid leukemia in first remission. N Engl J Med 339:1649–1656 Cavins JA, Scheer SC, Thomas ED et al (1964) The recovery of lethally irradiated dogs given infusions of autologous leukocytes preserved at −80◦ C. Blood 23: 38–42 Chalandon Y, Barnett MJ, Horsman DE et al (2002) Influence of cytogenetic abnormalities on outcome after allogeneic bone marrow transplantation for acute myeloid leukemia in first complete remission. Biol Blood Marrow Transplant 8:435–443

429 34. Chen L, Widhopf G, Huynh L et al (2002) Expression of ZAP-70 is associated with increased B-cell receptor signaling in chronic lymphocytic leukemia. Blood 100:4609–4614 35. Chevreau C, Droz JP, Pico JL et al (1993) Early intensified chemotherapy with autologous bone marrow transplantation in first line treatment of poor risk nonseminomatous germ cell tumours. Preliminary results of a French randomized trial. Eur Urol 23:213–217, discussion 8 36. Child JA, Morgan GJ, Davies FE et al (2003) Highdose chemotherapy with hematopoietic stem-cell rescue for multiple myeloma. N Engl J Med 348: 1875–1883 37. Childs R, Chernoff A, Contentin N et al (2000) Regression of metastatic renal-cell carcinoma after nonmyeloablative allogeneic peripheral-blood stem-cell transplantation. N Engl J Med 343:750–788 38. Chopra R, Goldstone AH, Pearce R et al (1992) Autologous versus allogeneic bone marrow transplantation for non-Hodgkin’s lymphoma: a case-controlled analysis of the European bone marrow transplant group registry data. J Clin Oncol 10:1690–1695 39. Clift RA, Buckner CD, Thomas ED et al (1994) Marrow transplantation for patients in accelerated phase of chronic myeloid leukemia. Blood 84:4368–4373 40. Clift RA, Buckner CD, Thomas ED et al (1987) The treatment of acute non-lymphoblastic leukemia by allogeneic marrow transplantation. Bone Marrow Transplant 2:243–258 41. Clift RA, Radich J, Appelbaum FR et al (1999) Long-term follow-up of a randomized study comparing cyclophosphamide and total body irradiation with busulfan and cyclophosphamide for patients receiving allogenic marrow transplants during chronic phase of chronic myeloid leukemia. Blood 94:3960–3962 42. Coiffier B, Lepage E, Briere J et al (2002) CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med 346:235–242 43. Collins RH Jr, Shpilberg O, Drobyski WR et al (1997) Donor leukocyte infusions in 140 patients with relapsed malignancy after allogeneic bone marrow transplantation. J Clin Oncol 15:433–444 44. Copelan EA, Biggs JC, Thompson JM et al (1991) Treatment for acute myelocytic leukemia with allogeneic bone marrow transplantation following preparation with BuCy2. Blood 78:838–843 45. Cornelissen JJ, Carston M, Kollman C et al (2001) Unrelated marrow transplantation for adult patients with poor-risk acute lymphoblastic leukemia: strong graftversus-leukemia effect and risk factors determining outcome. Blood 97:1572–1577 46. Cottler-Fox MH, Lapidot T, Petit I et al (2003) Stem cell mobilization. Hematology Am Soc Hematol Educ Program 1:419–437 47. Couban S, Simpson DR, Barnett MJ et al (2002) A randomized multicenter comparison of bone marrow and peripheral blood in recipients of matched sibling allogeneic transplants for myeloid malignancies. Blood 100:1525–1531

430 48. Crespo M, Bosch F, Villamor N et al (2003) ZAP-70 expression as a surrogate for immunoglobulin-variableregion mutations in chronic lymphocytic leukemia. N Engl J Med 348:1764–1775 49. Decatris MP, Wilkinson PM, Welch RS et al (2000) Highdose chemotherapy and autologous haematopoietic support in poor risk non-seminomatous germ-cell tumours: an effective first-line therapy with minimal toxicity. Ann Oncol 11:427–434 50. Devine SM, Flomenberg N, Vesole DH et al (2004) Rapid mobilization of CD34+ cells following administration of the CXCR4 antagonist AMD3100 to patients with multiple myeloma and non-Hodgkin’s lymphoma. J Clin Oncol 22:1095–1102 51. Doney K, Hagglund H, Leisenring W et al (2003) Predictive factors for outcome of allogeneic hematopoietic cell transplantation for adult acute lymphoblastic leukemia. Biol Blood Marrow Transplant 9:472–481 52. Dreger P, Brand R, Hansz J et al (2003) Treatment-related mortality and graft-versus-leukemia activity after allogeneic stem cell transplantation for chronic lymphocytic leukemia using intensity-reduced conditioning. Leukemia 17:841–848 53. Dreger P, Stilgenbauer S, Benner A et al (2004) The prognostic impact of autologous stem cell transplantation in patients with chronic lymphocytic leukemia: a riskmatched analysis based on the VH gene mutational status. Blood 103:2850–2858 54. Droz JP, Pico JL, Ghosn M et al (1991) Long-term survivors after salvage high dose chemotherapy with bone marrow rescue in refractory germ cell cancer. Eur J Cancer 27:831–835 55. Einhorn LH, Williams SD, Chamness A et al (2007) Highdose chemotherapy and stem-cell rescue for metastatic germ-cell tumors. N Engl J Med 357:340–348 56. Enright H, Daniels K, Arthur DC et al (1996) Related donor marrow transplant for chronic myeloid leukemia: patient characteristics predictive of outcome. Bone Marrow Transplant 17:537–542 57. Esteve J, Villamor N, Colomer D et al (2002) Different clinical value of minimal residual disease after autologous and allogenic stem cell transplantation for chronic lymphocytic leukemia. Blood 99:1873–1874 58. Faderl S, Jeha S, Kantarjian HM (2003) The biology and therapy of adult acute lymphoblastic leukemia. Cancer 98:1337–1354 59. Fais F, Ghiotto F, Hashimoto S et al (1998) Chronic lymphocytic leukemia B cells express restricted sets of mutated and unmutated antigen receptors. J Clin Invest 102:1515–1525 60. Federico M, Bellei M, Brice P et al (2003) High-dose therapy and autologous stem-cell transplantation versus conventional therapy for patients with advanced Hodgkin’s lymphoma responding to front-line therapy. J Clin Oncol 21:2320–2325 61. Fermand JP, Brechignac S (1999) The role of autologous stem cell transplantation in the management of multiple myeloma. Pathol Biol (Paris) 47:199–202 62. Fermand JP, Ravaud P, Chevret S et al (1998) Highdose therapy and autologous peripheral blood stem cell transplantation in multiple myeloma: up-front or rescue

E.D. Ball et al.

63.

64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

74.

treatment? Results of a multicenter sequential randomized clinical trial. Blood 92:3131–3136 Ferrant A, Labopin M, Frassoni F et al (1997) Karyotype in acute myeloblastic leukemia: prognostic significance for bone marrow transplantation in first remission: a European group for blood and marrow transplantation study. Acute leukemia working party of the European group for blood and marrow transplantation (EBMT). Blood 90:2931–2938 Flowers ME, Parker PM, Johnston LJ et al (2002) Comparison of chronic graft-versus-host disease after transplantation of peripheral blood stem cells versus bone marrow in allogeneic recipients: long-term follow-up of a randomized trial. Blood 100:415–419 Freedman AS, Neuberg D, Mauch P et al (1999) Longterm follow-up of autologous bone marrow transplantation in patients with relapsed follicular lymphoma. Blood 94:3325–3333 Gale RP, Horowitz MM, Rees JK et al (1996) Chemotherapy versus transplants for acute myelogenous leukemia in second remission. Leukemia 10:13–19 Gale RP, Horowitz MM, Weiner RS et al (1995) Impact of cytogenetic abnormalities on outcome of bone marrow transplants in acute myelogenous leukemia in first remission. Bone Marrow Transplant 16:203–208 Gaziev D, Galimberti M, Polchi P et al (2002) Fate of chronic myeloid leukemia patients treated with allogeneic bone marrow transplantation or chemotherapy and/or interferon at a single center: long-term results. Bone Marrow Transplant 29:1–8 Gianni AM, Bregni M, Siena S et al (1997) High-dose chemotherapy and autologous bone marrow transplantation compared with MACOP-B in aggressive B-cell lymphoma. N Engl J Med 336:1290–1297 Giralt S, Hester J, Huh Y et al (1995) CD8-depleted donor lymphocyte infusion as treatment for relapsed chronic myelogenous leukemia after allogeneic bone marrow transplantation. Blood 86:4337–4343 Gisselbrecht C, Lepage E, Molina T et al (2002) Shortened first-line high-dose chemotherapy for patients with poor-prognosis aggressive lymphoma. J Clin Oncol 20:2472–2479 Glass B, Nickelsen M, Dreger P et al (2004) Reducedintensity conditioning prior to allogeneic transplantation of hematopoietic stem cells: the need for T cells early after transplantation to induce a graft-versus-lymphoma effect. Bone Marrow Transplant 34:391–397 Goldman JM, Gale RP, Horowitz MM et al (1988) Bone marrow transplantation for chronic myelogenous leukemia in chronic phase: increased risk for relapse associated with T-cell depletion. Ann Int Med 108: 806–814 Goldstone AH, Richards SM, Lazarus HM et al (2008) In adults with standard-risk acute lymphoblastic leukemia, the greatest benefit is achieved from a matched sibling allogeneic transplantation in first complete remission, and an autologous transplantation is less effective than conventional consolidation/maintenance chemotherapy in all patients: final results of the international ALL Trial (MRC UKALL XII/ECOG E2993). Blood 111: 1827–1833

23 Current Status of Bone Marrow Transplantation 75. Gratwohl A, Hermans J, van Biezen A et al (1996) Splenic irradiation before bone marrow transplantation for chronic myeloid leukaemia. Chronic leukaemia working party of the European group for blood and marrow transplantation (EBMT). Br J Haematol 95:494–500 76. Grimwade D, Walker H, Oliver F et al (1998) The importance of diagnostic cytogenetics on outcome in AML: analysis of 1,612 patients entered into the MRC AML 10 trial. The medical research council adult and children’s leukaemia working parties. Blood 92:2322–2333 77. Gutierrez-Delgado F, Bensinger W (2001) Safety of granulocyte colony-stimulating factor in normal donors. Curr Opin Hematol 8:155–160 78. Haioun C, Lepage E, Gisselbrecht C et al (2000) Survival benefit of high-dose therapy in poor-risk aggressive nonHodgkin’s lymphoma: final analysis of the prospective LNH87–2 protocol – a groupe d’Etude des lymphomes de l’Adulte study. J Clin Oncol 18:3025–3030 79. Hammert LC, Ball ED (1997) Purging marrow or peripheral blood stem cells for autografting. Curr Opin Hematol 4:423–428 80. Hansen JA, Gooley TA, Martin PJ et al (1998) Bone marrow transplants from unrelated donors for patients with chronic myeloid leukemia. N Engl J Med 338:962–968 81. Harris NL, Jaffe ES, Diebold J et al (1999) World Health Organization classification of neoplastic diseases of the hematopoietic and lymphoid tissues: report of the clinical advisory committee meeting-Airlie house, Virginia, November 1997. J Clin Oncol 17:3835–3849 82. Harris NL, Jaffe ES, Stein H et al (1994) A revised European-American classification of lymphoid neoplasms: a proposal from the international lymphoma study group. Blood 84:1361–1392 83. Harstrick A, Schmoll HJ, Wilke H et al (1991) Cisplatin, etoposide, and ifosfamide salvage therapy for refractory or relapsing germ cell carcinoma. J Clin Oncol 9:1549–1555 84. Hasenclever D, Diehl V (1998) A prognostic score for advanced Hodgkin’s disease: international prognostic factors project on advanced Hodgkin’s disease. N Engl J Med 339:1506–1514 85. Helg C, Starobinski M, Jeannet M et al (1998) Donor lymphocyte infusion for the treatment of relapse after allogeneic hematopoietic stem cell transplantation. Leuk Lymphoma 29:301–313 86. Henslee-Downey PJ, Parrish RS, MacDonald JS et al (1996) Combined in vitro and in vivo T lymphocyte depletion for the control of graft-versus-host disease following haploidentical marrow transplant. Transplantation 61:738–745 87. Hoelzer D (1992) Prognostic factors in acute lymphoblastic leukemia. Leukemia 6(Suppl 4):49–51 88. Hoelzer D, Ludwig WD, Thiel E et al (1996) Improved outcome in adult B-cell acute lymphoblastic leukemia. Blood 87:495–508 89. Horowitz MM, Gale RP, Sondel PM et al (1990) Graftversus-leukemia reactions after bone marrow transplantation. Blood 75:555–562 90. International Germ Cell Cancer Collaborative Group (1997) International germ cell consensus classification: a prognostic factor-based staging system for metastatic germ cell cancers. J Clin Oncol 15:594–603

431 91. Johnson TA, Rassenti LZ, Kipps TJ (1997) Ig VH1 genes expressed in B cell chronic lymphocytic leukemia exhibit distinctive molecular features. J Immunol 158:235–246 92. Jones RJ, Ambinder RF, Piantadosi S et al (1991) Evidence of a graft-versus-lymphoma effect associated with allogeneic bone marrow transplantation. Blood 77:649–653 93. Jung AS, Holman PR, Castro JE et al (2009) Autologous hematopoietic stem cell transplantation as an intensive consolidation therapy for adult patients in remission from acute myelogenous leukemia. Biol Blood Marrow Transplant 15:1306–1313 94. Junghanss C, Boeckh M, Carter RA et al (2002) Incidence and outcome of cytomegalovirus infections following nonmyeloablative compared with myeloablative allogeneic stem cell transplantation, a matched control study. Blood 99:1978–1985 95. Keating MJ, Chiorazzi N, Messmer B et al (2003) Biology and treatment of chronic lymphocytic leukemia. Hematology Am Soc Hematol Educ Program 153–175 96. Keating MJ, Smith TL, Kantarjian H et al (1988) Cytogenetic pattern in acute myelogenous leukemia: a major reproducible determinant of outcome. Leukemia 2:403–412 97. Kebriaei P, Larson RA (2003) Progress and challenges in the therapy of adult acute lymphoblastic leukemia. Curr Opin Hematol 10:284–289 98. Khouri IF, Champlin RE (2004) Nonmyeloablative stem cell transplantation for lymphoma. Semin Oncol 31:22–26 99. Khouri IF, Keating MJ, Saliba RM et al (2002) Long-term follow-up of patients with CLL treated with allogeneic hematopoietic transplantation. Cytotherapy 4:217–221 100. Khouri IF, Keating MJ, Vriesendorp HM et al (1994) Autologous and allogeneic bone marrow transplantation for chronic lymphocytic leukemia: preliminary results. J Clin Oncol 12:748–758 101. Khouri IF, McLaughlin P, Saliba RM et al (2008) Eightyear experience with allogeneic stem cell transplantation for relapsed follicular lymphoma after nonmyeloablative conditioning with fludarabine, cyclophosphamide, and rituximab. Blood 111:5530–5536 102. Khouri IF, Saliba RM, Giralt SA et al (2001) Nonablative allogeneic hematopoietic transplantation as adoptive immunotherapy for indolent lymphoma: low incidence of toxicity, acute graft-versus-host disease, and treatmentrelated mortality. Blood 98:3595–3599 103. Klingemann HG, Storb R, Fefer A et al (1986) Bone marrow transplantation in patients aged 45 years and older. Blood 67:770–776 104. Kolb HJ, Mittermuller J, Clemm C et al (1990) Donor leukocyte transfusions for treatment of recurrent chronic myelogenous leukemia in marrow transplant patients. Blood 76:2462–2465 105. Kolb HJ, Schattenberg A, Goldman JM et al (1995) Graftversus-leukemia effect of donor lymphocyte transfusions in marrow grafted patients. Blood 86:2041–2050 106. Kollmannsberger C, Nichols C, Meisner C et al (2000) Identification of prognostic subgroups among patients with metastatic ‘IGCCCG poor-prognosis’ germ-cell cancer: an explorative analysis using cart modeling. Ann Oncol 11:1115–1120

432 107. Korbling M, Przepiorka D, Huh YO et al (1995) Allogeneic blood stem cell transplantation for refractory leukemia and lymphoma: potential advantage of blood over marrow allografts. Blood 85:1659–1665 108. Kurtzberg J, Martin P, Chao N et al (2000) Unrelated placental blood in marrow transplantation. Stem Cells 18:153–154 109. Lane TA, Bashey A, Carrier E et al (2004) Improving the efficiency of PBPC collection by pre-apheresis peripheral blood and mid-apheresis product measurements of CD34 cells. Cytotherapy 6:318–327 110. Lane TA, Law P, Maruyama M et al (1995) Harvesting and enrichment of hematopoietic progenitor cells mobilized into the peripheral blood of normal donors by granulocyte-macrophage colony-stimulating factor (GMCSF) or G-CSF: potential role in allogeneic marrow transplantation. Blood 85:275–282 111. Laport GF, Larson RA (1997) Treatment of adult acute lymphoblastic leukemia. Semin Oncol 24:70–82 112. Laughlin MJ, Barker J, Bambach B et al (2001) Hematopoietic engraftment and survival in adult recipients of umbilical-cord blood from unrelated donors. N Engl J Med 344:1815–1822 113. Lemoli RM, de Vivo A, Damiani D et al (2003) Autologous transplantation of granulocyte colonystimulating factor-primed bone marrow is effective in supporting myeloablative chemotherapy in patients with hematologic malignancies and poor peripheral blood stem cell mobilization. Blood 102:1595–1600 114. Lie AK, Hui CH, Rawling T et al (1998) Granulocyte colony-stimulating factor (G-CSF) dose-dependent efficacy in peripheral blood stem cell mobilization in patients who had failed initial mobilization with chemotherapy and G-CSF. Bone Marrow Transplant 22:853–857 115. Linch DC, Goldstone AH (1999) High-dose therapy for Hodgkin’s disease. Br J Haematol 107:685–690 116. Loehrer PJ Sr, Lauer R, Roth BJ et al (1988) Salvage therapy in recurrent germ cell cancer: ifosfamide and cisplatin plus either vinblastine or etoposide. Ann Int Med 109:540–546 117. Lokhorst HM, Wu K, Verdonck LF et al (2004) The occurrence of graft-versus-host disease is the major predictive factor for response to donor lymphocyte infusions in multiple myeloma. Blood 103:4362–4364 118. Makita K, Ohta K, Mugitani A et al (2004) Acute myelogenous leukemia in a donor after granulocyte colonystimulating factor-primed peripheral blood stem cell harvest. Bone Marrow Transplant 33:661–665 119. Maloney DG, Molina AJ, Sahebi F et al (2003) Allografting with nonmyeloablative conditioning following cytoreductive autografts for the treatment of patients with multiple myeloma. Blood 102:3447–3454 120. Marafioti T, Hummel M, Foss HD et al (2000) Hodgkin and reed-sternberg cells represent an expansion of a single clone originating from a germinal center B-cell with functional immunoglobulin gene rearrangements but defective immunoglobulin transcription. Blood 95:1443–1450 121. Mayer RJ, Davis RB, Schiffer CA et al (1994) Intensive postremission chemotherapy in adults with acute myeloid leukemia: cancer and leukemia Group B. N Engl J Med 331:896–903

E.D. Ball et al. 122. McElwain TJ, Powles RL (1983) High-dose intravenous melphalan for plasma-cell leukaemia and myeloma. Lancet 2:822–824 123. McGlave PB, Haake RJ, Bostrom BC et al (1988) Allogeneic bone marrow transplantation for acute nonlymphocytic leukemia in first remission. Blood 72:1512–1517 124. McGlave PB, Shu XO, Wen W et al (2000) Unrelated donor marrow transplantation for chronic myelogenous leukemia: 9 years’ experience of the national marrow donor program. Blood 95:2219–2225 125. McSweeney PA, Niederwieser D, Shizuru JA et al (2001) Hematopoietic cell transplantation in older patients with hematologic malignancies: replacing high-dose cytotoxic therapy with graft-versus-tumor effects. Blood 97: 3390–3400 126. Meisenberg B, Brehm T, Schmeckel A et al (1998) A combination of low-dose cyclophosphamide and colony-stimulating factors is more cost-effective than granulocyte-colony-stimulating factors alone in mobilizing peripheral blood stem and progenitor cells. Transfusion 38:209–215 127. Michallet M, Carraras E, Cornelissen JJ et al (1999) Allotransplants and autotransplants in CLL. Bone Marrow Transplant 23(Suppl 1):S53 128. Mielcarek M, Martin PJ, Leisenring W et al (2003) Graftversus-host disease after nonmyeloablative versus conventional hematopoietic stem cell transplantation. Blood 102:756–62 129. Mohle R, Pforsich M, Fruehauf S et al (1994) Filgrastim post-chemotherapy mobilizes more CD34+ cells with a different antigenic profile compared with use during steady-state hematopoiesis. Bone Marrow Transplant 14:827–832 130. Moreau P, Facon T, Attal M et al (2002) Comparison of 200 mg/m(2) melphalan and 8 Gy total body irradiation plus 140 mg/m(2) melphalan as conditioning regimens for peripheral blood stem cell transplantation in patients with newly diagnosed multiple myeloma: final analysis of the Intergroupe Francophone du Myelome 9502 randomized trial. Blood 99:731–735 131. Moreau P, Fiere D, Bezwoda WR et al (1997) Prospective randomized placebo-controlled study of granulocytemacrophage colony-stimulating factor without stem-cell transplantation after high-dose melphalan in patients with multiple myeloma. J Clin Oncol 15:660–666 132. Nash RA, Antin JH, Karanes C et al (2000) Phase 3 study comparing methotrexate and tacrolimus with methotrexate and cyclosporine for prophylaxis of acute graft-versushost disease after marrow transplantation from unrelated donors. Blood 96:2062–2068 133. Nichols CR, Andersen J, Lazarus HM et al (1992) Highdose carboplatin and etoposide with autologous bone marrow transplantation in refractory germ cell cancer: an Eastern cooperative oncology group protocol. J Clin Oncol 10:558–563 134. Nichols CR, Tricot G, Williams SD et al (1989) Doseintensive chemotherapy in refractory germ cell cancer – a phase I/II trial of high-dose carboplatin and etoposide with autologous bone marrow transplantation. J Clin Oncol 7:932–939

23 Current Status of Bone Marrow Transplantation 135. Nieto Y (2003) The verdict is not in yet: analysis of the randomized trials of high-dose chemotherapy for breast cancer. Haematologica 88:201–211 136. O’Brien SG, Guilhot F, Larson RA et al (2003) Imatinib compared with interferon and low-dose cytarabine for newly diagnosed chronic-phase chronic myeloid leukemia. N Engl J Med 348:994–1004 137. Passweg JR, Tiberghien P, Cahn JY et al (1998) Graftversus-leukemia effects in T lineage and B lineage acute lymphoblastic leukemia. Bone Marrow Transplant 21:153–158 138. Pavletic ZS, Arrowsmith ER, Bierman PJ et al (2000) Outcome of allogeneic stem cell transplantation for B cell chronic lymphocytic leukemia. Bone Marrow Transplant 25:717–722 139. Pavletic ZS, Bierman PJ, Vose JM et al (1998) High incidence of relapse after autologous stem-cell transplantation for B-cell chronic lymphocytic leukemia or small lymphocytic lymphoma. Ann Oncol 9:1023–1026 140. Peggs KS, Mackinnon S (2001) Cellular therapy: donor lymphocyte infusion. Curr Opin Hematol 8:349–354 141. Philip T, Guglielmi C, Hagenbeek A et al (1995) Autologous bone marrow transplantation as compared with salvage chemotherapy in relapses of chemotherapysensitive non-Hodgkin’s lymphoma. N Engl J Med 333: 1540–1545 142. Porter DL, Roth MS, McGarigle C et al (1994) Induction of graft-versus-host disease as immunotherapy for relapsed chronic myeloid leukemia. N Engl J Med 330:100–106 143. The International Non-Hodgkin’s Lymphoma Prognostic Factors Project (1993) A predictive model for aggressive non-Hodgkin’s lymphoma. N Engl J Med 329:987–994 144. Provan D, Bartlett-Pandite L, Zwicky C et al (1996) Eradication of polymerase chain reaction-detectable chronic lymphocytic leukemia cells is associated with improved outcome after bone marrow transplantation. Blood 88:2228–2235 145. Pui CH, Relling MV, Downing JR (2004) Acute lymphoblastic leukemia. N Engl J Med 350:1535–1548 146. Rabinowe SN, Soiffer RJ, Gribben JG et al (1993) Autologous and allogeneic bone marrow transplantation for poor prognosis patients with B-cell chronic lymphocytic leukemia. Blood 82:1366–1376 147. Radich JP, Gehly G, Gooley T et al (1995) Polymerase chain reaction detection of the BCR-ABL fusion transcript after allogeneic marrow transplantation for chronic myeloid leukemia: results and implications in 346 patients. Blood 85:2632–2638 148. Radich JP, Gooley T, Bensinger W et al (2003) HLAmatched related hematopoietic cell transplantation for chronic-phase CML using a targeted busulfan and cyclophosphamide preparative regimen. Blood 102:31–35 149. Rajkumar SV, Fonseca R, Lacy MQ et al (1999) Autologous stem cell transplantation for relapsed and primary refractory myeloma. Bone Marrow Transplant 23: 1267–1272 150. Ratanatharathorn V, Uberti J, Karanes C et al (1994) Prospective comparative trial of autologous versus allogeneic bone marrow transplantation in patients with nonHodgkin’s lymphoma. Blood 84:1050–1055

433 151. Ringden O, Horowitz MM, Gale RP et al (1993) Outcome after allogeneic bone marrow transplant for leukemia in older adults. Jama 270:57–60 152. Rini BI, Zimmerman T, Stadler WM et al (2002) Allogeneic stem-cell transplantation of renal cell cancer after nonmyeloablative chemotherapy: feasibility, engraftment, and clinical results. J Clin Oncol 20:2017–2024 153. Roche H, Viens P, Biron P et al (2003) High-dose chemotherapy for breast cancer: the French PEGASE experience. Cancer Control 10:42–47 154. Rodenhuis S, Bontenbal M, Beex LV et al (2003) Highdose chemotherapy with hematopoietic stem-cell rescue for high-risk breast cancer. N Engl J Med 349:7–16 155. Rondon G, Giralt S, Huh Y et al (1996) Graft-versusleukemia effect after allogeneic bone marrow transplantation for chronic lymphocytic leukemia. Bone Marrow Transplant 18:669–672 156. Rosenwald A, Alizadeh AA, Widhopf G et al (2001) Relation of gene expression phenotype to immunoglobulin mutation genotype in B cell chronic lymphocytic leukemia. J Exp Med 194:1639–1647 157. Rosinol L, Perez-Simon JA, Sureda A et al (2008) A prospective PETHEMA study of tandem autologous transplantation versus autograft followed by reduced-intensity conditioning allogeneic transplantation in newly diagnosed multiple myeloma. Blood 112:3591–3593 158. Roush KS, Hillyer CD (2002) Donor lymphocyte infusion therapy. Transfus Med Rev 16:161–176 159. Rowley SD, Donaldson G, Lilleby K et al (2001) Experiences of donors enrolled in a randomized study of allogeneic bone marrow or peripheral blood stem cell transplantation. Blood 97:2541–2548 160. Rubinstein P, Carrier C, Scaradavou A et al (1998) Outcomes among 562 recipients of placental-blood transplants from unrelated donors. N Engl J Med 339: 1565–1577 161. Ruggeri L, Capanni M, Urbani E et al (2002) Effectiveness of donor natural killer cell alloreactivity in mismatched hematopoietic transplants. Science 295: 2097–2100 162. Sawyers CL, Hochhaus A, Feldman E et al (2002) Imatinib induces hematologic and cytogenetic responses in patients with chronic myelogenous leukemia in myeloid blast crisis: results of a phase II study. Blood 99: 3530–3539 163. Schetelig J, Thiede C, Bornhauser M et al (2003) Evidence of a graft-versus-leukemia effect in chronic lymphocytic leukemia after reduced-intensity conditioning and allogeneic stem-cell transplantation: the cooperative German transplant study group. J Clin Oncol 21: 2747–2753 164. Schiller G, Feig SA, Territo M et al (1994) Treatment of advanced acute leukaemia with allogeneic bone marrow transplantation from unrelated donors. Br J Haematol 88:72–78 165. Schlenk RF, Dohner K, Krauter J et al (2008) Mutations and treatment outcome in cytogenetically normal acute myeloid leukemia. N Engl J Med 358:1909–1918 166. Schmitz N, Pfistner B, Sextro M et al (2002) Aggressive conventional chemotherapy compared with highdose chemotherapy with autologous haemopoietic

434

167.

168.

169.

170.

171.

172.

173.

174.

175.

176.

177.

178.

E.D. Ball et al. stem-cell transplantation for relapsed chemosensitive Hodgkin’s disease: a randomised trial. Lancet 359: 2065–2071 Schouten HC, Qian W, Kvaloy S et al (2003) High-dose therapy improves progression-free survival and survival in relapsed follicular non-Hodgkin’s lymphoma: results from the randomized European CUP trial. J Clin Oncol 21:3918–3927 Selby PJ, McElwain TJ, Nandi AC et al (1987) Multiple myeloma treated with high dose intravenous melphalan. Br J Haematol 66:55–62 Sierra J, Storer B, Hansen JA et al (2000) Unrelated donor marrow transplantation for acute myeloid leukemia: an update of the Seattle experience. Bone Marrow Transplant 26:397–404 Slovak ML, Kopecky KJ, Cassileth PA et al (2000) Karyotypic analysis predicts outcome of preremission and postremission therapy in adult acute myeloid leukemia: a Southwest oncology group/Eastern cooperative oncology group study. Blood 96:4075–4083 Stadtmauer EA, O’Neill A, Goldstein LJ et al (2000) Conventional-dose chemotherapy compared with highdose chemotherapy plus autologous hematopoietic stem-cell transplantation for metastatic breast cancer: Philadelphia bone marrow transplant group. N Engl J Med 342:1069–1076 Stewart AK, Vescio R, Schiller G et al (2001) Purging of autologous peripheral-blood stem cells using CD34 selection does not improve overall or progression-free survival after high-dose chemotherapy for multiple myeloma: results of a multicenter randomized controlled trial. J Clin Oncol 19:3771–3779 Stiff P, Micallef I, McCarthy P et al (2009) Treatment with plerixafor in non-Hodgkin’s lymphoma and multiple myeloma patients to increase the number of peripheral blood stem cells when given a mobilizing regimen of G-CSF: implications for the heavily pretreated patient. Biol Blood Marrow Transplant 15:249–256 Stockerl-Goldstein KE, Reddy SA, Horning SF et al (2000) Favorable treatment outcome in non-Hodgkin’s lymphoma patients with “poor” mobilization of peripheral blood progenitor cells. Biol Blood Marrow Transplant 6:506–512 Storb R (2003) Allogeneic hematopoietic stem cell transplantation – yesterday, today, and tomorrow. Exp Hematol 31:1–10 Storb R, Deeg HJ, Farewell V et al (1986) Marrow transplantation for severe aplastic anemia: methotrexate alone compared with a combination of methotrexate and cyclosporine for prevention of acute graft-versus-host disease. Blood 68:119–125 Storb R, Deeg HJ, Whitehead J et al (1986) Methotrexate and cyclosporine compared with cyclosporine alone for prophylaxis of acute graft versus host disease after marrow transplantation for leukemia. N Engl J Med 314: 729–735 Storb R, Raff RF, Appelbaum FR et al (1993) FK506 and methotrexate prevent graft-versus-host disease in dogs given 9.2 Gy total body irradiation and marrow grafts from unrelated dog leukocyte antigen-nonidentical donors. Transplantation 56:800–807

179. Storb R, Yu C, Barnett T et al (1999) Stable mixed hematopoietic chimerism in dog leukocyte antigenidentical littermate dogs given lymph node irradiation before and pharmacologic immunosuppression after marrow transplantation. Blood 94:1131–1136 180. Storb R, Yu C, Wagner JL et al (1997) Stable mixed hematopoietic chimerism in DLA-identical littermate dogs given sublethal total body irradiation before and pharmacological immunosuppression after marrow transplantation. Blood 89:3048–3054 181. Storb R, Yu C, Zaucha JM et al (1999) Stable mixed hematopoietic chimerism in dogs given donor antigen, CTLA4Ig, and 100 cGy total body irradiation before and pharmacologic immunosuppression after marrow transplant. Blood 94:2523–2529 182. Storek J, Dawson MA, Storer B et al (2001) Immune reconstitution after allogeneic marrow transplantation compared with blood stem cell transplantation. Blood 97:3380–3389 183. Suciu S, Mandelli F, de Witte T et al (2003) Allogeneic compared with autologous stem cell transplantation in the treatment of patients younger than 46 years with acute myeloid leukemia (AML) in first complete remission (CR1): an intention-to-treat analysis of the EORTC/GIMEMAAML-10 trial. Blood 102: 1232–1240 184. Sureda A, Robinson S, de Elvira C et al (2003) Non myeloablative allogeneic stem cell transplantation significantly reduces transplant related mortality in comparison with conventional allogeneic transplantation in relapsed or refractory hodgkin’s disease: results of the European group for blood and marrow transplantation for the EBMT lymphoma working party. 185. Tallman MS, Kopecky KJ, Amos D et al (1989) Analysis of prognostic factors for the outcome of marrow transplantation or further chemotherapy for patients with acute nonlymphocytic leukemia in first remission. J Clin Oncol 7:326–337 186. Tallman MS, Rowlings PA, Milone G et al (2000) Effect of postremission chemotherapy before human leukocyte antigen-identical sibling transplantation for acute myelogenous leukemia in first complete remission. Blood 96:1254–1258 187. Talpaz M, Silver RT, Druker BJ et al (2002) Imatinib induces durable hematologic and cytogenetic responses in patients with accelerated phase chronic myeloid leukemia: results of a phase 2 study. Blood 99:1928–1937 188. Tartarone A, Romano G, Galasso R et al (2003) Should we continue to study high-dose chemotherapy in metastatic breast cancer patients? A critical review of the published data. Bone Marrow Transplant 31:525–530 189. Thomas ED, Buckner CD, Clift RA et al (1979) Marrow transplantation for acute nonlymphoblastic leukemia in first remission. N Engl J Med 301:597–599 190. Thomas ED, Kasakura S, Cavins JA et al (1963) Marrow transplants in lethally irradiated dogs: the effect of Methotrexate on survival of the host and the homograft. Transplantation 1:571–574 191. Thomas ED, Lochte HL Jr, Cannon JH et al (1959) Supralethal whole body irradiation and isologous marrow transplantation in man. J Clin Invest 38:1709–1716

23 Current Status of Bone Marrow Transplantation 192. Thomas ED, Sanders JE, Flournoy N et al (1979) Marrow transplantation for patients with acute lymphoblastic leukemia in remission. Blood 54:468–476 193. Tricot G, Jagannath S, Vesole D et al (1995) Peripheral blood stem cell transplants for multiple myeloma: identification of favorable variables for rapid engraftment in 225 patients. Blood 85:588–596 194. van Besien K, Keralavarma B, Devine S et al (2001) Allogeneic and autologous transplantation for chronic lymphocytic leukemia. Leukemia 15:1317–1325 195. Verdonck LF (1999) Allogeneic versus autologous bone marrow transplantation for refractory and recurrent lowgrade non-Hodgkin’s lymphoma: updated results of the Utrecht experience. Leuk Lymphoma 34:129–136 196. Verdonck LF, van Putten WL, Hagenbeek A et al (1995) Comparison of CHOP chemotherapy with autologous bone marrow transplantation for slowly responding patients with aggressive non-Hodgkin’s lymphoma. N Engl J Med 332:1045–1051 197. Visani G, Rosti G, Bandini G et al (2000) Second chronic phase before transplantation is crucial for improving survival of blastic phase chronic myeloid leukaemia. Br J Haematol 109:722–728

435 198. Vose JM, Sharp G, Chan WC et al (2002) Autologous transplantation for aggressive non-Hodgkin’s lymphoma: results of a randomized trial evaluating graft source and minimal residual disease. J Clin Oncol 20:2344–2352 199. Weissinger F, Sandmaier BM, Maloney DG et al (2001) Decreased transfusion requirements for patients receiving nonmyeloablative compared with conventional peripheral blood stem cell transplants from HLA-identical siblings. Blood 98:3584–3588 200. Woolfrey E, Nash RA, Sanders JE et al (2000) A nonmyeloablative regimen for induction of multi-lineage hematopoietic mixed donor-host chimerism in nonmalignant disorders (abstract). Blood 98:784a 201. Zittoun RA, Mandelli F, Willemze R et al (1995) Autologous or allogeneic bone marrow transplantation compared with intensive chemotherapy in acute myelogenous leukemia. European organization for research and treatment of cancer (EORTC) and the Gruppo Italiano Malattie Ematologiche Maligne dell’Adulto (GIMEMA) leukemia cooperative groups. N Engl J Med 332:217–223

Chapter 24

Pain Management in Cancer Patients Hrachya Nersesyan, Jeffrey J. Mucksavage, Eljim Tesoro, and Konstantin V. Slavin

Cancer is one of the most debilitating and deadly diseases that, broadly speaking, shows no preference for demographic, sex, age, or culture. It is the second leading cause of mortality of all Americans as a single disease [1], and the sheer potential for mortality from cancer can be a horrifying experience for anyone bearing this diagnosis. Pain is probably one of the most common of all cancer symptoms and can be very frightening for patients and their families. According to statistics published by the American Cancer Society in 2002 [2], 50–70% of patients with cancer experience pain, which usually only intensifies as the disease progresses. It was estimated that less than half of cancer patients get adequate relief of their pain, and 25% actually die in pain [3]. This is particularly disappointing because the pain endured by 90% of these patients could have been well managed with relatively simple interventions [4]. This chapter will discuss different options for treating cancer pain focusing on the pharmacological agents and surgical modalities currently available for pain management. Pain associated with cancer is not only at times unbearable for patients, but also can be tormenting to their family members and caretakers [5, 6]. Patients and their families tend to be under great distress after the diagnosis of cancer, and although many of these patients carry a very poor prognosis, prompt and effective pain control can prevent needless suffering and may significantly improve the quality of their lives. Not only may proper management alleviate the pain,

H. Nersesyan () Illinois Neurological Institute, OSF Saint Francis Medical Center, 530 N.E. Glen Oak Avenue, Peoria, IL 61637, USA e-mail: [email protected]

it also could potentially spare families the feeling of helplessness and despair. “Of the increasing grades of pain – from mild through to moderate, severe, very severe, incapacitating to overwhelming – Jane had reached the last stage: the point where consciousness is pain” – this is how one family describes suffering of her daughter diagnosed with skin cancer in Britain in late 70s [7]. Because of the negative consequences on both patients and their families, and wide variety of pain management techniques available nowadays, patients with cancer should be comforted with maximally achievable pain control and not live in fear of inadequately treated pain. Suboptimal pain control can be very debilitating and may impede the healing process. Severe pain can interfere with physical rehabilitation, mobility, and proper nutrition and a significant number of cancer patients are subsequently diagnosed with depression. Therefore, the goals of pain control in any patient with cancer should be to optimize the patient’s comfort and function while avoiding unnecessary adverse effects from medications [8]. Although cancer can be a terminal disease, there should be no reason to deny a patient the opportunity to live productively and free of pain. However, there are many challenges encountered in the treatment of cancer pain. Generally, pain is a subjective feeling that has not to date been easily and universally quantified [9]. Patients with similar cancer types may experience different intensities of pain and may respond to the same analgesic in different ways. Patients may also exhibit varying sensitivities to the adverse effects from many of the drugs used. Because pain is multifaceted, a single analgesic may not be sufficient enough to alleviate all the aspects of pain that the patient is experiencing, thus complicating the pharmacological regimen. Depending on the

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_24, © Springer Science+Business Media B.V. 2011

437

438

type and extent of the cancer, the administration routes may be limited for some patients and more innovative methods of drug delivery may need to be utilized. For example, as cancer progresses, oral administration may not deliver the appropriate level of analgesia desired due to waning level of consciousness or failure of gastro-intestinal absorption. In addition, persistent nausea and vomiting some patients may experience during the course of chemotherapy will also interfere with oral administration of analgesics. Society has also placed limitations on pain control because of unfounded concerns of addiction or opioid abuse. Patients and their families must realize that in order to attain optimal pain control they must be educated about the pain process, the medications used, and the side effects they can realistically expect. They also need to know that there are many options available to the pain specialist, both pharmacological and surgical, and that pain management can be seen as a multidisciplinary activity, requiring the expertise of physicians, nurses, pharmacists, dietitians, etc. Another challenge to the treatment of cancer pain is the paucity of good clinical trials providing objective data that can be extrapolated to individual patients. Some of the limitations with the clinical trials found in the literature today include the heterogeneity of cancer pain types, the limited number of patients enrolled, the spectrum of available analgesics and doses used for optimal pain control, the lack of a single objective pain scale, and the variable duration of treatment provided in different textbooks or guidelines. Current approach to pain control should be individualized for every patient and will require knowledge of the cancer type, the drugs available on the market, the patients’ metabolism, drug tolerances, and even their genetic morphology. Periodical re-evaluation of patient’s medication regimen is essential to finely tune their analgesia and to minimize the exposure to potentially dangerous adverse effects.

24.1 Cancer Pain Types To adequately manage the pain, a basic understanding of its type and pathophysiology are warranted and addressed in details elsewhere. Determining the source of a patient’s pain is a useful first step in attempting to alleviate it. Also, understanding the stimulus for the

H. Nersesyan et al.

pain can guide clinicians in designing the most appropriate pharmacological, surgical, chemotherapeutic, or non-traditional intervention. Physiologically, there are two distinguished types of pain – nociceptive pain and neuropathic pain. Nociceptive pain stimulus is transmitted by peripheral nerves from specialized pain receptors, called nociceptors, whose function is to report any injury, which in cancer patients is usually secondary to invasion of tumor into bone, joints, or connective tissue. Other types of nociceptive pain are those associated with different procedures (i.e., lumbar puncture, biopsy). Nociceptive pain tends to respond well to opioids and non-opioid analgesics. Neuropathic pain, on the other hand, results from mechanical or metabolic injury to the nervous system itself, either centrally or peripherally, and is generally associated with mishandling of incoming somatosensory stimuli. In patients with advanced cancer this can be a result of tumor infiltration of nerves or nerve roots. Neuropathic pain may respond to traditional analgesics, but more commonly is better alleviated by antiepileptic drugs or tricyclic antidepressant agents, which modulate action potential propagation and the availability of chemical neurotransmitters such as norepinephrine and serotonin. It is important to keep in mind that patients will generally experience a combination of pain types, and the treatment of the disease, i.e. surgery, radiation, chemotherapy, may be a source of the painful stimuli along with progression of the disease itself. The assessment of cancer pain is confounded by its subjective nature placing the onus of judgment on the clinician. This should be avoided and all reports of pain should be appropriately responded to and addressed in a timely manner. It is recommended that pain should be evaluated at every clinical visit and incorporated as the “fifth vital sign” [10]. Ideally, the assessment should target the severity, duration, quality and location of the pain [11]. In addition, it is important for the clinician to inquire about how the pain has affected patient’s daily activities and relationship with others. To help introduce objectivity in the evaluation, a number of pain scales have been utilized to quantify pain intensity. Currently, it is recommended that pain should be measured using a numerical rating scales [10]. These scales generally range from 0 to 10 with 0 indicating no pain and a 10 indicating the worst imaginable pain. Children, the elderly, and patients with language differences, may have difficulty interpreting

24 Pain Management in Cancer Patients

the above scales. In these cases, scales with illustrations depicting levels of pain as facial expressions such as the Wong-Baker scale, should be considered [12]. This enables clinicians to make a continuous objective assessment of pain intensity throughout the course of the treatment. To assess for the quality of the painful stimulus, it is best to allow the patients to describe the pain themselves, which very often helps healthcare practitioners get a better understanding of the source and the type of pain. Clinicians should attempt to obtain more information about the pain by conducting pain histories to determine a cause and the best treatment modality [10]. It has also been suggested that clinicians pay more attention to psychological factors because fear and anxiety may have significant effects on the perception and experience of pain [11].

24.2 Pharmacological Management of Cancer Pain More than 20 years ago, the World Health Organization (WHO) recognized chronic cancer pain as a major public health problem, with the following development of the so-called three-level “analgesic ladder,” a therapeutic strategy designed to facilitate and standardize cancer pain management and advise physicians worldwide how to better provide pain management to their patients [13] (Fig. 24.1). In this guideline, the WHO recommends starting with non-opioid analgesics and then progresses to the addition of opioids in combination and then ends with pure opioid management. Although experience suggests that cancer pain can be relieved in more than 70% of patients using a simple opioid-based regimen [14], a number of specific characteristics may lead to a relatively lesser degree of opioid responsiveness in some patients. Some non-analgesic medications are found to be very helpful in amplifying the effect of many analgesic drugs, particularly in patients with neuropathic pain. The term “adjuvant analgesic” describes any drug with a primary indication other than pain, but with analgesic properties in some painful conditions. They can be added to the regimen at any time depending on the quality of the pain [15]. The non-opioid analgesics include acetaminophen, aspirin, non-steroidal anti-inflammatory drugs

439

(NSAIDs), such as ibuprofen or ketorolac, and the most recent addition, the COX-2 inhibitors celecoxib and valdecoxib. Most non-opioid analgesics used for cancer pain treatment are summarized in Table 24.1. Acetaminophen is recommended as a first step analgesic for mild to moderate pain. Although its mechanism of action is not fully understood, it is thought to inhibit central prostaglandin synthesis in the central nervous system, which explains its analgesic and antipyretic activity without any effects on inflammation. Acetaminophen is not generally used alone for cancer pain, but rather in combination with opioids (i.e., hydrocodone, codeine, etc.) Although acetaminophen is effective and well tolerated by most of the patients, its use is limited by a maximum daily dose of 4000 mg (2000 mg/day in patients with hepatic dysfunction) due to potential hepatic toxicity. On the other hand, the gastro-intestinal toxicities seen with chronic NSAIDs use are not seen with acetaminophen. Acetaminophen is excreted by kidneys and dosing must be adjusted in patients with significant renal insufficiency. Aspirin is another drug from this group that can be used for mild to moderate pain control. Unlike acetaminophen, aspirin serves not only as an analgesic and antipyretic but also as an anti-inflammatory agent, which may be an important addition to the therapeutic effect in patients who have severe inflammatory pain. It is a safe over-the-counter drug widely used for non-cancerous acute pain control and for management and prophylaxis of myocardial infarction due to its well-established anti-platelet action. However, it has to be used very cautiously in cancer patients, as in high doses required for adequate pain control (650–1000 mg orally every 4–6 h) aspirin can cause a number of unwanted side effects, such as tinnitus, vertigo, hyperventilation, as well as increased risk of peptic ulcer disease and gastro-intestinal (GI) bleedings. If overdosed, aspirin can cause cardiovascular instability, exacerbate underlying renal insufficiency, and even lead to coma with renal failure, metabolic acidosis and respiratory arrest. NSAIDs are potent analgesics, antipyretics and antiinflammatory agents, which makes them useful for cancer related pain of musculoskeletal origin. They work through non-specific inhibition of cyclooxygenase (COX), an enzyme that mediates prostaglandin synthesis from arachidonic acid. Because of this non-specific activity, all nonselective NSAIDs have

440 Fig. 24.1 The World Health Organization (WHO) cancer pain treatment step ladder

H. Nersesyan et al.

FREEDOM FROM PAIN

3

Opioids for moderate to severe pain ± Non-opioid ± Adjuvant

2

Opioids for mild to moderate pain ± Non-opioid ± Adjuvant

1

Non-opioids ± Adjuvant

Titrate until adequate pain control is achieved

Proceed to next step if pain persists or increases

Proceed to next step if pain persists or increases

PAIN

significant adverse effects on gastric mucosa and renal parenchyma, and some inhibit platelet function. With chronic use, they can cause serious gastric ulcerations and bleeding, which is a result of the inhibition of COX-1 isoenzyme. Therefore, NSAIDs may not be an optimal choice in patients who are experiencing nausea and vomiting associated with receiving chemotherapy. In addition, care must be taken in patients that may already have renal insufficiency related to advanced age or disease progression because of the potential to exacerbate these conditions due to modulation of prostaglandin activity on renal blood flow [16]. The NSAIDs have maximum daily doses that limit their utility in moderate to severe cancer pain management. All of the NSAIDs are available orally, but only ketorolac is available in parenteral form for pain control. Indomethacin, like aspirin, is available in suppository forms for rectal administration. COX-2 inhibitors have less potential for GI and hematological side effects seen with the traditional NSAIDs, a factor that makes them more attractive for cancer pain management. These drugs specifically inhibit the COX-2 isoenzyme, which is considered the inducible isoenzyme during painful stimuli. This selectivity spares the inhibition of COX-1, which is thought to be constitutive in the gastrointestinal tract and required for normal gastrointestinal function. In addition, there are emerging studies that show an antitumoral effect with these agents due to inhibition of cytokine production seen in many solid tumors [17]. This class of drugs is an attractive option in those patients with cancer involving inflammation (i.e., bone metastases) and those who are at high risk for

gastrointestinal bleeding or platelet dysfunction. These agents may also allow smaller doses of opioids to be used thereby minimizing potential risk for narcotic side effects. Because of their relatively short half-lives, they are also capable of treating breakthrough pain. However, like NSAIDs, COX-2 inhibitors should be used with caution with those at risk for renal failure, and case reports have emerged documenting this severe adverse effect [18]. Moreover, the overall safety of COX-2 inhibitors has come into question R ) was linked to increased since rofecoxib (Vioxx risk of acute myocardial infarction (MI) and sudden cardiac death among high-dose chronic users of this drug. The cardiovascular safety of rofecoxib has been questioned since 2000 when Merck submitted a study called VIGOR (Vioxx gastrointestinal outcomes research) to the US Food and Drug Administration (FDA) [19]. The analysis of the VIGOR study showed that patients taking rofecoxib had a higher relative risk of developing adverse cardiovascular events than patients taking naproxen [20]. This led to warnings of this risk imposed by the FDA on the drug’s label in April 2002. In October 2004 rofecoxib has been voluntarily withdrawn from the market by manufacturer (Merck Pharmaceutical) after a 3-year study, which R could prevent the was aimed at showing that Vioxx recurrence of colonic and rectal polyps (APPROVe), discovered that participants had twice the risk of acute MI compared to those taking a placebo [21, 22]. Mechanistically speaking, there are reasons why selectively inhibiting COX-2 isoenzyme might increase cardiovascular risk [23]. Because COX-1 helps promote thrombosis and COX-2 helps inhibit it,

Capsules – 50, 100 mg

Capsules – 250 mg

Tablets – 7.5, 15 mg Suspension – 7.5 mg/5 mL Tablets – 500, 750 mg Tablets – 250, 375, 500 mg

Tablets – 600 mg

Capsules – 10, 20 mg

Tablets – 150, 200 mg Capsules – 400 mg Tablets – 200, 600 mg Capsules – 100, 200 mg Tablets – 12.5, 25, 50 mg Suspension – 12.5 mg/5 ml, 25 mg/5 ml Tablets – 10, 20 mg

Meclofenamate

Mefenamic acid

Meloxicam

Nabumetone Naproxen

Oxaprozin

Piroxicam

Sulindac Tolmetin

∗ Rofecoxib

600 mg–1200 mg PO once a day 10–20 mg PO once a day 150–200 mg PO BID 200–600 mg PO BID-TID 200 mg PO BID 50 mg PO daily for 5 days, then 25 mg PO daily 10–20 mg PO BID

10 mg PO q4–6 h PRN or 30 mg IV/IM q6h 50–100 mg PO q4–6 h PRN 250 mg PO q4–6 PRN 7.5–15 mg PO once a day 500 mg–1000 mg QD to BID 250–500 mg PO BID

25–50 mg PO q6h-q8h

400 mg PO q4–6 h PRN 25–50 mg PO TID

50 mg PO BID-TID 200–400 mg PO q6–8 h

400 mg/day 50 mg/day

400 mg/day 1800 mg/day

20 mg/day

2 g/day 1500 mg/day for 3–5 days 1800 mg/day

15 mg/day

40 mg/day PO OR 120 mg/day IV/IM 400 mg/day

300 mg/day

200 mg/day

3200 mg/day

1200 mg/day

150 mg/day

4000 mg/day

4000 mg/day

Maximum

COX-2 inhibitor

COX-2 inhibitor COX-2 inhibitor

for therapy less than 1 week in duration COX-2 preferential NSAID

IV therapy should not exceed 5 days

Use with caution in patients with history of peptic ulcer Use with caution in patients with history of peptic ulcer

Bleeding risk is the most significant concern.

No anti-inflammatory effect. Hepatotoxic if overdosed.

Comments

(Vioxx) and Valdecoxib (Bextra) were removed from the market at the time of writing this chapter due to increased cardiovascular and dermatological risks

Valdecoxib∗

Celecoxib Rofecoxib∗

Ketorolac

Ketoprofen

Indomethacin

Ibuprofen

Etodolac

Diclofenac

325–650 mg PO q4h PRN

325–650 mg PO q4h PRN

Tablets – 325, 500, 650 mg Suspension – 160 mg/5 ml Suppository – 80, 120, 125, 200, 300, 325, 600, 650 mg Tablets – 81, 162, 325, 500, 650, 975 mg Suppository – 60, 120, 325, 650 mg Tablets – 50 mg Delayed-release – 25, 50, 75, 100 mg Tablets – 400, 500 mg Extended-release – 400, 500, 600 mg Capsules – 200, 300 mg Tablets – 200, 400, 600, 800 mg Suspension – 40 mg/ml, 100 mg/5 ml Capsules – 25, 50 mg Extended-release – 75 mg Suspension – 25 mg/5 ml Suppository – 50 mg Tablets – 12.5 mg Capsules – 25, 50, 75 mg Extended-release – 100, 150, 200 mg Tablets – 10 mg Parenteral – 15 mg/ml, 30 mg/ml

Acetaminophen

Aspirin

Dose

Table 24.1 Most commonly used non-opioid analgesics in U.S. Drug Preparation

24 Pain Management in Cancer Patients 441

442

blocking COX-2 but not COX-1 could theoretically increase the risk of myocardial infarction and other thrombotic events. On the other hand, inflammation has also been implicated in cardiovascular events, so controlling inflammation via COX-2 inhibition could conceivably be protective. Although two other COX-2 inhibitors from Pfizer (celecoxib and valdecoxib) available on the market today may be also implicated in increasing cardiovascular risk with chronic use, the Celecoxib Long Term Arthritis Safety Study (CLASS) trial conducted in 2000 did not show a significantly increased rate of myocardial infarction with celecoxib compared with the nonspecific NSAIDs ibuprofen or diclofenac [24]. Therefore, COX-2 inhibitors continue to serve as a good option for long term relief of musculoskeletal pain in patients with terminal cancer. No parenteral forms of COX-2 inhibitors are commercially available at present in the Unites States. Tramadol is a centrally acting non-opiate agonist at the mu receptors, and is effective in the treatment of moderate to severe pain. Unlike the NSAIDs, it has no anti-inflammatory activity. It can be beneficial in patients who fail non-opioid therapy and wish to delay opioid therapy and avoid the common side effects of constipation, somnolence, and fatigue. It has been studied mostly for post-operative pain control after tumor resections, but some studies in chronic cancer pain show marginal to moderate success [25]. It is only available in tablet form. As pain progresses, non-opioid regimens may not be sufficient to provide necessary analgesia or may be approaching maximum recommended daily doses. At this point, a trial of opioid and non-opioid analgesic combination should be instituted. A variety of fixed combinations are available that usually include codeine, hydrocodone, oxycodone, or propoxyphene. This phase requires frequent and constant evaluation of the patient to titrate each drug to a successful dose. The doses of these agents are generally limited by the nonopioid component. Once the limit is reached for these agents (e.g., >4 g/day of acetaminophen), the next step is to advance to pure opioid therapy. The opioids are typically the most common drug class used in the treatment of cancer pain. They work by binding to opioid receptors within the central nervous system. The receptor responsible for the most significant opioid actions is the mu receptor, which mediates analgesia, respiratory depression, sedation, physiological dependence, and tolerance

H. Nersesyan et al.

[26]. Analgesic effect of opioids is largely dependent on mu receptor saturation and is thus influenced by the type and severity of the pain, prior exposure to opioids, and individual distribution of receptors [4]. There is no maximum dose for these agents; they are only limited by the development of side effects that are patient specific in their onset and severity. Common opioid side effects include nausea, constipation, sedation, and confusion, and they can be often managed without compromising pain control by adjusting the daily dose of the drug or in persistent cases by instituting additional medications, such as metoclopramide for nausea, laxatives for constipation, or methylphenidate for sedation. Wide variety of opioids are currently available in the market (Table 24.2), and are roughly categorized R , into controlled release (CR), such as MS Contin R R R R Avinza , Kadian , Oxycontin , Duragesic , and immediate release (IR) formulations, such as MSIR, R , etc. Oxycodone, Hydromorphone, Actiq It was suggested that for patients with mild to moderate cancer pain opioid analgesic therapy may start with the trial of codeine or hydrocodone [27]. Codeine is a weak opium alkaloid with a potency 1/10 of morphine. Hydrocodone is the more potent hydrogenated ketone derivative of codeine, which is typically available only as a combination product with acetaminophen (Vicodin, Norco) or aspirin. Although both these drugs are very well suited for the treatment of different mild to moderate pain syndromes, they have almost no role in the treatment of severe cancer pain. Morphine is considered the standard opiate and the drug of first choice in the treatment of moderate to severe cancer pain. It should be titrated to maximum tolerability before moving on to another opiate such as fentanyl, hydromorphone, or oxycodone. Morphine, first identified nearly 200 years ago, is available in a variety of formulations (i.e., parenteral, oral, rectal) and the oral form is available in a range of preparations, from immediate release to sustained release, allowing it to be precisely titrated to the patient’s response (Table 24.2). The oral formulation is recommended initially due to its ease of administration and convenience of use. A typical regimen consists of a sustained-release (SR) preparation given every 8–12 h with breakthrough doses in immediate-release (IR) form given every 3–4 h in between if needed. As a guide, the cumulative as-needed doses should not

24 Pain Management in Cancer Patients

443

Table 24.2 Most commonly used opioid analgesics in U.S. Drug name Morphine sulfatea MSIR (immediate release) R MS Contin R Oramorph SR R Kadian R Avinza Codeine

Hydromorphonea R Dilaudid (immediate release) R Palladone Oxycodone R Roxycodone (immediate release) R OxyContin Propoxyphene R Darvon Pulvule

Methadone Meperidine (Demerol)

Duration of action (h)

Formulation Tablets: 15 and 30 mg and Suppositories: 5, 10, 20, 30 mg Controlled-release tablets: 15, 30, 60, 100, 200 mg Sustained-release tablets: 15, 30, 60, 100 mg Sustained-release capsules: 20, 30, 50, 60, 100 mg Extended-release capsules: 30, 60, 90, 120 mg Tablets: 15, 30, 60 mg Oral solution: 15 mg/5 ml, 30 mg/5 ml

2–4

Tablets: 2, 4, 8 mg; Oral solution: 5 mg/5 mL; Parenteral solution: 1 mg/ml, 2 mg/ml, 4 mg/ml; and Suppositories: 3 mg Extended-release capsules: 12, 16, 24, 32 mg

2–4

Tablets: 5, 15, 30 mg; Capsules: 5 mg; and Oral solution: 5 mg/5 ml, 20 mg/ml Controlled-release tablets: 10, 20, 40, 80, 160 mg

2–4

Capsules: 65 mg

2–4

Oral solution: 5 mg/5 ml, 10 mg/5 ml, 10 mg/ml Tablets: 5, 10, 40 mg Oral solution: 50 mg/5 ml Tablets: 50, 100 mg

4–8

8–12 8–12 24 24 2–4

24

12

2–4

Fentanyl Actiq

Oral transmucosal lozenge: 200, 400, 600, 800, 2–4 1200, 600 mcg R Duragesic Transdermal patch: 25, 50, 75, 100 mcg/h 72 a Morphine and hydromorphone are the only drugs from this list which are currently approved for intrathecal administration

exceed the total dose given as a sustained preparation for that interval. Thus, a patient requiring morphine 120 mg SR every 12 h should receive morphine 30 mg IR every 3 h for breakthrough pain. Regimens will require frequent adjustments allowing 3–4 days for the patient to respond before initiating a change unless toxicity is apparent. One double-blind, multi-centered crossover study compared the efficacy, safety, and pharmacokinetics of a novel once-daily morphine formulation and a 12-h SR morphine formulation in the treatment of chronic cancer pain [28]. The investigators found that there was no significant difference betweens treatments for evaluations of overall pain intensity, analgesic efficacy, or adverse events. However, the

once-daily formulation showed less fluctuation in plasma morphine concentration to compare with SR form, and most patients chose once-daily morphine dosing for continuing pain management, as it was providing more stable pain control over the day. The most common adverse effects of morphine include sedation and some degree of cognitive impairment which patients may develop a tolerance to given time. Nausea and vomiting are frequently seen upon initiation of therapy and after large dose increases, but usually subside with time. Constipation is seen with chronic therapy; patients do not develop tolerance to it and typically require preemptive treatment with laxatives. The effects of active morphine metabolites can be induced or inhibited by a variety of medications.

444

Anti-epileptic drugs carbamazepine, phenobarbital, and phenytoin, as well as antibiotic rifampin can accelerate clearance of morphine. Phenothiazines, tricyclic antidepressants, and cimetidine will interfere with morphine metabolism and may potentate its effect if administered simultaneously. Co-administration of morphine and benzodiazepines may produce strong synergic action resulting in sedation, hypotension, and sometimes delirium [29]. Should a patient fail morphine therapy, another opiate should be instituted and dosed according to its morphine equivalency. Initial dosing of the new opioid should be 25–50% less than the expected equivalent dose of morphine since the patient may not be crosstolerant to the new agent. Cross-tolerance can be seen when changing from a more potent to a less potent agent and is a result of variable effects of each opioid on the pain receptors. R ) is a water-soluble Hydromorphone (Dilaudid opioid that is several times more potent than morphine allowing for smaller doses to be used. It is available in parenteral, rectal, subcutaneous and oral formulations. However, hydromorphone can be also administered via epidural and intrathecal routes [27]. Hydromorphone should be considered particularly for patients on morphine who are having side effects of increased confusion or myoclonus [4]. When using injectable hydromorphone, clinicians must be aware of its potency. Although IV hydromorphone is six to seven times more potent than IV morphine [30], it could be 20 times more potent than oral morphine. Hydromorphone relieves continuous dull pain more effectively than sharp intermittent pain, and when mixed with epinephrine it provides superior pain relief [27]. Fentanyl is a quick acting lipophilic opiate available in parenteral, transmucosal, and transdermal formulations. Intravenous fentanyl is 70 to 100 times more potent than IV morphine [31] and has very rapid onset of action – 5 min to peak analgesia, versus at least 15 min for IV morphine [26]. Fentanyl is most widely used in palliative medicine in the form of a transderR ), which is especially useful mal patch (Duragesic in those patients who do not have enteral access for analgesia or for whom nausea and vomiting limit the ingestion of the required dose of opioid. It is not recommended for breakthrough pain though, since it may take 12–24 h for the onset of action to occur [32], and it is better suited for those patients whose analgesic

H. Nersesyan et al.

requirements are already stable. Another drawback of transdermal fentanyl is that its elimination half-life is 18 h after patch removal, thus patients who experience side effects will need to be monitored and supported for a full day following discontinuation. A R – the better choice for breakthrough pain is Actiq oral transmucosal fentanyl citrate (OTFC) lozenge that patients can dissolve in the buccal space for immediate relief, usually within 5–10 min. One study compared its use with oral immediate-release morphine and found OTFC to be superior for fast pain control [33]. Other study demonstrated that OTFC may be an effective alternative to intravenous opioids in rapidly titrating analgesia in selected opioid-tolerant cancer patients who are in pain crisis [34]. Another centrally acting synthetic opioid, transdermal buprenorphine, is now being widely prescribed in Europe and Australia for cancer pain management [35, 36]. Transdermal buprenorphine is contained in a matrix patch as opposed to traditional reservoir patch technology used for transdermal fentanyl, which makes it more robust in handling. In a matrix system, the substance is an integral part of the polymer structure of the patch. Thus, while damaging a reservoir patch might result in “dose dumping” and potentially overdosing the patient, damaging a matrix patch will not interfere with the controlled release of the medication [37]. Morphine has also been compared to oral oxycodone, a synthetic opioid that is metabolized hepatically to the active oxymorphone [38]. This study compared controlled-release oxycodone and morphine tablets in 45 cancer patients, and although the authors found that both drugs have provided similar analgesic effects, there were differences in pain relief in those patients who had underlying renal or hepatic dysfunction with pain control in patients receiving oxycodone. This may be due to the accumulation of active metabolites or differences in the phenotype for CYP2D6 that metabolizes oxycodone. This study stresses the importance of pharmacogenomics in guiding and individualizing pain therapy in the future. In most markets, oxycodone is significantly more expensive than morphine and is thus less attractive as a first-line analgesic R ) based on special [4]. CR oxycodone (Oxycontin drug delivery system, known as AcroContin system, and uses a dual-control matrix with two hydrophobic polymers, which are not influenced by pH and R is therefore are independent of acidity. Oxycontin

24 Pain Management in Cancer Patients

effective in moderate to severe cancer pain and allows for convenience of every 12 h administration [27]. Methadone is an inexpensive synthetic opioid agonist that has a very long half-life, no active metabolites, and little tendency to induce tolerance in patients. It has unique properties that make it useful in treating pain which is poorly controlled by other opioids. In addition to binding to the opioid mu receptor, methadone produces analgesic effects through its antagonism at the N-methyl-D-aspartate (NMDA) receptor site and by increasing the availability of neurotransmitters serotonin and norepinephrine within the central nervous system [39]. NMDA antagonism also reduces morphine tolerance at the opioid receptor site. Methadone may be an effective alternative for cancer patients, although its equianalgesic dosing to morphine has not been firmly established and can vary widely depending on the cumulative dose of morphine [40–42]. It occurs more frequently in patients previously exposed to high doses of opioids than in patients receiving low dose [27]. Methadone is available for oral, sublingual, rectal, intravenous and subcutaneous administration. Ketamine also has effects in blocking the NMDA receptors and has found some success in treating neuropathic pain [43]. Although it has not been shown to be effective in acute pain, ketamine does have some opioid-sparing benefits, allowing smaller doses of morphine to be given [44]. Limiting its use are the side effects that include sedation and hallucinations at higher doses. There are many other opioids available on the market today. However, they are not usually recommended for routine use in cancer pain management. These include meperidine, propoxyphene, partial agonists (i.e., buprenorphine), and mixed agonist-antagonist agents (i.e., butorphanol, pentazocine, nalbuphine). Meperidine is metabolized to a neurotoxic metabolite normeperidine which can induce seizures if accumulated. The effect of propoxyphene can be considered more euphoric than analgesic. The mixed agents have a ceiling effect as well as the potential in reversing analgesic effects of any pre-existing opioid the patient is already taking and, therefore, they are not considered efficacious. Patients may have varying responses to an individual opioid based on various pharmacodynamic and pharmacokinetic interactions. For example, morphine is hepatically glucuronidated to two

445

metabolites: morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). M3G has no analgesic properties but may be involved in certain side effects such as myoclonus. M6G is a more potent analgesic than the parent compound and passes much more readily into the central nervous system. Morphine and its metabolites are excreted by the kidneys and toxicity can be seen in patients with underlying renal insufficiency or failure. In cirrhosis, the bioavailability of morphine is increased due to the lack of first pass metabolism; however, the production of the more potent M6G metabolite may decrease resulting in a less than optimal analgesic effect. In addition, it should be noted that older individuals, who make the vast majority of terminal cancer patients, may have an increased sensitivity to opioids, due to decreased hepatic metabolism and decreased renal excretion, as well as a reduced number of opioid receptors due to brain atrophy [45]. Therefore, it is vital to incorporate interpatient differences into the dosing scheme in order to arrive at a tolerable but effective regimen. Patients who experience little or no pain relief despite substantial analgesic doses of opiates or who develop intolerable adverse effects are said to exhibit opioid poorly-responsive pain. The terms opioidtolerant or opioid-resistant previously used to label these patients do not reflect the multidimensional aspect of the phenomenon, as unsatisfactory analgesic response may be due to a variety of factors: differences in patient metabolism, multiple pain mechanisms, disease progression, and sensitivity to side effects. In such cases, a variety of strategies can be implemented to improve the pain control and balance between analgesia and side effects [14]. Among these strategies is the use of adjuvant analgesics, although very few of these drugs have been actually studied in cancer populations. There are several major groups of adjuvant analgesics (i.e. antidepressants, antiepileptic drugs, muscle relaxants, corticosteroids, etc.) that are used nowadays to intensify the effect of opioids and NSAIDs on longterm pain control. In some cases, the type of pain suggests the value of one category of adjuvant analgesic over another; in others, the existence of another symptom concurrent with pain favors the use of a specific drug [15]. For example, pain that is neuropathic in nature is typically not amenable to standard opiate therapy, and the addition of tricyclic antidepressants (TCA) or/and antiepileptic drugs (AED) can offer a very effective treatment strategy in such patients [46].

446

TCA such as amitriptyline are attractive adjuvant agents in cancer patients due to their positive effects on mood and sleep. The analgesic properties of TCA have been extensively studied in a variety of chronic nonmalignant pain conditions [47, 48]. Although few clinical trials have specifically evaluated these drugs for cancer pain [49, 50], our experience supports their analgesic effects. Early use of antidepressants is also justified when pain is accompanied by depression, which is fairly common in patients with advanced cancer. However, the use of TCA, especially in medically ill or elderly patients may be limited due to frequent side effects similar to those seen with opiates, which include drowsiness, constipation, urinary retention, and dry mouth, as well as such serious adverse effects as orthostatic hypotension and cardiotoxicity [51]. TCA are contraindicated in patients with a known history of glaucoma and should be avoided in patients who are suicidal. It should be noted that the secondary amine TCA, desipramine and nortriptyline, are less anticholinergic and usually better tolerated than the tertiary amines [15]. In addition, the non-tricyclic compounds, such as selective serotonin reuptake inhibitors (SSRI), are generally safer, have much less side effects than TCA and, therefore, may be considered for patients who have relative contraindications to tricyclics or have experienced severe adverse effects during the treatment [52]. However, there are very limited data supporting the analgesic efficacy of few SSRI, i.e. paroxetine [53], citalopram [54] and venlafaxine [55], in non-malignant pain management, and no studies have been reported on cancer pain. There is good evidence that AED are particularly useful as adjuvant therapy in the long-term management of neuropathic pain [56–60]. These agents can be instituted at any stage of the WHO ladder (Fig. 24.1). Of the all AED, gabapentin (Neurontin) is probably the most widely prescribed medication for the treatment of cancer-related neuropathic pain [61, 62], although its specific mechanism of action has not been fully elucidated at this time. Nonetheless, due to its proven analgesic effects, good tolerability, and a rarity of drugdrug interactions, gabapentin is now recommended as a first-line agent for the treatment of neuropathic pain of diverse etiologies, especially in the medically ill population [63, 64]. It should be initiated at a daily dose of 100–300 mg and can be increased every 3 days. The usual maximum dose is 3,600 mg daily, but can be higher if needed, and an adequate trial should include 1–2 weeks at the maximum-tolerable

H. Nersesyan et al.

dose [15]. Gabapentin is usually well tolerated, and the most common side effects are somnolence, dizziness, and unsteadiness, which are typically not severe if carefully titrated. There are several other AED, such as carbamazepine [56], phenytoin [65], lamotrigine [66, 67], pregabalin [68], and levetiracetam [69], that have been reported to be efficacious in alleviating different neuropathic pain syndromes, including cancer related pain [65]. In general, the last three drugs are well-tolerated and lack a significant drug-drug interaction, which makes them superior to carbamazepine or phenytoin for the long-term management of neuropathic pain. Corticosteroids belong to another major group of medications widely used as an adjuvant therapy for cancer-related pain syndromes, which include bone pain, neuropathic pain from infiltration or metastatic compression of neural structures, headache due to increased intracranial pressure, arthralgias, and pain due to obstruction of hollow viscus or distention of an organ capsule [15, 70–72]. They can also improve appetite, nausea, malaise, and overall quality of life [73, 74]. The use of adjuvant medications to treat opiate side effects can allow an increase in the analgesic dose. The second-generation (atypical) agent olanzapine (Zyprexa) was reported to decrease pain intensity and opioid consumption, and improve cognitive function and anxiety, in a recent case series of cancer patients [75]. Stimulants such as methylphenidate or caffeine can increase alertness in patients who are experiencing somnolence on a dose of morphine that provides sufficient pain control [76]. In addition, it has been shown that in cancer patients, methylphenidate not only can reduce opioid-induced somnolence, but can also significantly improve cognition, treat depression, and alleviate fatigue [77]. Liberal use of laxatives to treat constipation can also allow an opioid dose to be escalated. Patients who have pain associated with bone metastases may especially benefit from the use of bisphosphonate compounds, such as pamidronate or zolendronate [78, 79]. These agents decrease the effect of bone osteoclast resorption and are typically given intravenously every 4 weeks. Calcitonin has also shown beneficial effects in alleviating the pain associated with bone metastases [80, 81]. Other adjunctive strategies may include topical agents (local anesthetics, capsaicin) useful for mucositis or peripheral neuropathies [82]; clonidine, an alpha-2 adrenergic agonist usually given

24 Pain Management in Cancer Patients

intraspinally (to avoid systemic side effects) for the management of severe intractable cancer pain partly responding to opioids [83]; amantadine, a noncompetitive NMDA antagonist, which has been shown to reduce surgical neuropathic cancer pain [84]; or any other unusual adjuvant analgesics, that may be beneficial for the treatment of severe refractory pain not responsive to traditionally used drug combinations.

24.3 Surgical Management of Cancer Pain Surgery is rarely used for the treatment of cancer pain, particularly since longer-acting opioids, such as slow-release oxycodone or morphine, and transcutaneous fentanyl patches became available. In addition to that, prior to considering surgical intervention, one should try a variety of less-invasive techniques, such as nerve blocks, radiofrequency ablations or neurolytic destructions, as well as many other procedures available nowadays from the wide pain management arsenal. When it comes to the choice of pain-relieving surgical procedures, these are usually divided into two broad categories: neurodestruction and neuromodulation. Neurodestructive procedures involve interruption of pain pathways, which can be performed anywhere starting at the level of the nerve, nerve root, ganglion, spinal cord, thalamus or the brain stem depending on the nature and extent of the pain. One of the most commonly used procedures is spinal cordotomy that targets the spinothalamic tract on the cervical or upper thoracic level and results in eliminating pain sensation from the opposite side of the body [85]. Although safe and effective if done on one side only, it may be associated with a very high rate of complications if performed bilaterally. Midline myelotomy is reserved for patients with severe bilateral or visceral pain [86]; it interrupts a non-specific pain-transmitting pathway located in the vicinity of the central canal of the spinal cord. Thalamotomy is usually aimed at either nuclei involved in somatosensory perception or more anteriorly located centers that relay affective aspects of pain [87]. Cingulotomy targets the part of the limbic system that appears to modulate painful sensations and certain psychological aspects of pain experience; it is usually reserved for patients with intractable cancer pain after

447

failure of antineoplastic and palliative pharmacological treatments and when more conservative analgesic procedures are not applicable [88]. Among positive sides of neurodestructive procedures are: the relative ease of performance, lower cost due to absence of expensive implantable equipment, lack of hardware related complications, and most of all, immediate pain relief, making these procedures quite attractive to many suffering patients. However, the problems associated with destruction of the nervous tissue include: the irreversibility of action, particularly of the side effects (numbness and weakness that come directly as a result or as a complication of destructive operation may take very long time to recover), inability to test or reliably predict the effect of procedure due to individual anatomical and physiological variability, relatively short duration of the effect (most neurodestructive procedures result in 3 months to 1 year pain relief, mainly due to the plasticity of the central nervous system), and higher risk of complications with bilateral procedures. Also, neurodestructive procedures cannot be performed in patients with coagulopathies, which are developed due to their disease itself or as an unwanted side effect of the treatment. Despite all these, carefully selected and performed neurodestructive procedures may be ideal for certain cancer patient populations [89]. For example, a patient with gynecological malignancy who suffers from unilateral pelvic and leg pain due to radiation effect or direct tumor invasion of the lumbar plexus and has life expectancy of 2–3 months, may be an excellent candidate for a cervical cordotomy, which has a unique chance of rendering patient painless and free of narcotic medication side effects for the rest of her life. As to the neuromodulation, electrical stimulation of neural structures (peripheral nerve, spinal cord or brain stimulation) is rarely used for treatment of cancer pain [90]. It may help significantly for those with primary neuropathic nature of pain, such as patients with arachnoiditis, but is unlikely to eliminate the significant nociceptive component of cancer pain. Chemical neuromodulation, on the other hand, has become widely accepted in the treatment of cancer pain. Intrathecal opioids (such as morphine and hydromorphone) given alone or in combination with adjuvant medications (alpha-adrenergic agonists, e.g., clonidine, or local anesthetics, e.g., bupivacaine) are now commonly used for medically intractable cancer pain [91, 92]. Although these agents may be delivered via variety of catheters and ports, most accepted

448

practice consists of the implantation of a self-contained pump that delivers medication at a specific rate into the subarachnoid space via a dedicated intrathecal catheter [93]. Intrathecal administration of opioids is an option for those patients whose effective systemic dose cannot be tolerated due to presence of unacceptable side effects or whose pain is refractory to conventional therapy. Intrathecal infusion bypasses the blood-brain barrier and results in much higher cerebrospinal fluid concentrations with less medication. Compared with the epidural route, intrathecal infusion is associated with higher rates of satisfactory pain relief and lower rates of treatment failure and technical complications [92, 94]. Morphine has been extensively studied intrathecally for patients with cancer and found to be more effective in relieving nociceptive pain versus neuropathic pain [95]. An intrathecal pump can be implanted into the subcutaneous fat of the abdomen to provide a continuous infusion of morphine or other opioid. Some older pumps have pre-set infusion rate (continuous flow pumps); therefore each dose adjustment must be done by changing the concentration of the drug inside the pump. More commonly used nowadays programmable pumps contain an electronic module that can adjust the rate of drug infusion using telemetry programming. All pumps have to be refilled at regular time intervals, but patients usually tolerate these refills quite well as they are done every one to three months in the office or clinic settings by simple insertion of the needle into the center of the reservoir through the skin over the side of the abdomen where the pump is usually placed. The most common side effects of intrathecal opioid therapy noted are nausea and vomiting and the complications include infection or hematoma at the surgical site. Other drugs that can be administered intrathecally include bupivacaine and clonidine. About 10 years ago Elan Pharmaceuticals has introduced a new analgesic drug, ziconotide, which has been now approved by FDA for intrathecal treatment of acute persistent neuropathic pain in the United States. Ziconotide binds to specific N-type voltage-sensitive calcium channels found in neural tissue and acts by blocking neurotransmitter release from primary nociceptive afferents terminating in the superficial layers of the dorsal horn of the spinal cord [96, 97]. This mechanism of action distinguishes ziconotide from all other analgesics, including opioids. In fact, ziconotide is potently anti-nociceptive in animal models of pain in

H. Nersesyan et al.

which morphine exhibits poor anti-nociceptive activity [98]. The results from few multicenter randomized, double-blind, placebo-controlled trials showed that intrathecal ziconotide provided clinically and statistically significant analgesia in patients with severe pain from cancer or AIDS [99, 100]. However, although the safety of ziconotide administered as a continuous intrathecal infusion has been evaluated in over 1000 patients participating in acute and chronic pain clinical trials, lack of long-term prospective studies and high incidence of dose-dependent adverse effects during the initial titration stage of continuous intrathecal infusion of ziconotide [101–103] currently limit its use as a drug of first choice even in patients with advanced cancer who fail the traditional methods of pain control. Benefits of intrathecal pumps are quite obvious: due to drug delivery route, equianalgesic effect may be reached at doses about 100 times lower than with systemic administration, which significantly decreases dose-related side effects of opioid medications; the patient does not have to think about constant need to have the oral medication available (with associated reduction of risks related to abuse and mishandling of opioids); continuous drug delivery eliminates fluctuations in the drug level that are inevitable with bolus oral or parenteral dosing [104]. In addition to this, chemical neuromodulation is both adjustable and reversible, so the side effects of the treatment may be minimized by either changing the rate of infusion or drug composition, or by stopping the therapy altogether without any lasting side effects. The treatment is also testable; the patient and the caregiver may estimate the degree of pain relief from the results of a pre-surgical medication trial. At the same time, implantable devices are associated with higher upfront costs related to the procedure and the device itself, potential risk for infection and hardware malfunction, need for general anesthesia for system implantation, and similar procedural contraindications (coagulopathy, active systemic infection, etc.) as with any other surgical intervention. Overall, however, hard-to-control cancer related pain in patients with more than 3 months survival is a well-founded indication for intrathecal drug delivery pump implantation. A recent randomized study showed statistically significant superiority of implantable drug delivery systems compared with comprehensive medical management of patients with refractory pain due to cancer not only in degree of pain

24 Pain Management in Cancer Patients

449

control and reduced drug-related toxicities, but also in improvement of patient survival [92]. As the survival of patients with cancer becomes longer, reliable pain relief is now a high-priority issue that warrants both scientific research and industrial development of new devices and pharmaceutical agents that would make this pain relief complete, safe and lasting. With ongoing progress in the pain management field, a number of palliative care specialists argue that the WHO program, although updated in 1990, had not kept pace with the rapidly changing developments in oncology and pain research [105]. It was reported that the ladder method consistently failed to provide sufficient relief to 10–20% of advanced cancer patients with pain [106].

Pain intensity

Non-opioid analgesics Psychological counseling ± Adjuvant therapy

Thus, it may be reasonable to adjust the WHO pain management ladder from its current three-step approach to a more sophisticated 5-step algorithm that would include physical and psychological modalities along the entire continuum of care and add two more steps related to neuromodulative and neurodestructive procedures once opioids and other drugs fail (Fig. 24.2). The most important part of the entire approach, however, must be its interdisciplinary nature [107]. A surgeon, oncologist, pain anesthesiologist, pharmacist, psychologist, and physical therapist cannot treat the cancer pain alone; only by working together can these specialists give the cancer patient relief from the most fearsome symptom of their disease – their persistent pain.

Proceed to next step if pain persists or increases

Weak opioids Psychological counseling ± Non-opioid analgesics ± Adjuvant therapy

Proceed to next step if pain persists or increases

Immediate or sustained release strong opioids Psychological counseling ± Non-opioid analgesics ± Adjuvant therapy

Titrate until adequate pain control is achieved; proceed to next step if patient is still in pain or develops severe side effects from therapy

Intrathecal opioids (tunneled catheters, implantable pumps) Peripheral neurodestruction (alcohol/phenol blocks, radiofrequency procedures, etc.) Spinal cord or peripheral nerve stimulation Psychological counseling ± Non-opioid analgesics ± Adjuvant therapy

Central neurodestructive procedures (rhizotomy, ganglionectomy, cordotomy, myelotomy, tractotomy, thalamotomy, etc.) Operations on limbic system (cingulotomy) Psychological counseling ± Intrathecal opioids ± Adjuvant therapy

Fig. 24.2 Modified analgesic ladder for the treatment of cancer pain

Considered in patients who failed all nonsurgical treatment options or developed severe side effects from conventional opioid therapy and have life expectancy more than 3 months

Rarely used nowadays but may be still considered if all other treatment modalities fail particularly in patients with life expectancy less then 3 months

450

References 1. Centers for Disease Control and Prevention (2007) Leading causes of death reports. CDC Report website. http://www.cdc.gov/nchs/fastats/lcod.htm 2. American Cancer Society (2002) Cancer facts and figures 2002, p 41 3. AHCPR (1994) Clinical practice guideline #9: management of cancer pain. (Publication #94-0592). Department of Health and Human Services, Washington, DC 4. Friedman LL, Rodgers PE (2004) Pain management in palliative care. Clin Family Pract 6(2):371 5. Valdimarsdottir U et al (2002) The unrecognized cost of cancer patients’ unrelieved symptoms: a nationwide follow-up of their surviving partners. Br J Cancer 86:1540–1545 6. Winslow M, Seymour J, Clark D (2005) Stories of cancer pain: a historical perspective. J Pain Symptom Manage 29(1):22–31 7. Zorza R, Zorza V (1980) A way to die. Andre Deutsch, London 8. Cherny NJ (2000) The management of cancer pain. CA Cancer J Clin 50:70–116 9. Noble B et al (2005) The measurement of pain, 1945–2000. J Pain Symptom Manage 29:14–21 10. National Comprehensive Cancer Network (2000) NCCN practice guidelines for cancer pain. Oncology 14:135–150 11. Turk DC, Monarch ES, Williams AD (2002) Cancer patients in pain: considerations for assessing the whole person. Hematol Oncol Clin North Am 16:511–525 12. Wong DL, Baker CM (1988) Pain in children: comparison of assessment scales. Pediatr Nurs 14:9–17 13. WHO (1986) Cancer pain relief. World Health Organization, Geneva 14. Vielhaber A, Portenoy RK (2002) Advances in cancer pain management. Hematol Oncol Clin North Am 16:527–541 15. Lussier D, Huskey AG, Portenoy RK (2004) Adjuvant analgesics in cancer pain management. Oncologist 9: 571–591 16. Dunn MJ (1984) Nonsteroidal anti-inflammatory drugs and renal function. Ann Rev Med 35:411–428 17. Rouff G, Lema M (2003) Strategies in pain management: new and potential indications for COX-2 specific inhibitors. J Pain Symptom Manage 25(Suppl):S21–S31 18. Morales E, Mucksavage JJ (2002) Cyclooxygenase-2 inhibitor-associated acute renal failure: case report with rofecoxib and review of the literature. Pharmacotherapy 22:1317–1321 19. Bombardier C et al (2000) Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Eng J Med 343:1520–1528 20. Mukherjee D, Nissen SE, Topol EJ (2001) Risk of cardiovascular events associated with selective COX-2 inhibitors. JAMA 286:954–959 21. Merck (2004) Merck announces voluntary worldwide R withdrawal of VIOXX . News release. Whitehouse Station, NJ. www.vioxx.com/vioxx/documents/english/ vioxx_press_release.pdf 22. Singh D (2004) Merck withdraws arthritis drug worldwide. BMJ 329:816

H. Nersesyan et al. 23. Fitzgerald GA (2004) Coxibs and cardiovascular disease. N Engl J Med 351:17 24. Silverstein FE et al (2000) Gastrointestinal toxicity with celecoxib vs. nonsteroidal anti- inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: a randomized controlled trial. Celecoxib long-term arthritis safety study. JAMA 284:1247–1255 25. Grond S et al (1999) High-dose tramadol in comparison to low-dose morphine for cancer pain relief. J Pain Symptom Manage 18:174–179 26. Gutstein HB, Akil H (2001) Opioid analgesics. In: Hardman JG, Limbrid E (eds) Goodman and Gilman’s the pharmacological basis of therapeutics. McGraw-Hill, New York, pp 569–619 27. Fukshansky M, Are M, Burton AW (2005) The role of opioids in cancer pain management. Pain Pract 5(1): 43–54 28. Hagen NA et al (2005) Efficacy, safety, and steady-state pharmacokinetics of once-a-day controlled-release morphine (MSContinXL) in cancer pain. J Pain Symptom Manage 29:80–90 29. Donnely S et al (2002) Morphine in cancer pain management: a practical guide. Support Care Cancer 10:13–35 30. Sarhill N, Walsh D, Nelson KA (2001) Hydromorphone: pharmacology and clinical applications in cancer patients. Support Care Cancer 9:84–96 31. Pereira, J et al (2001) Equianalgesic dose ratios for opioids: a critical review and proposals for long-term dosing. J Pain Symptom Manage 22:672–687 32. Korte W, Stoutz N, Morant R (1996) Day-to-day titration to initiate transdermal fentanyl in cancer patients: shortand long-term experience in a prospective study of 39 patients. J Pain Symptom Manage 11:139–146 33. Coluzzi PH et al (2001) Breakthrough cancer pain: a randomized trial comparing oral transmucosal fentanyl citrate (OTFC) and morphine sulfate immediate release (MSIR). Pain 91:123–130 34. Burton AW et al (2004) Oral transmucosal fentanyl citrate in the outpatient management of severe cancer pain crises. Clin J Pain 20:195–197 35. Budd K (2003) Buprenorphine and the transdermal system: the ideal match in pain management. Int J Clin Pract 133:9–14 36. Skaer TL (2004) Practice guidelines for transdermal opioids in malignant pain. Drugs 64(23):2629–2638 37. Evans HC, Easthope SE (2003) Transdermal buprenotphine. Drugs 63(19):1999–2010 38. Heiskanen TE et al (2000) Morphine or oxycodone in cancer pain? Acta Oncologica 39:941–947 39. Davis MP, Walsh D (2001) Methadone for relief of cancer pain: a review of pharmacokinetics, pharmacodynamics, drug interactions and protocols of administration. Support Care Cancer 9:73–83 40. Berland D (2000) Pain management in patients with advanced cancer. Ann Intern Med 132:593 41. Lawlor PG et al (1998) Dose ratio between morphine and methadone in patients with cancer pain: a retrospective study. Cancer 82:1167–1173 42. Ripamonti C et al (1998) Switching from morphine to oral methadone in treating cancer pain: what is the equianalgesic dose ratio? J Clin Oncol 16:3216–3221

24 Pain Management in Cancer Patients 43. Kannan TR et al (2002) Oral ketamine as an adjuvant to oral morphine for neuropathic pain in cancer patients. J Pain Symptom Manage 23:60–65 44. Mercadante S et al (2000) Analgesic effects of intravenous ketamine in cancer patients on morphine therapy: a randomized, controlled, double-blind, crossover, double-dose study. J Pain Symptom Manage 2000(20) 45. Balducci L (2003) Management of cancer pain in geriatric patients. J Support Oncol 1(3):175–191 46. Collins SL et al (2000) Antidepressants and anticonvulsants for diabetic neuropathy and postherpetic neuralgia: a quantitative systematic review. J Pain Symptom Manage 20:449–458 47. Onghena P, van Houdenhove B (1992) Antidepressantinduced analgesia in chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies. Pain 49: 205–219 48. Watson CP (2000) The treatment of neuropathic pain: antidepressants and opioids. Clin J Pain 16(Suppl 2): 49–55 49. Magni G, Arsie D, De Leo D (1987) Antidepressants in the treatment of cancer pain: a survey in Italy. Pain 29:347–353 50. Walsh TD (1986) Controlled study of imipramine and morphine in chronic pain due to advanced cancer. Proc Am Soc Clin Oncol 5:237 51. Glassman AH, Bigger JT (1981) Cardiovascular effects of therapeutic doses of tricyclic antidepressants. A review. Arch Gen Psychiatr 38:815–820 52. Masand PS, Gupta S (1999) Selective serotoninreuptake inhibitors: an update. Harvard Rev Psychiatr 52: 547–552 53. Sindrup SH et al (1990) The selective serotonin reuptake inhibitor paroxetine is effective in the treatment of diabetic neuropathy symptoms. Pain 42(2):135–144 54. Sindrup SH et al (1992) The selective serotonin reuptake inhibitor citalopram relieves the symptoms of diabetic neuropathy. Clin Pharmacol Ther 52(5):547–552 55. Sindrup SH et al (2003) Venlafaxine versus imipramine in painful polyneuropathy: a randomized, controlled trial. Neurology 60(8):1284–1289 56. Backonja MM (2000) Anticonvulsants (antineuropathics) for neuropathic pain syndromes. Clin J Pain 16(Suppl 6): 67–72 57. Jensen TS (2002) Anticonvulsants in neuropathic pain: rationale and clinical evidence. Eur J Pain 6A:61–68 58. Rice AS, Maton S (2001) Gabapentin in postherpetic neuralgia: a randomized, double blind, placebo-controlled study. Pain 94:215–224 59. Rowbotham M et al (1998) Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial. JAMA 280:1837–1842 60. Tremont-Lukats IW, Megeff C, Backonja MM (2000) Anticonvulsants for neuropathic pain syndromes: mechanism of action and place in therapy. Drugs 60:1029–1052 61. Caraceni A et al (1999) Gabapentin as an adjuvant to opioid analgesia for neuropathic cancer pain. J Pain Symptom Manage 17:441–445 62. Oneschuk D, al-Shahri MZ (2003) The pattern of gabapentin use in a tertiary palliative care unit. J Palliat Care 195:185–187

451 63. Caraceni A et al (2004) Gabapentin for neuropathic cancer pain: a randomized controlled trial from the Gabapentin cancer pain study group. J Clin Oncol 22(14):2909–2917 64. Dworkin RH et al (2003) Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol 60:1524–1534 65. Yajnik S et al (1992) Phenytoin as a coanalgesic in cancer pain. J Pain Symptom Manage 7:209–230 66. Vestergaard K et al (2001) Lamotrigine for central poststroke pain: a randomized controlled trial. Neurology 56:184–190 67. Zakrzewska JM et al (1997) Lamotrigine (lamictal) in refractory trigeminal neuralgia: results from a doubleblind placebo controlled crossover trial. Pain 73:223–230 68. Dworkin RH et al (2003) Pregabalin for the treatment of postherpetic neuralgia: a randomized, placebo-controlled trial. Neurology 60:1274–1283 69. Price MJ (2004) Levetiracetam in the treatment of neuropathic pain: three case studies. Clin J Pain 20:33–36 70. Ettinger AB, Portenoy RK (1988) The use of corticosteroids in the treatment of symptoms associated with cancer. J Pain Symptom Manage 3:99–103 71. Greenberg HS, Kim JH, Posner JB (1980) Epidural spinal cord compression from metastatic tumor: results with a new treatment protocol. Ann Neurol 8:361–366 72. Watanabe S, Bruera E (1994) Corticosteroids as adjuvant analgesics. J Pain Symptom Manage 9:442–445 73. Farr WC (1990) The use of corticosteroids for symptom management in terminally ill patients. Am J Hosp Care 7:41–46 74. Mercadante S, Fulfaro F, Casuccio A (2001) The use of corticosteroids in home palliative care. Support Care Cancer 9:386–389 75. Khojainova N et al (2002) Olanzapine in the management of cancer pain. J Pain Symptom Manage 23:346–350 76. Dalal S, Melzack R (1998) Potentiation of opioid analgesia by psychostimulant drugs: a review. J Pain Symptom Manage 16:245–253 77. Rozans M et al (2002) Palliative uses of methylphenidate in patients with cancer: a review. J Clin Oncol 20:335–339 78. Rosen LS et al (2001) Zoledronic acid versus pamidronate in the treatment of skeletal metastases in patients with breast cancer or osteolytic lesions of multiple myeloma: a phase III, double-blind, comparative trial. Cancer J 7:377–387 79. Serafini AN (2001) Therapy of metastatic bone pain. J Nucl Med 42:895–906 80. Roth A, Kolaric K (1986) Analgesic activity of calcitonin in patients with painful osteolytic metastases of breast cancer: results of a controlled randomized study. Oncology 43:283–287 81. Szanto J, Ady N, Jozsef S (1992) Pain killing with calcitonin nasal spray in patients with malignant tumors. Oncology 49:180–182 82. Slavin KV, Tesoro EP, Mucksavage JJ (2004) The treatment of cancer pain. Drugs Today 40(3):235–245 83. Eisenach JC et al (1995) Epidural clonidine analgesia for intractable cancer pain. The epidural clonidine study group. Pain 61:391–399 84. Pud D et al (1998) The NMDA receptor antagonist amantadine reduces surgical neuropathic pain in cancer

452

85.

86.

87.

88. 89.

90.

91.

92.

93.

94. 95.

H. Nersesyan et al. patients: a double blind, randomized, placebo-controlled trial. Pain 75:349–354 Jones B et al (2003) Is there still a role for open cordotomy in cancer pain management? J Pain Symptom Manage 25:179–184 Nauta HJ et al (2000) Punctate midline myelotomy for the relief of visceral cancer pain. J Neurosurg 92(Suppl 2): 125–130 Whittle IR, Jenkinson JL (1995) CT-guided stereotactic antero-medial pulvinotomy and centromedianparafascicular thalamotomy for intractable malignant pain. Br J Neurosurg 9:195–200 Wong ET et al (1997) Palliation of intractable cancer pain by MRI-guided cingulotomy. Clin J Pain 13:260–263 Kanpolat Y et al (1995) CT-guided pain procedures for intractable pain in malignancy. Acta Neurochir Suppl (Wien) 64:88–91 Taub E (2003) Spinal cord stimulation for cancer-related pain: a neglected indication? Quadrennial Meeting Am Soc Stereotactic Funct Neurosurg, New York (May 18–21). p 52 Rauck RL et al (2003) Long-term intrathecal opioid therapy with a patient-activated, implanted delivery system for the treatment of refractory cancer pain. J Pain Symptom Manage 4(8):441–447 Smith TJ et al (2002) Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol 20:4040–4049 Slavin KV, Hsu FPK, Fessler RG (2002) Intrathecal opioids: intrathecal drug-delivery systems. In: Burchiel KJ (eds) Surgical management of pain. Thieme, New York, pp 603–613 Dews TE, Mekhail N (2004) Safe use of opioids in chronic noncancer pain. Cleve Clin J Med 71(11):897–904 Becker R et al (2000) The significance of intrathecal opioid therapy for the treatment of neuropathic cancer pain conditions. Stereotact Funct Neurosurg 75:16–26

96. McGivern JG, McDonough SI (2004) Voltage-gated calcium channels as targets for the treatment of chronic pain. Curr Drug Targets CNS Neurol Disord 3(6): 457–478 97. Miljanich GP, Ramachandran J (1995) Antagonists of neuronal calcium channels: structure, function, and therapeutic implications. Annu Rev Pharmacol Toxicol 35: 707–734 98. Miljanich GP (2004) Ziconotide: neuronal calcium channel blocker for treating severe chronic pain. Curr Med Chem 11(23):3029–3040 99. Mathur V (2000) Ziconotide: a new pharmacological class of drug for the management of pain. Semin Anesth Periop Med Pain 19:67–75 100. Staats PS et al (2004) Intrathecal ziconotide in the treatment of refractory pain in patients with cancer or AIDS. JAMA 291:63–70 101. Doggrell SA (2004) Intrathecal ziconotide for refractory pain. Expert Opin Investig Drugs 13(7):875–877 102. Webster L et al (2001) (233) characterization of confusion, an adverse event associated with intrathecal ziconotide infusion in chronic pain patients. Pain Med 2(3): 253–254 103. Wermeling D et al (2003) Pharmacokinetics and pharmacodynamics of intrathecal ziconotide in chronic pain patients. J Clin Pharmacol 43(6):624–636 104. Slavin KV, Solko AM (2003) Intrathecal narcotics: spinal and intraventricular. In: Schulder M (eds) Handbook of stereotactic and functional neurosurgery. Marcel Dekker, New York, pp 443–457 105. Meldrum M (2005) The ladder and the clock: cancer pain and public policy at the end of the twentieth century. J Pain Symptom Manage 29:41–54 106. Ahmedzai S (1997) New approaches to pain control in patients with cancer. Eur J Can 33(Suppl 6): S8–S14 107. Slavin KV, Laurito C (2003) Surgical approaches to cancer pain: experience of single institution. J Pain 4 (Suppl 1):90

Chapter 25

Management of Nausea and Vomiting in Cancer Patients Rudolph M. Navari, Paula P. Province, and Steven D. Passik

25.1 Introduction Nausea and vomiting in patients with cancer may be due to the patient’s specific disease state or may be due to cancer treatment interventions such as chemotherapy, radiation therapy, opioids, or other medications. The main approach to the treatment of nausea and vomiting has been the use of antiemetic agents developed primarily for the prevention of chemotherapyinduced nausea and vomiting (CINV). Agents that were considered useful in the prevention of CINV have then been used for the treatment of established nausea and vomiting in cancer patients. Although there have been many clinical trials in the development of agents for the prevention of CINV [62, 64, 70], there have been very few clinical trials evaluating the efficacy of antiemetics in cancer patients with established nausea and vomiting [49, 82].

(CNS). Figure 25.1 shows that chemotherapy agents, or their metabolites in the blood or cerebrospinal fluid, may directly affect areas in the medulla oblongata or stimulate the GI tract via the vagus nerve to send impulses to the medulla. A vomiting center (VC) appears to be located in the lateral reticular formation of the medulla, which coordinates the mechanism of nausea and vomiting. An additional important area, also located in the medulla, is the chemoreceptor trigger zone (CTZ) in the area postrema near the 4th ventricle [7]. It is strongly suspected that the nucleus tractus solitarius (NTS) neurons lying ventrally to the area postrema initiate emesis [108]. This medullary area is a convergence point for projections arising from the area postrema and the vestibular and vagal afferents [108]. The NTS is a good candidate for the site of action of centrally acting antiemetics.

25.2.2 Neurotransmitters and Receptors 25.2 Mechanisms of Emesis 25.2.1 Anatomy The mechanisms of emesis are not well defined, but investigations suggest that emesis may be primarily mediated through neurotransmitters in the gastrointestinal (GI) tract and the central nervous system

The main approach to the control of emesis has been to identify the active neurotransmitters and their receptors in the CNS and the GI tract that mediate the afferent inputs to the VC (Fig. 25.2). Agents that may block these neurotransmitter receptors in the CTZ, the VC, or the GI tract may be useful in preventing or controlling emesis (Table 25.1).

25.2.3 Dopamine Receptor Antagonists R.M. Navari () Department of Medicine, Indiana University School of Medicine, South Bend, IN 46617, USA e-mail: [email protected]

Dopamine receptors are known to exist in the CTZ, and this is the main area of activity of the dopamine

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_25, © Springer Science+Business Media B.V. 2011

453

454

R.M. Navari et al.

Higher CNS centers

Chemoreceptor trigger zone Medulla oblongata Vomiting center

Small intestine

Chemotherapy

Increased afferent input to the chemoreceptor trigger zone and vomiting center Cell damage Activation of vagus and splanchnic nerves

Release of neuroactive agents

Fig. 25.1 Proposed pathways of chemotherapy-induced emesis

Fig. 25.2 Neurotransmitters involved in emesis

Histamine

Dopamine

Serotonin

Endorphins

Emetic center Substance P

Acetylcholine

GABA

Table 25.1 Antiemetic receptor antagonists Dopamine Receptor 5-HT3 Receptor Antagonists Antagonists Phenothiazines Butyrophenones

Azasetron Dolasetron Granisetron Ondansetron Palonosetron Ramosetron Tropisetron

antagonists, such as the phenothiazines and the butyrophenones (droperidol, haloperidol). A high level of blockade of the dopamine receptors however, results

Dopa-5-HT3 Receptor Antagonists

NK-1 Receptor Antagonists

Metoclopramide

Vofopitant CP-122,721 CJ-11,794 Fosaprepitant (L758,298) Aprepitant (MK-869) Casopitant

in extrapyramidal reactions, as well as disorientation and sedation, limiting the clinical use of these agents.

25 Management of Nausea and Vomiting in Cancer Patients

25.2.4 Serotonin (5-HT3 ) Receptor Antagonists Serotonin receptors, specifically the 5-HT3 receptors, exist in the CNS and in the GI tract. The 5-HT3 receptor antagonists, such as dolasetron, granisetron, ondansetron, and tropisetron, appear to act through both the CNS and the GI tract via the vagus and splanchnic nerves. The main toxicities of these 5-HT3 receptor antagonists consist only of a mild headache and occasional diarrhea. The effectiveness of the 5-HT3 receptor antagonists in cisplatin-induced acute emesis [42, 73, 74, 85] is believed to be due to a predominately peripheral site of action, the prevention of the stimulation of abdominal vagal afferent fibers by serotonin released from the enterochromaffin cells of the gut by cytotoxic agents. This has been well documented in animal ferret models [92]. 5-HT3 receptor antagonists have been less effective in delayed cisplatin-induced emesis both in humans [4, 55, 76, 100, 101] and in ferret animal models [90]. This may be due to the lack of central effect by the 5-HT3 receptor antagonists, as demonstrated by the ineffectiveness of the 5-HT3 receptor antagonists against the emesis induced by the centrally acting opioids (apomorphine, morphine) in experimental animals [3].

25.2.5 Dopamine-Serotonin Receptor Antagonists Metoclopramide has antiemetic properties both in low doses as a dopamine antagonist and in high doses as a serotonin antagonist. However, high doses may precipitate undesirable extrapyramidal reactions and akathisia.

25.2.6 Substance P Receptor Antagonists Substance P is a mammalian tachykinin that is found in vagal afferent neurons innervating the brainstem NTS, which sends impulses to the VC [19]. Substance P induces vomiting and binds to neurokinin-1 (NK-1) receptors in the abdominal vagus, the NTS, and the area postrema [19]. Compounds that block NK-1

455

receptors lessen emesis after cisplatin, ipecac, apomorphine, and radiation therapy [19]. These observations have recently led to the development of NK-1 receptor antagonists and the study of the role they may play in controlling CINV. Studies in rhesus monkeys using PET scans have demonstrated that the NK-1 receptor antagonist vofopitant, when administered peripherally, has a distribution into brain regions consistent with specific binding to NK-1 receptors [25]. Injection of the NK-1 receptor antagonists CP-99,994 or MK-0869 (aprepitant) directly into the vicinity of the NTS neurons inhibited cisplatin-induced emesis in the ferret [99]. These results suggest that NK-1 receptor antagonists may exert their main antiemetic action by depressing the neural activity of the NTS neurons, with possibly some antiemetic effects from peripheral sites through a blockade of the NK-1 receptors located on the vagal terminals in the gut [59, 60]. Tattersall et al. [98] have recently reported that aprepitant (L-754,030, MK-0869) and its watersoluble phosphoryl prodrug, L-758,298, inhibited acute and delayed cisplatin-induced emesis in a ferret animal model. A single dose of aprepitant prior to cisplatin decreased emesis during a 72 h period, and daily dosing eliminated emesis during the entire 72 h observation period. The antiemetic activity of aprepitant also appeared to be enhanced by combination with either dexamethasone or the 5-HT3 receptor antagonist ondansetron. These animal studies have recently led to phase II –III studies of NK-1 receptor antagonists in humans [11, 13, 14, 16, 17, 32, 35, 38, 39, 51, 63–65, 68, 77, 88, 93, 105, 107]. The six investigational NK-1 receptor antagonists studied to date in humans have been GR205171 (vofopitant), CP-122,721, CJ-11,974, MK-0869 (L-754,030; aprepitant), aprepitant’s prodrug fosaprepitant, and casopitant.

25.3 Chemotherapy-Induced Nausea and Vomiting Chemotherapy-induced nausea and vomiting can be a significant problem for patients. They consistently report that vomiting and nausea are among the most unpleasant and distressing aspects of chemotherapy [15, 30]. Even one or two emetic episodes is associated

456

R.M. Navari et al.

with a significant deterioration in the quality of life, as well as physical and cognitive functioning, and may cause patients to delay or refuse potentially curative therapy [80]. There are five distinct but related CINV syndromes [6]: (1) acute CINV; (2) delayed CINV; (3) anticipatory CINV; (4) breakthrough CINV; and (5) refractory CINV. Acute CINV has been traditionally defined as nausea and vomiting occurring within the first 24 h after chemotherapy administration. Delayed CINV has been defined as nausea and vomiting occurring 24 h after chemotherapy and lasting up to 5 days, with recent evidence suggesting that it may begin as early as 16 h after chemotherapy administration. Anticipatory CINV is a conditioned response which occurs prior to a planned course of chemotherapy following significant nausea and vomiting due to previous chemotherapy. Breakthrough CINV occurs despite patients being treated with preventive therapy, and refractory CINV occurs during subsequent cycles of chemotherapy when antiemetic prophylaxis or rescue therapy has failed in earlier cycles. The potential for CINV is influenced by the emetogenicity of the chemotherapeutic agents [29, 41, 79] and patient characteristics [84]. Table 25.2 lists the emetic risk groups with representative agents, and although the emetogenicity of a chemotherapeutic agent is the primary risk factor, coadministration of chemotherapeutic agents [29, 84], as well as repeated cycles of chemotherapy [18], increases the potential for nausea and vomiting. Additional factors contributing to an increased risk for CINV are female gender, younger age, a history of

Table 25.2 Emetic risk groups with representative agents Emetogenic potential Typical agents Definition High

Moderate

Low Minimal

Cisplatin Dacarbazine Nitrogen mustard Carboplatin Anthracyclines Cyclophosphamide Irinotecan Mitoxantrone Taxanes Hormones Vinca alkaloids Bleomycin

Emesis in nearly all patients Emesis in >70% of patients

Emesis in 10%–70% of patients Emesis in < 10% of patients

Table 25.3 Patient-related risk factors for emesis following chemotherapy Major factors Female Age < 50 years History of low prior chronic alcohol intake History of previous chemotherapy-induced emesis Minor factors History of motion sickness Emesis during past pregnancy

motion sickness, and consumption of minimal amounts of alcohol (less than 11/2 ounces of alcohol per day) [29, 79, 84]. The presence or absence of these risk factors, as well as the emetogenicity of the chemotherapeutic agents being administered, determines each patient’s risk of CINV (Table 25.3).

25.4 Agents in Clinical Use for the Treatment of Chemotherapy-Induced Nausea and Vomiting 25.4.1 Serotonin (5-HT3 ) Receptor Antagonists The introduction of 5-hydroxytryptamine3 (5-HT3 ) receptor antagonists for the prevention of CINV, as well as post-operative and radiotherapy-induced nausea and vomiting, has resulted in a major improvement in supportive care [37, 42, 56, 61, 73–75, 85]. Treatment guidelines for the prevention of CINV recommended by a number of international groups [50, 67, 78, 89] suggest the use of a 5-HT3 receptor antagonist and dexamethasone pre-chemotherapy for the prevention of acute CINV and the use of dexamethasone with or without a 5-HT3 receptor antagonist following chemotherapy for the prevention of delayed nausea and vomiting. Table 25.4 shows the 5-HT3 receptor antagonists currently in use. The first generation serotonin (5-HT3 ) receptor antagonists dolasetron, granisetron, and ondansetron, tropisetron [94], azasetron [47] and ramosetron [97] are equivalent in efficacy and toxicities when used in the recommended doses and compete only on an economic basis [36]. They have not been

25 Management of Nausea and Vomiting in Cancer Patients Table 25.4 Serotonin antagonists and chemotherapya Antiemetic Route Dosage

dosage

before

Azasetron Dolasetron

IV 10 mg IV 100 mg or 1.8 mg/kg PO 100 mg Granisetron IV 10 μg/kg or 1 mg PO 2 mg (or 1 mg twice daily) Ondansetron IV 8 mg or 0.15 mg/kg PO 24 mg Palonosetron IV 0.25 mg PO 0.50 mg Ramosetron IV 0.30 mg Tropisetron IV or PO 5 mg a The same doses are used for highly and moderately emetic chemotherapy

associated with major toxicities, with the most commonly reported adverse events being mild headache and mild diarrhea [42, 56, 73, 75, 86]. A prolongation of cardiac conduction intervals has been reported for this class of compounds with dolasetron being more extensively studied than granisetron and ondansetron, but there have been no reported clinical cardiovascular adverse events [75]. The first generation 5-HT3 receptor antagonists have not been as effective against delayed emesis as they are against acute CINV [4, 55, 76, 101]. The available studies show that with corticosteroids alone, or combined with either metoclopramide or a 5-HT3 receptor antagonist in patients receiving cisplatin, the incidence of delayed emesis has been reduced, but remains a significant problem [44, 62]. The first generation 5-HT3 receptor antagonists do not add significant efficacy to that obtained by dexamethasone alone in the control of delayed emesis [101]. Hickok et al. [43] reported that the first generation 5-HT3 receptor antagonists used in the delayed period were no more effective than perchlorperazine in controlling nausea. A recent meta analysis [26] showed that there was neither clinical evidence nor considerations of cost effectiveness to justify using the first generation 5-HT3 receptor antagonists beyond 24 h after chemotherapy for the prevention of delayed emesis. The second generation 5-HT3 receptor antagonist palonosetron has recently been approved for clinical use. Recent studies suggest that it may have efficacy in controlling delayed CINV compared to the first generation 5-HT3 receptor antagonists.

457

25.4.2 Palonosetron Palonosetron is a new 5-HT3 receptor antagonist which has antiemetic activity at both central and GI sites. In comparison to the older 5-HT3 receptor antagonists, it has a higher binding affinity to the 5-HT3 receptors, a higher potency, a significantly longer halflife (approximately 40 h, 4–5 times longer than that of dolasetron, granisetron, or ondansetron), and an excellent safety profile [22, 62]. A dose-finding study demonstrated that the effective dose was ≥0.25 mg [22]. In two large studies in patients receiving moderately emetogenic chemotherapy (MEC), complete response (no emesis, no rescue) was significantly improved in the acute and the delayed period for the patients who received 0.25 mg of palonosetron alone compared to either ondansetron or dolasetron alone [21, 28]. Dexamethasone was given with the 5-HT3 receptor antagonists in only a small number of patients (5%) in only one of these studies [21], and it remains to be determined if the differences in complete response would persist if dexamethasone was used. In another study, 650 patients receiving highly emetogenic chemotherapy (HEC) (cisplatin, 60 mg/m2 ) received dexamethasone and one of two doses of palonosetron (0.25 mg or 0.75 mg) or dexamethasone and ondansetron (32 mg) pre-chemotherapy. Patients pre-treated with palonosetron (0.25 mg) plus dexamethasone had significantly higher complete response rates than those receiving ondansetron plus dexamethasone during the delayed and overall periods [1]. In an analysis of the patients in these studies who received repeated cycles of chemotherapy, Cartmell et al. [12] reported that the complete response rates for both acute and delayed CINV were maintained with the single intravenous doses of palonosetron without concomitant corticosteroids. Based on the above studies, palonosetron was approved by the FDA in July, 2003 for the prevention of acute nausea and vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy. It was also approved for the prevention of delayed nausea and vomiting associated with initial and repeat course of moderately emetogenic cancer chemotherapy. Saito et al. [91] conducted a double-blind, doubledummy, randomized, comparative phase III trial in 1143 patients receiving HEC (cisplatin or the

458

combination of an anthracycline and cyclophosphamide). Patients were recruited from 75 institutions in Japan and were randomly assigned to either singledose palonosetron (0.75 mg) or granisetron (40 ug/kg) 30 min before chemotherapy on day 1. Both groups also received dexamethasone, (16 mg IV) on day 1 followed by additional doses (8 mg IV for patients receiving cisplatin and 4 mg orally for patients receiving an anthracycline and cyclophosphamide) on days 2 and 3. Four hundred eighteen of 555 patients (75.3%) in the palonosetron group had a complete response during the first 24 h (acute period) compared with 410 of 559 patients (73.3%) in the granisetron group. During the delayed period, 315 of 555 patients (56.8%) had a complete response in the palonosetron group compared with 249 of 559 patients (44.5%) in the granisetron group (p<0.0001). When administered with dexamethasone, palonosetron prevented CINV which was non-inferior to granisetron in the acute period and better than granisetron in the delayed period, with a comparable safety profile for the two treatments. Despite the use of both first generation and second generation 5-HT3 receptor antagonists, the control of acute CINV, and especially delayed nausea and vomiting, is suboptimal with the agents listed in Table 25.4. There is considerable opportunity for improvement with either the addition or substitution of new agents in current regimens [44, 49, 62].

25.4.3 Dopamine-Serotonin Receptor Antagonists Metoclopramide has antiemetic properties both in low doses as a dopamine antagonist and in high doses as a serotonin antagonist. The use of metoclopramide may be somewhat efficacious in relatively high doses (20 mg orally, three times/day) in the delayed period, but may result in sedation and extrapyramidal side effects [37, 49, 62].

25.4.4 Substance P (NK-1) Receptor Antagonists Aprepitant The initial clinical studies using the NK-1 receptor antagonists [38, 52, 77] demonstrated that the addition of a NK-1 receptor antagonist (CP-122,721, CJ-11,794, MK-0869) to a 5-HT3 receptor antagonist

R.M. Navari et al.

and dexamethasone prior to cisplatin chemotherapy improved the control of acute emesis compared to the 5-HT3 and dexamethasone and improved the control of delayed emesis compared to placebo. In addition, as a single agent, L-758,298 had a similar effect on cisplatin-induced acute emesis as ondansetron, but was superior in the control of delayed emesis [14]. Subsequent studies [11, 105] showed that the combination of aprepitant (MK-0869) and dexamethasone was similar to a 5-HT3 receptor antagonist and dexamethasone in controlling acute emesis, was inferior in controlling acute emesis compared to triple therapy (aprepitant, 5-HT3 receptor antagonist, dexamethasone), and confirmed the improvement of delayed emesis with the use of aprepitant compared to placebo. In a dosing study of oral MK-869, which was the final capsule formulation of aprepitant, involving 563 chemotherapy naïve patients receiving cisplatin (≥ 70 mg/m2 ), Chawla et al. [13] reported an improvement in the control of acute emesis when MK-869 was added to ondansetron and dexamethasone and an improvement in the control of delayed emesis with the combination of MK-869 and dexamethasone compared to dexamethasone alone. One hundred twenty-five milligrams of MK-869 on day one followed by 80 mg on subsequent days appeared to be the regimen appropriate for further study. In two randomized, double-blind, parallel, multicenter, controlled studies (520 patients in each study), patients received cisplatin (≥ 70 mg/m2 ) and were randomized to receive “standard therapy” of a 5-HT3 receptor antagonist (ondansetron) and dexamethasone pre-chemotherapy and dexamethasone postchemotherapy (days 2–4) or “standard therapy” plus aprepitant given prior to chemotherapy and on days 2 and 3 post-chemotherapy [39, 88]. The complete response (no emesis, no rescue) of the aprepitant group in both studies was significantly higher in the acute period (83–89%), the delayed period (68–75%), and overall (days 1–5) (62.7–72.7%) compared to that in the acute period (68–78%), the delayed period (47–56%) and overall (days 1–5) (43.3–52.3%) of the “standard therapy.” The improvement in complete response with the addition of aprepitant was maintained over multiple cycles of chemotherapy [16, 17]. Nausea was improved in the aprepitant group only in the delayed period in only one of the studies [88].

25 Management of Nausea and Vomiting in Cancer Patients

459

The studies discussed above formed the basis for the approval of aprepitant by the FDA in March, 2003. In combination with other antiemetics, aprepitant is indicated for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy, including high-dose cisplatin. In a follow-up study to the two randomized studies described, the aprepitant regimen was shown to have a higher complete response in patients receiving cisplatin not only to the 1-day ondansetron and 4-day dexamethasone regimen in previous trials, but also to a 4-day ondansetron and 4-day dexamthasone regimen [93]. All of the initial studies using aprepitant were performed with cisplatin chemotherapy. Warr et al. [107] subsequently presented a study on the use of aprepitant in 862 breast cancer patients receiving MEC. An aprepitant regimen of Day 1: aprepitant (125 mg), ondansetron (8 mg) and dexamethasone (12 mg) pre-chemotherapy, ondansetron (8 mg) 8 h later; Days 2,3: aprepitant, (80 mg/day) was compared to a “standard” regimen of Day 1; ondansetron (8 mg) and dexamethasone (20 mg) pre-chemotherapy and ondansetron (8 mg) 8 h later; Days 2,3: ondansetron (8 mg BID). There was a significant improvement in complete response (no emesis, no rescue) in the 24 h after chemotherapy in the patients receiving aprepitant, but there was no significant improvement in complete response days two to five in the post-chemotherapy period when aprepitant alone was compared to ondansetron alone. The overall (days 1–5) complete response was significantly improved for the aprepitant-containing regimen, most likely due to the improvement in the first 24 h. The control of nausea was not improved with the use of aprepitant.

form of aprepitant is available. An intravenous alternative to the current oral formulation for aprepitant would allow more convenient dosing in some clinical settings while maintaining efficacy and overall therapeutic margins. The treatment of established CINV and the rescue of failed prophylaxis may be other potential uses for an intravenous form of an antiemetic, although few studies have been conducted for these situations. Fosaprepitant (also known as MK-0517 and L758,298) is a water soluble phosphoryl pro-drug for aprepitant which, when administered intravenously, is converted to aprepitant within 30 min after intravenous administration via the action of ubiquitous phosphatases. The pharmacological effect of fosaprepitant is attributed to aprepitant. Due to the rapid conversion of fosaprepitant to the active form (aprepitant) by phosphatase enzymes, it is expected to provide the same aprepitant exposure in terms of area under the curve (AUC) and a correspondingly similar antiemetic effect [65]. The tolerability of fosaprepitant has been evaluated in clinical trials with approximately 150 patients [14, 105]. In these studies, fosaprepitant was given as a single intravenous dose (0.2–200 mg), infused over 15–30 min, reconstituted in saline or polysorbate 80 to concentrations ranging from 1 to 25 mg/ml. Fosaprepitant has also been administered in single daily doses (25–100 mg) on four consecutive days. The studies showed acceptable venous tolerability at 1 mg/ml, infused over 15–30 min, but a concentration of 25 mg/ml at doses of 50 mg and 100 mg, infused over 30 seconds, was associated with venous irritation. Based on these studies, the incidence of venous irritation depends on the total dose, the concentration, and the rate of infusion [54]. During the development of aprepitant, certain studies which assessed the tolerability of fosaprepitant, also evaluated its efficacy in patients receiving chemotherapy. In a comparison of fosaprepitant versus ondansetron, each given as monotherapy prior to cisplatin, fosaprepitant was active against cisplatininduced emesis, in particular in the delayed phase [14]. Moreover, an additional trial demonstrated the tolerability and efficacy of fosaprepitant as part of combination therapy with dexamethasone [105]. The clinical profile of fosaprepitant in these early studies suggested that fosaprepitant could be appropriate as an intravenous alternative to the aprepitant oral capsule.

25.4.5 Fosaprepitant A medical need exists for chemotherapy patients to have the option of parenteral administration of prophylactic antiemetics. Patients who cannot tolerate orally administered medications due to active mucositis, difficulty in swallowing, or poor function of the GI tract may require intravenous antiemetics prior to chemotherapy. Intravenous dexamethasone and intravenous 5-HT3 receptor antagonists are available, but only an oral

460

In a study in healthy subjects, fosaprepitant was well tolerated up to 150 mg (1 mg/ml), and fosaprepitant 115 mg was AUC bioequivalent to aprepitant 125 mg [54]. Fosaprepitant in the intravenous dose of 115 mg has been recently approved (February, 2008) by the FDA and the European Union (January, 2008) as an alternative to oral aprepitant 125 mg on Day 1 of a 3-day regimen, with oral aprepitant 80 mg administered on Days 2 and 3. Further studies are in progress to determine the efficacy, safety, and tolerability of a single dose of intravenous fosaprepitant necessary to replace the 3-day oral regimen [65].

25.4.6 Casopitant Casopitant is a novel substituted piperazine derivative, which has potential for the treatment of conditions mediated by tachykinins, including substance P and other neurokinins. Casopitant competitively binds to the NK-1 receptor, thereby inhibiting NK-1 receptor binding of substance P and blocking the activity of the receptor [68]. Casopitant and its mesylate salt are being developed for the potential treatment of CINV, post-operative nausea and vomiting (PONV), anxiety, depression, and insomnia. Phase II and phase III clinical trials have been completed for CINV [5, 32, 35, 68] and application to the FDA was made in 2009. Two phase III clinical trials with intravenous and oral casopitant have been completed. The first was designed to demonstrate that casopitant, when used in addition to dexamethasone plus ondansetron, is more effective in the prevention of vomiting than dexamethasone and ondansetron alone in patients with solid malignant tumors receiving cisplatin-based HEC [32]. Patients (n = 810) received either oral casopitant (150 mg), intravenous ondansetron (32 mg) and oral dexamethasone (8 mg) on day 1, and then oral dexamethasone (8 mg bid) on days 2–4; or intravenous casopitant (90 mg), intravenous ondansetron (32 mg) and oral dexamethasone (8 mg) on day 1, and then oral casopitant (50 mg) on days 2–3 and oral dexamethasone (8 mg qd) on days 2–4. Treatment was continued for up to six cycles. A control group received intravenous ondansetron (32 mg) and oral dexamethasone (20 mg) on day 1 and then oral dexamethasone (8 mg bid) on days 2 to 4. In the first 120 h of the first treatment cycle, complete responses were observed in 86%

R.M. Navari et al.

of patients in the oral casopitant (150 mg) group, compared with 66% for controls (p < 0.0001), and in the first 24 h, complete response rates were 95% and 88% for the 150 mg oral casopitant and control groups, respectively (p = 0.0044). No vomiting occurred in 89% of patients and no significant nausea (NSN), as defined by the study, occurred in 78% of patients in the 150 mg oral casopitant group, compared with 68% (p < 0.0001) and 69% (p = 0.0272) for the control group, respectively. In treatment cycles two to six, the complete response rates were 94, 92, 93, 91 and 100%, respectively, in the casopitant treatment group, compared with 77, 78, 74, 97 and 56%, respectively, for the control group. For the first treatment cycle in the intravenous casopitant (90 mg) group, 80% of patients demonstrated a complete response (p = 0.0004) in 120 h and 94% of patients (p = 0.0165) in 24 h; there was no vomiting in 83% of patients (p = 0.0001) and NSN in 76% of patients (p = 0.0740). In treatment cycles two to six, the complete response rates were 89, 87, 88, 83 and 60%, respectively. The second of these phase III clinical trials was designed to establish whether casopitant, when used in addition to dexamethasone plus ondansetron, is more effective in the prevention of vomiting than dexamethasone and ondansetron alone in patients receiving non-cisplatin-based MEC [35]. The enrollment was 1933 patients with solid malignant tumors, mostly breast cancer (96%), with the primary endpoint again being complete response in the first 120 h postchemotherapy. Patients received oral casopitant in a schedule of oral casopitant (150 mg on day 1 and 50 mg/day on days 2 and 3); intravenous casopitant (90 mg) on day 1, followed by 2 days of oral casopitant (50 mg/day); or oral casopitant (150 mg) on day 1. Treatment was continued for up to four cycles. Patients also received oral ondansetron (8 mg bid on days 1 to 3) and intravenous dexamethasone (8 mg on day 1). In the first 120 h of the first treatment cycle for the intravenous/oral casopitant dose group, the complete response rate was 74% compared with 59% for controls (p < 0.0001). In the first 24 h, the complete response rate was 86% compared with 85% for controls (p = 0.585). There was no vomiting over 120 h in 78 and 63% of patients for the casopitant and control groups, respectively (p < 0.0001). In treatment cycles two to four, complete responses were achieved in 81, 80 and 84% of patients in the intravenous/oral casopitant dose group compared with 63, 67 and 69% for

25 Management of Nausea and Vomiting in Cancer Patients

461

the control group, respectively. In the single oral casopitant dose group and the three oral casopitant dose groups, complete responses were observed in 73 and 73% of patients (p < 0.0001), respectively, over the first 120 h of the first treatment cycle, and in 88% (p = 0.1586) and 89% (p = 0.0545) of patients in the first 24 h. No vomiting occurred in 80 and 81% of patients (p < 0.0001) in these two dose groups, respectively. In treatment cycles two to four, complete responses were achieved in 80, 79 and 82% of patients in the single oral casopitant dose group and in 81, 80 and 84% of patients in the three oral casopitant dose group, respectively. In the phase II and phase III studies reported, there have been no reported serious adverse events related to casopitant. The reported common adverse events (neutropenia, constipation, alopecia, fatigue) occurred with comparable frequency across control and treatment groups [68].

alpha1 adrenergic receptors, acetylcholine at muscarinic receptors, and histamine at H1 receptors [9, 10]. Common side effects are sedation and weight gain [2, 34], as well as an association with the onset of diabetes mellitus [27]. Olanzapine’s activity at multiple receptors, particularly at the D2 and 5-HT3 receptors which appear to be involved in nausea and emesis, suggest that it may have significant antiemetic properties. There have been case reports on the use of olanzapine as an antiemetic [46, 81, 82, 87, 96]. Pirl and Roth [87] reported improvement in a patient’s chronic nausea with the use of olanzapine, and in six patients receiving palliative care, Jackson and Tavernier [46] found olanzapine to be effective for intractable nausea due to opioids, neoplasm, and/or medications. Srivastava et al. [96] reported that olanzapine was effective in controlling refractory nausea and vomiting in two patients with advanced cancer, and in an open label trial, olanzapine was effective in reducing nausea in fifteen advanced cancer patients with opioidinduced nausea [82]. In a retrospective chart review of twenty-eight patients who received olanzapine on an as needed basis following moderate to highly emetogenic chemotherapy, the data suggested that olanzapine may decrease delayed emesis [81]. These case reports prompted a Phase I study in which olanzapine was used for the prevention of delayed emesis in cancer patients receiving their first cycle of chemotherapy consisting of cyclophosphamide, doxorubicin, cisplatin and/or irinotecan [83]. Fifteen patients completed the protocol, and no grade 4 toxicities were seen. The maximum tolerated dose was 5 mg/day for the 2 days prior to chemotherapy and 10 mg/day for 7 days post-chemotherapy. Four of 6 patients receiving HEC (cisplatin, ≥70 mg/m2 ) and 9 of 9 patients receiving MEC (doxorubicin, ≥50 mg/m2 ) had a complete response (no vomiting episodes, no rescue medication) of delayed emesis. Based on these data, olanzapine appeared to be a safe and effective agent for the prevention of delayed emesis in chemotherapy naïve cancer patients receiving cyclophosphamide, doxorubicin, cisplatin and/or irinotecan. Using the maximum tolerated dose of olanzapine in the Phase I trial, a Phase II trial was performed for the prevention of CINV in patients receiving their first course of either HEC or MEC. The regimen was 5 mg/day of oral olanzapine on the 2 days prior to chemotherapy, 10 mg of olanzapine

25.4.7 Corticosteroids Corticosteroids have been shown in a number of studies to be effective antiemetics in the prevention of CINV [40, 45, 55, 101–104]. When used in combination with the 5-HT3 receptor antagonists [40, 55, 102] and in combination with the NK-1 receptor antagonists [63], the control of CINV is markedly enhanced compared to the use of the 5-HT3 receptor antagonists or the NK-1 antagonists alone. The mechanism of action of the antiemetic effects of the corticosteroids is unknown. There are no data which suggest an active receptor of a site of action. The most widely used corticosteroids antiemetic is dexamethasone with studies showing the optimal pre-chemotherapy doses [103, 104]. Although dexamethasone is effective for both acute and delayed emesis, the optimal dose for the control of delayed emesis has not been determined.

25.4.8 Olanzapine Olanzapine is a FDA approved antipsychotic that blocks multiple neurotransmitters: dopamine at D1, D2, D3, D4 brain receptors, serotonin at 5-HT2a , 5-HT2c , 5-HT3 , 5-HT6 receptors, catecholamines at

462

on the day of chemotherapy, day 1, (added to intravenous granisetron, 10 mcg/kg, and dexamethasone 20 mg) and 10 mg/day on days 2–4 after chemotherapy (added to dexamethasone, 8 mg p.o. BID, days 2,3, and 4 mg p.o. BID, day 4). Thirty patients (median age 58.5 years, range 25–84; 23 females; ECOG PS 0,1) consented to the protocol and all were evaluable. Complete response (no emesis, no rescue) was 100% for the acute period (24 h post chemotherapy), 80% for the delayed period (days 2–5 post-chemotherapy), and 80% for the overall period (0–120 h post-chemotherapy) in 10 patients receiving HEC (cisplatin, ≥ 70 mg/m2 ). Complete response was also 100% for the acute period, 85% for the delayed period, and 85% for the overall period in 20 patients receiving moderately emetogenic chemotherapy (doxorubicin, ≥ 50 mg/m2 ). Nausea was very well controlled in the patients receiving HEC with no patient having nausea (0 on scale of 0–10, M.D. Anderson Symptom Inventory, MDASI) in the acute or delayed periods. Nausea was also well controlled in patients receiving MEC with no nausea in 85% of patients in the acute period, and 65% in the delayed and overall periods. There were no Grade 3 or 4 toxicities and no significant pain, fatigue, disturbed sleep, memory changes, dyspnea, lack of appetite, drowsiness, dry mouth, mood changes or restlessness experienced by the patients. Complete response and control of nausea in subsequent cycles of chemotherapy (25 patients, cycle 2; 25 patients, cycle 3; 21 patients, cycle 4) were equal to or greater than cycle 1. The study concluded that olanzapine was safe and highly effective in controlling acute and delayed CINV in patients receiving HEC and MEC [71]. An additional phase II study was performed to determine the control of acute and delayed CINV in patients receiving MEC and HEC with the combined use of palonosetron and olanzapine, and dexamethasone with the dexamethasone given on day one only. Forty chemotherapy naïve patients received on the day of chemotherapy, day 1, an antiemetic regimen consisting of dexamethasone, palonosetron, and olanzapine. Patients continued olanzapine for days 2–4 following chemotherapy administration. Patients recorded daily episodes of emesis, daily symptoms utilizing the M. D. Anderson Symptom Inventory, and the utilization of rescue therapy. For the first cycle of chemotherapy, the complete response (no emesis, no rescue) for the acute period (24 h post-chemotherapy) was 100%,

R.M. Navari et al.

the delayed period (days 2–5 post-chemotherapy) 75%, and the overall period (0–120 h post-chemotherapy) 75% in 8 patients receiving HEC and was 97, 75, and 72% in 32 patients receiving MEC. No nausea for patients in the acute period was 100%, the delayed period 50%, and the overall period 50% in 8 patients receiving HEC and was 100, 78, and 78% in 32 patients receiving MEC. The complete response and control of nausea in subsequent cycles of chemotherapy were not significantly different from cycle one. Olanzapine combined with a single dose of dexamethasone and a single dose of palonosetron was very effective in controlling acute and delayed CINV in patients receiving both HEC and MEC [72].

25.4.9 Gabapentin A recent report by Guttuso et al. [33] in a small number of patients receiving adjuvant chemotherapy (doxorubicin, cyclophosphamide) for breast cancer suggested that the anticonvulsant gabapentin may reduce delayed nausea. Further studies will be necessary to determine the efficacy of this agent.

25.4.10 Cannabinoids Two oral formulations of cannabinoids, dronabinol and nabilone, have been approved by the FDA for use in CINV refractory to conventional antiemetic therapy [106]. The National Comprehensive Cancer Network (NCCN) has suggested the use of cannabinoids for breakthrough treatment [78]. Cannabinoid receptors of the CB1 type are present in the area postrema, NTS, and dorsal motor nucleus which are key sites within the brainstem for emetogenic control [57]. Recent evidence suggests that cannabinoid CB2 receptors are present on brainstem neurons and may have a role in mediating the cannabinoids effects on emesis [57, 95]. There have been no comparative studies of dronabinol and nabilone with the 5-HT3 receptor antagonists and the NK-1 receptor antagonists in the prevention of CINV. The role of the cannabinoids in the prevention of CINV remains to be established [106].

25 Management of Nausea and Vomiting in Cancer Patients

25.5 Clinical Management of Chemotherapy-Induced Nausea and Vomting 25.5.1 Principles in the Management of CINV In 2006–2009, updated antiemetic guidelines were published by the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) [50, 67, 78]. The updates were based in part on the Multinational Association Supportive Care in Cancer (MASCC) [58] Antiemetic Guideline Update Meeting held in Perugia, Italy, in 2004. Representatives from nine cancer organizations (including ASCO and NCCN) participated using a literature update and consensus statements to create organization-specific guidelines [89]. NCCN guidelines are based on clinical consensus, with recommendations reflecting uniform agreement based on lowerlevel evidence such as clinical experience, unless specifically stated [78].

25.5.2 Single Day-Chemotherapy For patients receiving HEC, current evidence suggests the following [50, 67, 78]: • Pre-chemotherapy – Any of the 5-HT3 receptor antagonists with dexamethasone and aprepitant. Fosaprepitant may be administered intravenously as an alternative to oral aprepitant on day 1. • Post-chemotherapy – Aprepitant on days two and three and dexamethasone on days 2–4. For patients receiving MEC, current evidence suggests the following [50, 67, 78]: • Pre-chemotherapy – Any of the 5-HT3 receptor antagonists plus dexamethasone. • Post-chemotherapy – Dexamethasone or a first generation oral 5-HT3 receptor antagonist on days 2–4. It should be noted that all four of the 5-HT3 receptor antagonists available in the United States are approved for the prevention of acute CINV, and palonosetron is

463

the only 5-HT3 receptor antagonist approved for the control of delayed CINV (in patients receiving MEC). The MASCC antiemesis guidelines [89], and the ASCO antiemesis guidelines [50] have stated that at appropriate dosages, all of the 5-HT3 antagonists are interchangeable without preference for any agent. The NCCN antiemetic guidelines [78] for the prevention of CINV have now listed palonosetron as the preferred 5-HT3 receptor antagonist. Based on the recent studies on palonosetron, it appears that there are distinct scientific and clinical differences between palonosetron and the first generation 5-HT3 receptor antagonists. When new guidelines are issued by ASCO and MASCC, it is assumed that these differences will be included [69]. The guidelines also suggest consideration of the use of aprepitant for patients receiving the combination of cyclophosphamide and doxorubicin [50, 67, 78]. The recent guidelines [50, 67, 78] have included the available oral first generation 5-HT3 receptor antagonists as optional therapy for the prevention of delayed emesis, but the level of evidence supporting this practice is low [26, 43, 62]. For patients receiving low emetogenic chemotherapy, a single agent in the form of a 5-HT3 receptor antagonist, dexamethasone, or a phenothiazine, depending on the clinical situation, should be used prechemotherapy, and an antiemetic following chemotherapy should be given only as needed.

25.5.3 Multiple-Day Chemotherapy Although there have been significant improvements in the prevention of CINV in patients receiving singleday HEC and MEC, there has been limited progress in the prevention of CINV in patients receiving multipleday chemotherapy or high-dose chemotherapy with stem cell transplant. The current recommendation is to give a first generation 5-HT3 receptor antagonist and dexamethasone daily during each day of chemotherapy in patients receiving multiple-day chemotherapy or high-dose chemotherapy with stem cell transplant [66]. This regimen appears to be at least partially effective in controlling acute CINV, but is not very effective in controlling delayed CINV. The complete response in most studies of 5 days of cisplatin and in various high-dose chemotherapy regimens is 30–70% with the majority of studies reporting a complete response of < 50% [66].

464

The new antiemetic agents palonosetron, aprepitant, casopitant, and olanzapine have shown effectiveness in controlling both acute and delayed CINV in patients receiving single-day MEC and HEC. With the exception of the use of palonosetron in one report of patients receiving 5 days of cisplatin [20], these agents have not been studied in patients receiving multiple-day or high-dose chemotherapy.

25.5.4 Rescue Therapy Intravenous phenothiazines, intravenous metoclopramide, or intravenous dexamethasone may be effective in the treatment of established nausea and vomiting. A 5-HT3 receptor antagonist may also be effective unless a patient presents with nausea and vomiting which developed following the use of a 5-HT3 receptor antagonist as prophylaxis for chemotherapy- or radiotherapy-induced emesis. It is very unlikely that established nausea and vomiting will respond to an agent in the same drug class after unsuccessful prophylaxis with an agent with the same mechanism of action. In patients receiving MEC and ondansetron and dexamethasone prior to chemotherapy and dexamethasone after chemotherapy, Fabi et al. [24] used ondansetron as a rescue medication with oral ondansetron being more effective than intramuscular ondansetron. It is important to note that aprepitant has been approved as an additive agent to a 5-HT3 receptor antagonist and dexamethasone for the prevention of CINV. It has not been studied and should not be used to treat established nausea and vomiting.

R.M. Navari et al.

25.6 Radiation-Induced Emesis There have been some studies for the prevention of radiation-induced emesis using dexamethasone and the 5-HT3 receptor antagonists. Dexamethasone was superior to placebo as a preventative antiemetic for the first 5 days in patients receiving fractionated radiotherapy to fields involving the upper abdomen [48]. Patients receiving granisetron 1 h prior to upper abdominal fractionated radiotherapy had better control of emesis during the 10 to 30 daily treatment period compared to placebo [53]. There was poor control of nausea and vomiting with the use of 5-HT3 receptor antagonists with or without dexamethasone in patients who received high-dose chemotherapy and total-body radiation in preparation for hematopoietic stem cell transplantation [8].

25.6.1 Prevention of Radiotherapy-Induced Nausea and Vomiting Patients receiving upper abdomen radiotherapy may benefit from the use of daily oral 5-HT3 receptor antagonists or from daily oral dexamethasone. The long term use of daily corticosteroids may result in significant toxicities in a number of patients. There have not been any reported toxictites with the long term (weeks) use of daily 5-HT3 receptor antagonists [75].

25.7 Opioid-Induced Chronic Nausea and Emesis

25.5.5 Refractory Therapy Vomiting occurring after chemotherapy in subsequent chemotherapy cycles when antiemetic prophylaxis and/or rescue therapy have failed in earlier cycles is known as refractory emesis [78]. A number of studies have shown that palonosetron [12] and aprepitant [16] are effective in preventing CINV over multiple cycles of chemotherapy, but there have been few formal studies in treating refractory CINV. Most practitioners will change the pre- and post-chemotherapy antiemetics in order to attempt to control refractory nausea and vomiting.

A common clinical problem is opioid-induced nausea and emesis. This has not been well studied in terms of etiology or most effective treatments. Olanzapine has been used empirically in this setting to treat chronic nausea with some reported success [46, 81, 82].

25.7.1 Treatment of Opioid-Induced Chronic Nausea Olanzapine in varying doses may be useful in the treatment of opioid-induced chronic nausea.

25 Management of Nausea and Vomiting in Cancer Patients

465

Dexamethasone may also be effective, but has not been formally studied for this application.

was no difference in complete response in days two to five post-chemotherapy when aprepitant alone was compared to ondansetron alone. Aprepitant did not improve nausea in the study. The appropriate use of aprepitant in patients receiving MEC will be determined by future studies. Fosaprepitant in the intravenous dose of 115 mg has been recently approved (February, 2008) by the FDA and the European Union (January, 2008) as an alternative to oral aprepitant 125 mg on Day 1 of a three-day regimen, with oral aprepitant 80 mg administered on Days 2 and 3. Further studies are in progress to determine the doses of fosaprepitant necessary to replace the 3-day oral regimen. There are no published studies on the use of aprepitant alone compared with aprepitant and dexamethasone for the prevention of delayed CINV. Such a comparison would determine whether dexamethasone might be withheld for patients who cannot tolerate corticosteroids. Recently completed phase III trials of casopitant have demonstrated that there is a significant improvement in the prevention of CINV with the addition of casopitant to dexamethasone and ondansetron compared to ondansetron and dexamethasone alone in patients receiving cisplatin or non-cisplatin chemotherapy. Casopitant can be administered orally and intravenously, and the specific doses for use will await the FDA review of the recently reported phase III trials. The control of nausea in patients receiving MEC and HEC remains a significant problem. The current 5-HT3 receptor antagonists, while very effective in controlling emesis in a large percentage of patients in the initial 24 h post-chemotherapy, nevertheless fail to adequately control nausea in a significant number of patients, and the recent palonosetron studies provided only marginal improvement. Pre-chemotherapy triple therapy (a 5-HT3 receptor antagonist plus dexamethasone plus aprepitant) may control acute nausea better than a 5-HT3 antagonist and dexamethasone, and three studies have suggested that daily dosing of aprepitant for 5 days may improve the control of delayed nausea. Delayed nausea was improved by the addition of aprepitant to dexamethasone in one of the studies using 3-day dosing, but there was no improvement in nausea when the 3-day aprepitant dosing was added to ondansetron and dexamethasone in patients receiving MEC.

25.8 Summary and Conclusions The first generation 5-HT3 receptor antagonists (dolasetron, granisetron, ondansetron, tropisetron, ramosetron, and azasetron) have significant and similar efficacy in the prevention of acute CINV for patients receiving MEC and HEC. However, these agents do not appear to have significant efficacy in the prevention of delayed CINV, and these 5-HT3 agents compete primarily on an economic basis. Based on initial and recent clinical studies, palonosetron is highly effective in controlling acute and delayed CINV in patients receiving either MEC or HEC. Compared to the first generation 5-HT3 receptor antagonists, palonosetron has equivalent efficacy in controlling acute CINV and appears to be more effective in controlling delayed CINV. The complete response rates for palonosetron appear to be maintained over repeated cycles of chemotherapy for patients receiving either MEC or HEC. The effect of palonosetron on the control of acute and delayed CINV in combination with other antiemetics will be the subject of further studies. For patients receiving MEC or HEC, dexamethasone significantly improves acute CINV when added to the 5-HT3 receptor antagonists. It is also moderately effective in the prevention of delayed CINV when used alone or in combination with other agents. Aprepitant significantly improves the control of acute CINV when added to a 5-HT3 receptor antagonist and dexamethasone for patients receiving HEC. Aprepitant alone does not appear to control acute emesis as well as the 5-HT3 agents, nor in combination with dexamethasone, compared with the 5-HT3 agents and dexamethasone. Aprepitant also improves the control of delayed CINV for patients receiving HEC, when compared to placebo, and in combination with dexamethasone, when compared to dexamethasone alone. The efficacy of aprepitant appears to be maintained over repeated cycles of cisplatin chemotherapy. Studies on the use of aprepitant in patients receiving MEC suggest that the addition of aprepitant to ondansetron and dexamethasone improved the complete response in the 24 h post-chemotherapy, but there

466

The addition of casopitant to ondansetron and dexamethasone improved NSN compared to ondansetron and dexamethasone alone in patients receiving cisplatin chemotherapy in the recently reported phase III trial. There was no improvement in nausea or significant nausea with the use of casopitant in the phase III trial of breast cancer patients receiving moderately emetogenic chemotherapy. A recent phase II study using olanzapine in combination with granisetron and dexamethasone showed promise in controlling acute and delayed nausea in patients receiving MEC and HEC. Based on their mechanism of action, cannabinoids may be useful in the control of chemotherapy-induced nausea. However, there are no current trials that define the use of the available agents. The introduction of the second generation 5-HT3 receptor antagonist palonosetron and the NK-1 receptor antagonists aprepitant and casopitant have significantly improved the control of CINV. This will allow more patients to experience more normal functioning during chemotherapy with fewer toxicities. The overall cost of care as well as job absences should be reduced.

25.9 Future Developments Clinicians and other healthcare professionals who are involved in administering chemotherapy should be aware that studies have strongly suggested that patients experience more acute and delayed CINV than is perceived by practitioners [31], and patients often do not receive adequate prophylaxis [23, 49]. In addition, it is essential to emphasize that the current and new agents have been used as prophylaxis for acute and delayed CINV and have not been studied for use in established CINV [49, 62]. Oncology practitioners now have a number of new antiemetics for use in preventing acute and delayed CINV. Future studies will determine how these agents are best used and what combinations of new and older agents will be the most beneficial for patients. Some questions that have arisen concerning palonosetron include: How does it differ in mechanism of action from the current 5-HT3 agents? Does the higher binding affinity, the longer halflife, or the high potency account for the differences, or does palonosetron affect 5-HT3 receptors in a

R.M. Navari et al.

different way or in a different location? What are the effects of palonosetron on nausea in combination with dexamethasone, or in combination with aprepitant? Future research may answer some of these questions. Palonosetron is the only 5-HT3 receptor antagonist with an indication for the control of delayed CINV which suggests it may be more effective than first generation 5-HT3 receptor antagonists in patients receiving multiple-day and high-dose chemotherapy. The use of palonosetron on an every other day or daily dosing schedule during the period of the multiple-day chemotherapy may be a reasonable approach in patients receiving multiple-day or highdose chemotherapy. The use of palonosetron to treat both acute and delayed CINV and in combination with dexamethasone may result in a relatively high complete response. A specific dosing schedule will require future studies. Aprepitant is approved as an additive agent to a 5-HT3 receptor antagonist and dexamethasone in controlling acute and delayed CINV in patients receiving single-day chemotherapy. It is given for 3 days beginning on the day of chemotherapy. For patients receiving multiple-day or high-dose chemotherapy, a consideration for clinical implementation and for a potential clinical trial would be to add aprepitant to a 5-HT3 receptor antagonist and dexamethasone for the first 3 days of chemotherapy and then repeat the 3-day aprepitant regimen on the final day of chemotherapy. This approach may improve both the acute and delayed CINV during and after the multiple-day chemotherapy regimen. Based on the results of the phase II and phase III clinical trials, it appears that casopitant will be efficacious when used in conjunction with ondansetron and dexamethasone in the prevention of CINV for patients receiving either HEC or MEC. It is anticipated that the current data will be used for FDA review and potential approval of casopitant. It is anticipated that casopitant will have similar utility to that of aprepitant (and its prodrug fosaprepitant) and if approved by the FDA, casopitant would become the second distinct NK-1 receptor antagonist available for the prevention of CINV. The indications and potential adverse events for casopitant are likely to be similar to those of aprepitant. Based on the clinical data available, casopitant currently does not appear to offer any clinical advantage over aprepitant. Although

25 Management of Nausea and Vomiting in Cancer Patients

467

aprepitant has been highly effective in controlling emesis, it has not been effective in controlling nausea, and this appears to be also true for casopitant. Olanzapine has been shown to be an effective agent in controlling CINV in patients receiving single-day chemotherapy when added to a 5-HT3 receptor antagonist and dexamethasone. The addition of olanzapine to a 5-HT3 receptor antagonist and dexamethasone during each day of multiple-day chemotherapy and for 3 days after the completion of the chemotherapy may significantly improve the complete response. This would be a consideration for clinical implementation and for a potential clinical trial. Future studies of aprepitant and the new NK-1 drug class will explore their use in MEC as well as in specific clinical situations, such as bone marrow transplantation and multiple-day chemotherapy regimens. Such studies will also determine the most effective use of these agents, both alone and in combination with other antiemetics. Palonosetron, aprepitant, casopitant, and olanzapine have not been studied in radiotherapyinduced nausea and vomiting. Future studies may address whether these new agents would be effective in patients who experience nausea and vomiting during radiotherapy. Finally, future studies on the use of agents such as olanzapine, gabapentin, and cannabinoids as antiemetics, agents having been initially used for other clinical indications, may not only provide additional options for the control of acute and delayed CINV but may also provide new information on the mechanism of CINV.

5. Arpornwirat W, Albert I, Hansen V et al (2009) Phase 2 trial results with the novel neurokini-1 receptor antagonist casopitan in combainat with ondansetron and dexamethasone for the prevention of chemotherapy-induced nausea and vomiting in cancer patients receiving moderately emetogenic chemotherapy. Cancer 115:5807–5816 6. Berger, AM, Clark-Snow RA (2001) Adverse effects of treatment. In: Devita VT Jr, Helman S, Rosenberg E (eds) Principles and practice of oncology. Lippincott Williams and Wilkins, PA, USA, pp 2869–2880 7. Borison HL, McCarthy LE (1983) Neuropharmacology of chemotherapy-induced emesis. Drugs 25:8–17 8. Bubalo J, Seelig F, Karbowicz S, Maziarz RT (2001) Randomized open-label trial of dolasetron for the control of nausea and vomiting associated with high-dose chemotherapy with hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 7:439–445 9. Bymaster FP, Calligaro D, Falcone J, Marsh RD, Moore NA, Tye NC et al (1996) Radioreceptor binding profile of the atypical antipsychotic olanzapine. Neuropsychopharmacology 14:87–96 10. Bymaster FP, Falcone JF, Bauzon D, Kennedy JS, Schenck K, DeLapp NW et al (2001) Potent antagonism of 5HT3 and 5HT6 receptors by olanzapine. Eur J Pharmacol 430:341–349 11. Campos D, Pereira JR, Reinhardt RR, Carracedo C, Poli S, Vogel C et al (2001) Prevention of cisplatin-induced emesis by the oral neurokinin-1 antagonist, MK-869, in combination with granisetron and dexamethasone or with dexamethasone alone. J Clin Oncol 19:1759–1767 12. Cartmell AD, Ferguson S, Yanagihara R, Moiseyenko V, Van Marwijk Kooy R, Tripp F et al (2003) Protection against chemotherapy-induced nausea and vomiting is maintained over multiple cycles of moderately of highly emetogenic chemotherapy by palonosetron, a potent 5HT3 receptor antagonist. In: Program/proceedings of the 39th annual meeting of the American society of clinical oncology, May 31–June 3, 2003. Chicago, IL. Abstract 3041 13. Chawla SP, Grunberg SM, Gralla RJ, Hesketh PJ, Rittenberg C, Elmer ME et al (2003) Establishing the dose of oral NK-1 antagonist aprepitant for chemotherapy induced nausea and vomiting. Cancer 97:2290–2300 14. Cocquyt V, Van Belle S, Reinhardt RR, Decramer ML, O’Brien M, Schellens JH et al (2001) Comparison of L-758,298, a prodrug for the selective neurokinin1 antagonist L-754,030, with ondansetron for the prevention of cisplatin-induced emesis. Eur J Cancer 37: 835–842 15. de Boer-Dennert M, de Wit R, Schmitz PI, Djontono J, Beurden V, Stoter G et al (1997) Patient perceptions of the side effects of chemotherapy: the influence of the 5-HT3 antagonists. Br J Cancer 76:1055–1061 16. de Witt R, Herrstedt J, Rapoport BL, Carides AD, Casrides G, Elmer M et al (2003) Addition of the oral NK1 antagonist aprepitant to standard anti-emetics provides protection against nausea and vomiting during multiple cycles of cisplatin-based chemotherapy. J Clin Oncol 21:4105–4111 17. de Witt R, Herrstedt J, Rapoport BL, Carides AD, Guogwang-Ma J, Elmer M et al (2004) The oral NK-1

References 1. Aapro MS, Grunberg SM, Manikhas GM et al (2003) A phase III, double-blind, randomized trial of palonosetron compared with ondansetron in preventing chemotherapyinduced nausea and vomiting following highly emetogenic chemotherapy. Ann Oncol 17:1441–1449 2. Allison DB, Casey DE (2001) Antipsychotic-associated weight gain: A review of the literature. J Clin Psychiatr 62:22–31 3. Andrews PLR (1994) 5-HT3 receptor antagonists and antiemesis. In: King FD, Jones BJ, Sanger GJ (eds) s5hydroxytryptamine-3 receptor antagonists. CRC, Boca Raton/London 4. Antiemetic Subcommittee of the Multinational Association of Supportive Care in Cancer (1998) Prevention of chemotherapy and radiotherapy-induced emesis: results of Perugia consensus conference. Ann Oncol 9:811–819

468

18.

19. 20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

R.M. Navari et al. antagonist, aprepitant, given with standard anti-emetics provides protection against nausea and vomiting over multiple cycles of cisplatin-based chemotherapy: a combined analysis of two randomized, placebo-controlled Phase III clinical trials. Eur J Cancer 40:403–410 deWit R, Schmitz PIM, Verweij J, de Boer-Dennert M, de Mulder PH, Planting AS et al (1996) Analysis of cumulative probabilities shows that the efficacy of 5-HT3 antagonist prophylaxis is not maintained. J Clin Oncol 14:644–651 Diemunsch P, Grelot L (2000) Potential of substance P antagonists as anti-emetics. Drugs 60:533–546 Einhorn LH, Brames ML, Dreicer R et al (2007) Palonosetron plus dexamethasone for the prevention of chemotherapy-induced nausea and vomiting in patients receiving multiple-day cispaltin chemotherapy for germ cell cancer. Support Care Cancer 15:1293–1300 Eisenberg P, Figueroa-Vadillo J, Zamora R, Charu V, Hajdenberg J, Cartmell A et al (2003) Improved prevention of moderately emetogenic chemotherapy-induced nausea and vomiting with palonosetron, a pharmacologically novel 5-HT3 receptor antagonist. Results of a Phase III, single-dose trial versus dolasetron. Cancer 98: 2473–2482 Eisenberg P, MacKintosh FR, Ritch P Cornett PA, Macciocchi A (2004) Efficacy, safety, and pharmacokinetics of palonosetron in patients receiving highly emetogenic, cisplatin-based chemotherapy: a dose-ranging, clinical study. Ann Oncol 15:330–337 Fabi A, Barduagni M, Lauro S, Portalone L, Mauri M, Marinis F et al (2003) Is delayed chemotherapyinduced emesis well managed in oncological clinical practice? An observational study. Support Care Cancer 11: 156–161 Fabi A, Ciccaresev M, Metro G et al (2008) Oral ondansetron is highly active as rescue antiemetic treatment for moderately emetogenic chemotherapy: results of a randomized phase II study. Support Care Cancer 16:1375–1380 Fasth KJ, Bergstrom M, Kilpatrick G (1997) Brain uptake and receptor binding of two C11 labeled selective high affinity NK-1 antagonists, GR203040 and GR 205171. J Labeled Comp Radiopharm 40:665–667 Geling O, Eichler H (2005) Should 5-Hydroxytryptamine3 receptor antagonists be administered beyond 24 hours after chemotherapy to prevent delayed emesis? Systematic re-evakluation of clinical evidence and drug cost implications. J Clin Oncol 23:1289–1294 Goldstein LE, Sporn J, Brown S, Kim H, Finkelstein J, Gaffey GK et al (1999) New-onset diabetes mellitus and diabetic ketoacidosis associated with olanzapine treatment. Psychosomatics 40:438–443 Gralla R, Lichinitser M, Van der Vegt S, Sleeboom H, Mezger J, Peschel C et al (2003) Palonosetron improves prevention of chemotherapy-induced nausea and vomiting following moderately emetogenic chemotherapy: results of a double-blind randomized Phase III trial comparing single doses of palonosetron with ondansetron. Ann Oncol 14:1570–1577 Gralla RJ, Osoba D, Kris MG, Kirkbride P, Hesketh PJ, Chinnery LW et al (1999) Recommendations for the use of

30.

31.

32.

33.

34. 35.

36.

37.

38.

39.

40.

41.

42.

43.

antiemetics: evidence-based clinical practice guidelines. J Clin Oncol 17:2971–2994 Griffin AM, Butow PN, Coates AS, Childs AM, Ellis PM, Dunn SM et al (1996) On the receiving and. V: Patient perceptions of the side effects of cancer chemotherapy in 1993. Ann Oncol 7:189–195 Grunberg SM, Deuson R, Mavros P, Geling O, Hansen M, Cruciani G et al (2004) Incidence of chemotherapyinduced nausea and emesis after modern anti-emetics: perception versus reality. Cancer 100:2261–2268 Grunberg SM, Rolski J, Strausz J et al (2009) Efficacy and safety of casoitant mesylate, a neurokinin 1 (NK-1) receptor antagonist, in prevention of chemotherapy-induced nausea and vomiting in patients receiving cisplatin-based highly emetogenic chemotherapy: a randomized, doubleblind. placebo-controlled trial. Lancet Oncol 10:549–558 Guttuso T, Roscoe J, Griggs J (2003) Effect of gabapentin on nausea induced by chemotherapy in patients with breast cancer. Lancet 361:1703–1705 Hale AS (1997) Olanzapine. Br J Hosp Med 58:443–445 Herrstedt J, Apornwirat W, Shaharyar A et al (2009) Phase III of casopitant, a novel neurokinin-1 receptor antagonist, for the prevention of nausea and vomiiting in patients receiving moderately emetogenic chemotherapy. J Clin Oncol 27:5363–5369. Hesketh PJ (2000) Comparative review of 5-HT3 receptor antagonists in the treatment of acute chemotherapyinduced nausea and vomiting. Cancer Invest 18:163–173 Hesketh PJ (2004) New treatment option for chemotherapy-induced nasusea and vomiting. Support Care Cancer 12:550–554 Hesketh PJ, Gralla RJ, Webb RT, Ueno W, DelPrete S, Bachinksy ME et al (1999) Randomized Phase II study of the neurokinin-1 receptor antagonist CJ-11,974 in the control of cisplatin-induced emesis. J Clin Oncol 17: 338–343 Hesketh PJ, Grunberg SM, Gralla RJ, Warr DG, Roila F, de Wit R et al (2003) The oral neurokinin-1 antagonist aprepitant for the prevention of chemotherapyinduced nausea and vomiting: a multinational, randomized, double-blind placebo-controlled trial in patients receiving high-dose cisplatin-aprepitant protocol 052 study group. J Clin Oncol 21:4112–4119 Hesketh PJ, Harvey WH, Harker WG, Beck TM, Ryan T, Bricker LJ et al (1994) A randomized double blind comparison of intravenous ondansetron and in combination with intravenous dexamethasone in the prevention of high dose cisplatin induced emesis. J Clin Oncol 12: 596–600 Hesketh PJ, Kris MG, Grunberg SM, Beck T, Hainsworth JD, Harker G et al (1997) Proposal for classifying the acute emetogenicity of cancer chemotherapy. J Clin Oncol 15:103–109 Hesketh PJ, Navari RM, Grote T, Gralla R, Hainsworth J, Kris M et al (1996) Double blind randomized comparison of the antiemetic efficacy of intravenous dolasetron and intravenous ondansetron in the prevention of acute cisplatin induced emesis in patients with cancer. J Clin Oncol 14:2242–2249 Hickok JT, Roscoe JA, Morrow GR et al (2005) 5-HT3 receptor antagonists versus perchlorperazine for control

25 Management of Nausea and Vomiting in Cancer Patients

469

of delayed emesis caused by doxrubicin: a URCC CCOP randomized controlled trial. Lancet Oncol 6:756–772 Hickok JT, Roscoe JA, Morrow GR, King DK, Atkins JN, Fitch TR (2003) Nausea and emesis remain significant problems of chemotherapy despite prophylaxis with 5-hydroxytryptamine-3 anti-emetics. Cancer 97: 2880–2886 Ioanmidis JP, Hesketh PJ, Lau J (2000) Contribution of dexamethasone to control of chemotherapy-induced nausea and vomiting: a meta-Analysis of randomized evidence. J Clin Oncol 18:3409–3422 Jackson WC, Tavernier L (2003) Olanzapine for intractable nausea in palliative care patients. J Palliative Med 6:251–255 Kimura E, Niimi E, Watanabe A (1996) Study on clinical effect of a continuous intravenous infusion of azasetron against the nausea and vomiting induced by anticancer drugs including CDDP. Gan To Kagaku Ryoho 23: 477–481. Kirkbride P, Bezjak A, Pater J, Zee B, Palmer MJ, Wong P et al (2000) Dexamethasone for the prophylaxis of radiation-induced Emesis: a national cancer institute of Canada clinical trials group study. J Clin Oncol 18: 1960–1966 Kris MG (2003) Why do we need another anti-emetic? J Clin Oncol 21:4077–4080 Kris MG, Hesketh PJ, Somerfield MR et al (2006) American Society of clinical Oncology guidelines for antiemtics in oncology: update. J Clin Oncol 24: 2932–2934 Kris MG, Pendergrass KB, Navari RM, Grote TH, Nelson AM, Thomas V et al (1997) Prevention of acute emesis following high dose cisplatin with the combination of oral dolasetron and dexamethasone. J Clin Oncol 15: 2135–2138 Kris MG, Radford JE, Pizzo BA, Inabinet R, Hesketh A, Hesketh PJ (1997) Use of a NK1 receptor antagonist to prevent delayed emesis after cisplatin (letter). J Natl Cancer Inst 89:817–818 Lanciano R, Sherman DM, Michalski J. Preston AJ, Yocom K, Friedman, C (2001) The efficacy and safety of once- daily granisetron tablets in the prophylaxis of nausea and emesis following fractionated upper abdominal radiotherapy. Cancer Invest 19:763–772 Lasseter KC, Gambale J, Jin B et al (2007) Tolerability of foasaprepitant and bioequivalency to aprepitant in healthy subjects. J Clin Pharmacol 47:834–840 Latreille J, Pater J, Johnston D. Laberge F, Stewart D, Rusthoven J et al (1998) Use of dexamethasone and granisetron in the control of delayed emesis for patients who receive highly emetogenic chemotherapy. J Clin Oncol 16:1174–1178 Mantovani G, Maccio A, Alesandro B, Curreli L, Ghiani M, Proto E et al (1996) Comparison of granisetron versus ondansetron versus tropisetron in the prophylaxis of acute nausea and vomiting induced by cisplatin for the treatment of head and neck cancer; a randomized controlled trial. Cancer 77:941–948 Martin BR, Wiley JL (2004) Mechanism of action of cannabinoids; how it may lead to treatment of cachexia, emesis, and pain. J Support Oncol 2:305–316

58. Antiemetic Consensus Conference, Perugia, Italy (2004) Multi-national association, supportive care in cancer. Retrieved Nov 2009 from http://www.mascc.org 59. Minami M, Endo T, Kikuchi K, Ihira E, Hirafuji M, Hamaue N et al (1998) Antiemetic effects of sendide, a peptide tachykinin NK-1 receptor antagonist, in the ferret. Eur J Pharmacol 363:49–55 60. Minami M, Endo T, Yokoda H, Ogawa M, Nemoto N, Hamaue M et al (2001) Effects of CP-99,994, a tachykinin NK-1 receptor antagonist, on abdominal afferent vagal activity in ferrets: evidence for involvement of NK-1 and 5-HT3 receptors. Eur J Pharmacol 428:215–220 61. Morrow GR, Hickok JT, Rosenthal SN (1995) Progress in reducing nausea and emesis: comparisons of ondansetron, granisetron, and tropisetron. Cancer 76:343–357 62. Navari RM (2003) Pathogenesis-based treatment of chemotherapy induced nausea and vomiting: two new agents. J Support Oncol 1:89–103 63. Navari RM (2004) Aprepitant: a neurokinin-1 receptor antagonist for the treatment of chemotherapy-induced nausea and vomiting. Expert Rev Anticancer Ther 4(5) 715–724 64. Navari RM (2004) Inhibiting substance P pathway for prevention of chemotherapy-induced emesis: Preclinical data, clinical trials of neurokinin-1 receptor antagonists. Support Cancer Therapy 1:89–96 65. Navari RM (2007) Fosaprepitant (MK-0517): a neurokinin-1 receptor antagonist for the prevention of chemotherapy-induced nausea and vomting. Expert Opin Invest Drugs 16,1977–1985 66. Navari RM (2007) Prevention of emesis from multipleday chemotherapy regimens. J Natl Compr Canc Netw 5:51–59 67. Navari RM (2007) Review of updated antiemetic guidelines for chemotherapy-nnduced nausea and vomiting. Commun Oncol 4(1 Suppl) 3S–11S 68. Navari RM (2008) Casopitant, a neurokinin-1 receptor antagonist with anti-emetic and antinausea activties. Curr Opin Investig Drugs 9:774–785 69. Navari RM (2009) Palonosetron: A second generation 5-hysroxytryptamin-3 receptor antagonist. Expert Opion Drug Metab Toxicol 5(12) 1–10 70. Navari RM (2009) Pharmacological management of chemotherapy-induced nausea and vomiting. Focus on recent developments. Drugs 69:515–523 71. Navari RM, Einhorn LH, Passik SD, Loehrer PJ, Vinson J, Johnson C et al (2005) A Phase II trial of olanzapine for the prevention of chemotherapy induced nausea and vomiting: a Hoosier oncology group study. Support Care Cancer 13:529–534 72. Navari RM, Einhorn LH, Passik SD, Loehrer PJ, Vinson J, Johnson C et al (2007) A Phase II trial of olanzapine, dexamethasone, and palonosetron for the prevention of chemotherapy induced nausea and vomiting: a Hoosier oncology group study. Support Care Cancer 15: 1285–1291 73. Navari RM, Gandara D, Hesketh P, Hall S, Maillard J, Ritter H et al (1995) Comparative clinical trial of granisetron and ondansetron in the prophylaxis of cisplatin induced emesis. J Clin Oncol 13: 1242–1248

44.

45.

46.

47.

48.

49. 50.

51.

52.

53.

54.

55.

56.

57.

470 74. Navari RM, Kaplan HG, Gralla RJ, Grunberg SM, Palmer R, Fitts D (1994) Efficacy and safety of granisetron, a selective 5-hydroxytryptamine receptor antagonist, for the prevention of nausea and vomiting induced by high dose cisplatin. J Clin Oncol 12:2204–2210 75. Navari RM, Koeller JM (2003) Electrocardiographic and cardiovascular effects of the 5-hydroxytryptamine3 receptor antagonists. Ann Pharmacother 37: 1276–1286 76. Navari RM, Madajewicz S. Anderson N, Tchekmedyian NS, Whaley W, Garewal H et al (1995) Oral ondansetron for the control of cisplatin-induced delayed emesis: a large,multicenter, double-blind, randomized comparative trial of ondansetron versus placebo. J Clin Oncol 13:2408–241 77. Navari RM, Reinhardt RR, Gralla RJ, Kris MG, Hesketh PJ, Khojasteh A et al (1999) Reduction of cisplatininduced emesis by a selective neurokinin-1 receptor antagonist. N Engl J. Med 340:190–195 78. Clinical Practice Guidelines in Oncology: Antiemesis (2009) National comprehensive cancer network. Retrieved Nov 2009 from http://www.nccn.org 79. Osoba D, Zee B, Pater J, Warr D, Latreille J, Kaizer L (1997) Determinants of postchemotherapy nausea and vomiting in patients with cancer. J Clin Oncol 15:116–123 80. Osoba D, Zee B, Warr D, Latreille J, Kaizer L, Pater J (1997) Effect of post-chemotherapy nausea and vomiting on health related quality of life. Support Care Cancer 5:307–313 81. Passik SD, Kirsh KL, Theobald DE, Dickerson P, Trowbridge R, Gray D et al (2003) A retrospective chart review of the use of olanzapine for the prevention of delayed emesis in cancer patients. J Pain Symptom Manage 25:485–489 82. Passik SD, Lundberg J, Kirsh K, Theobald D, Donaghy K, Holtsclaw E et al (2002) A pilot exploration of the antiemetic activity of olanzapine (Zyprexa) for the relief of nausea in patients with advanced cancer and pain. J Pain and Symptom Manage 23:526–532 83. Passik SD, Navari RM, Jung S, Nagy C, Vinson J, Kirsh K et al (2004) A phase I trail of olanzapine (Zyprexa) for the prevention of delayed emesis in cancer patients receiving chemotherapy. Cancer Invest 22:383–388 84. Perez EA (1999) 5-HT3 antiemetic therapy for patients with breast cancer. Breast Cancer Res Treat 57:207–214 85. Perez EA (1995) Review of the preclinical pharmacology and comparative efficacy of 5-hydroxytryptamine-3 receptor antagonists for chemotherapy-induced emesis. J Clin Oncol 13:1036–1043 86. Perez EA, Navari RM, Kaplan HG, Gralla RJ, Grunberg SM, Palmer RH et al (1997) Efficacy and safety of different doses of granisetron for the prophylaxis of cisplatin induced emesis. Support Care Cancer 5:31–37 87. Pirl WF, Roth AJ (2000) Remission of chemotherapyinduced emesis with concurrent olanzapine treatment: a case report. Psychooncology 9:84–87 88. Poli-Bigelli S, Rodrigues-Pereira J, Carides AD, Julie Ma G, Eldridge K, Hipple A et al (2003) Addition of the neurokinin-1 receptor antagonist aprepitant to standard anti-emetic therapy improves control of chemotherapyinduced nausea and vomiting. Cancer 97:3090–3098

R.M. Navari et al. 89. Roila F, Hesketh PJ, Herrstedt J (2006) Antiemetic subcommittee of the multinational association of supportive care in cancer. Ann Oncol 17:22–28 90. Rudd JA, Naylor RJ (1994) Effects of 5-HT3 receptor antagonists on models of acute and delayed emesis induced by cisplatin in the ferret. Neuropharmacology 33:1607–1608 91. Saito M, Aogi K, Sekine I et al (2009) Palonosetron plus dexamethasoneversus granisetron plus dexamethasone for the prevention of nausea and vomiting during chemotherapy: a double-blind, double dummy, randomized comparative phase III trial. Lancer Oncol 10:115–124 92. Sanger GJ (1992) The involvement of the 5-HT3 receptors in visceral function. In: Harmon M (ed) Central and peripheral 5-HT3 Receptors (pp. 207–255). Academic, London 93. Schmoll HJ, Aapro MS, Poli-Bigelli S et al (2006) Comparison of an aprepitant regimen with a multi-day ondansetron regimen, both with dexamethasone, for the antiemetic efficacy in high-dose cisplatin treatment. Ann Oncol 17(6):1000–1006 94. Simpson K, Spencer CM, McClellan KJ (2000) Topisetron: an update of its use in the prevention of chemotherapy-induced nausea and vomiting. Drugs 59:1297–1315 95. Slatin MD (2007) Cannabinoids in the treatment of chemotherapy-induced nausea and vomiting beyond prevention of acute emesis. J Support Oncol 5(3 Suppl): 1S–9S 96. Srivastava M, Brito-Dellan N, Davis MP, Leach M, Lagman R (2003) Olanzapine as an antiemetic in refractory nausea and vomiting in advanced cancer. J. Pain Symptom Manage 25:578–582 97. Taguchi T, Tsukamoto F, Watanabe T (1999) Usefulness of ramosetron hydrochloride on nausea and vomting in CMF or CEF therapy for breast cancer. Gan To Kagaku Ryoho 26:1163–1170 98. Tattersall FD, Rycroft W, Cumberbatch M, Mason G, Tye S, Williamson DJ et al (2000) The novel NK1 receptor antagonist MK-0869 (L-754,030) and its water soluble phsophoryl prodrug, L-758,298, inhibit acute and delayed cisplatin-induced emesis in ferrets. Neuropharmacology 39:652–663 99. Tattersall FD, Rycroft W, Francis B, Pearce D, Merchant K, MacLeod AM et al (1996) Tachykinins NK-1 receptor antagonists act centrally to inhibit emesis induced by the chemotherapeutic agent cisplatin in ferrets. Neuropharmacology 35:1121–1129 100. Tavorath FD, Hesketh PJ (1996) Drug treatment of chemotherapy-induced delayed emesis. Drugs 52: 639–648 101. The Italian Group for Anti-emetic Research (2000) Dexamethasone alone or in combination with ondansetron for the prevention of delayed nausea and vomiting induced by chemotherapy. N Engl J Med 342:1554–1559 102. The Italian Group for Anti-emetic Research (1995) Dexamethasone, granisetron, or both for the prevention of nausea and vomiting during chemotherapy for cancer. N Engl J Med 332:1–5 103. The Italian Group for Anti-emetic Research (1998) Double blind dose finding study of four intravenous doses

25 Management of Nausea and Vomiting in Cancer Patients

471

of dexamethasone in the prevention of cisplatin induced acute emesis. N Engl J Med 16:2937–2942 104. The Italian Group for Anti-emetic Research (2004) Randomized, double-blind, dose-finding study of dexamethasone in preventing acute emesis induced by anthrcyclines, carboplatin, or cyclophosphamide (published erratum appears in J Clin Oncol 22:2038). J Clin Oncol 22:725–729 105. Van Belle S, Liechinitser M, Navari RM, Garin AM, Decramer ML, Riviere A et al (2002) Prevention of cisplatin-induced acute and delayed emesis by the selective neurokinin-1 antagonists, L-758,298 and MK-0869. Cancer 94:3032–3041

106. Van Sickle MD, Duncan M, Kingsley PJ et al (2005) Identification and functional characterization of brainstem cannabinoid CB2 receptors. Science 310: 329–332 107. Warr DG, Hesketh PJ, Gralla RJ et al (2005) Efficacy and tolerability of aprepitant for the prevention of chemotherapy-induced nausea and vomiting in patients with breast cancer after moderately emetogenic chemotherapy. J Clin Oncol 23:2822–2830 108. Yates BJ, Grelot L, Kerman IA, Balaban CD, Jakus J, Miller AD (1994) Organization of the vestibular inputs to nucleus tractus solitarius and adjacent structures in cat brain stem. Am J Physiol 207–255

Chapter 26

Nutrition in the Management of the Cancer Patient Cheryl L. Rock

26.1 Introduction Nutrition can play an important role in the management of the cancer patient, across the spectrum from the initial phases of treatment and recovery through the long-term continuum of care in which the goals are to prevent recurrence, reduce risk for comorbid disease, and increase likelihood of survival. Maintaining good nutritional status during the initial post-diagnosis treatment phase may enable the successful completion of prescribed treatments, reduce time to recovery, and improve the quality of life of the patient. Evidence from observational studies of cohorts of individuals who have been diagnosed with cancer suggests that dietary patterns and nutritional factors also may influence the long-term prognosis and overall survival, and a few randomized clinical trials have tested the effect of diet modification on cancer outcomes. This chapter reviews evidence relating to the role of nutrition in the treatment and long-term care of the patient who has been diagnosed with cancer, with a focus on epidemiological and clinical nutrition studies that have examined associations or tested interventions at the point of cancer diagnosis and beyond. Results from clinical intervention studies that have targeted selected established precancerous lesions also are reviewed. A key concept is that nutritional needs differ across the continuum of care from initial treatment

C.L. Rock () Department of Family and Preventive Medicine, and Cancer Prevention and Control Program, School of Medicine, University of California, San Diego, CA, USA e-mail: [email protected]

through long-term survival, with the type of cancer and the characteristics of the patient and prescribed treatments being important influencing variables. Compared with the amount of scientific effort that has been devoted to examining the relationships between nutritional factors and cancer incidence, there are substantially fewer studies on the relationships between these factors and cancer progression and survival. Nonetheless, general principles and nutritional recommendations for individuals who have been diagnosed with cancer have been summarized and communicated to clinicians and the public by an expert group [34, 37, 129], partly in response to the high level of interest in this topic among patients. Nutritional factors and food choices involve modifiable behaviors that enable patients to actively participate in their care and favorably affect their long-term prognosis. Cancer survivors are often highly motivated to learn and apply strategies that may improve their status and help them to maintain optimal functioning [29].

26.2 Nutrition at Initial Diagnosis and Rationale for Intervention In several clinical series reports [32, 70, 76], substantial weight loss and poor nutritional status have been observed in more than 50% of patients at the time of cancer diagnosis. However, the prevalence of weight loss and malnutrition varies widely across cancer types, as evident in the data from 3,047 patients enrolled in 12 chemotherapy protocols of the Eastern Cooperative Oncology Group [32]. Patients with nonHodgkin’s lymphoma subtypes with favorable tumor

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_26, © Springer Science+Business Media B.V. 2011

473

474

tissue characteristics, breast cancer, acute nonlymphocytic leukemia, and sarcomas had the lowest prevalence of weight loss, with 60–69% of patients with those cancer types having no weight loss. Intermediate prevalence of weight loss, which was defined as a frequency of 48–61%, was observed in those with unfavorable non-Hodgkin’s lymphoma subtypes, colon cancer, prostate cancer, and lung cancer. The highest frequency of weight loss (83–87%) was observed in patients with pancreatic or gastric cancer, with approximately one-third of these patients reporting a loss of >10% of pre-diagnosis body weight. Also, these investigators found that when grouped by cancer type, tumor extent, and activity level, median survival time was shorter in those who had experienced weight loss compared with those who had not experienced weight loss [32]. Historically, providing nutritional care to the patient with cancer has not always been believed to be therapeutically advantageous, due to fear of promoting cancer progression. In laboratory animal and cell culture studies, starvation has been observed to slow tumor growth and proliferation of cancer cells [9, 124], and concern that nutritional repletion would stimulate tumor growth, based on the early studies with animal models, was the basis for concern [27]. However, the health status of the host is concurrently adversely affected by nutritional depletion, and historically, malnutrition was a major cause of cancer-related mortality [127]. More recent studies have shown that providing adequate energy and essential nutrients may improve the efficacy and reduce the toxicity of chemotherapy and other cancer treatments [8, 94]. Another concern has been that the weight loss and malnutrition observed in some cancer patients may not be modifiable. The syndrome of weight loss and malnutrition that occurs in some cancer patients has been termed cancer cachexia, characterized by muscle wasting and increased resting metabolic rate [9]. Cancer cachexia differs from simple starvationrelated protein-energy malnutrition primarily because the compensatory mechanisms that would promote the preservation of muscle mass and adaptation to alternate fuels are not functioning. Specific metabolic characteristics associated with this syndrome include increased protein turnover, decreased muscle protein synthesis, increased glycolysis, increased lipolysis, decreased fat synthesis, decreased glucose tolerance and increased glucose uptake [70, 115]. The fundamental metabolic

C.L. Rock

problem is cytokine-induced gluconeogenesis and increased utilization of protein stores for fuel, similar to the acute metabolic stress response, which is promoted by the release of cytokines due to the presence of the tumor and associated circulating factors. However, cancer cachexia and weight loss in those patients who are affected with this syndrome also typically involve loss of appetite (anorexia) and inadequate dietary intake. Low levels of energy intake can occur as a result of altered taste perceptions, due either to systemic effects of the cancer itself or treatment modalities, and psychological factors, such as anxiety, depression, fatigue, and the emotional stress of diagnosis and treatment [15]. Several strategies can be useful to overcome barriers to inadequate intakes of energy and nutrients, and good response to chemotherapy and other treatments of the cancer is associated with normalization of the metabolic effects that increase risk for adverse nutritional consequences [58].

26.3 Nutrition Strategies During Treatment and Recovery The overall goals of nutritional care for the patient undergoing initial treatments for cancer are to maintain a healthy weight, meet requirements for essential nutrients, and minimize adverse effects of treatment that might be modulated by dietary strategies. Table 26.1 lists the current definitions, which are based on body mass index (BMI), for identifying underweight, overweight and obesity. For patients who are underweight and exhibiting weight loss, the goal is to maintain or gain weight. In contrast, evidence suggests that being overweight or obese may increase risk for recurrence

Table 26.1 Underweight, overweight and obesity as defined by body mass index (BMI) BMI (weight [kg]/height Classification [m2 ]) Underweight <18.5 Normal 18.5–24.9 Overweight 25.0–29.9 Obesity 30.0–39.9 Extreme >40 obesity Expert panel on the identification, evaluation, and treatment of overweight in adults (1998)

26 Nutrition in the Management of the Cancer Patient

for some cancers, such as breast cancer, so for the latter group, modest weight loss (e.g., 1–2 pounds/week) promoted by a moderate reduction in energy intake and increased physical activity can be encouraged during treatment [34, 101]. Cancer treatments (surgery, radiation and chemotherapy) can influence nutrient requirements and eating patterns, which in turn affects nutritional status [77]. Recovery from surgery requires adequate energy, protein and nutrient intakes to enable wound healing and adequate immune system function. Surgeries for cancers of the gastrointestinal tract, in particular, may affect the patient’s ability to swallow, digest and absorb food, so post-surgery diet modifications are typically indicated in order to maintain adequate energy and nutrient intakes. Patients usually benefit from a progressive approach to diet (from clear liquid to low-fiber to regular diet), with the goal being a return to a normal diet based on regular foods. However, there are some patients in whom long-term dietary modifications are necessary, for example, in the management of dumping syndrome following surgical resection of the stomach [1]. Modern approaches to radiation therapy aim to affect only the specific target site, although fatigue is a common systemic side effect that can adversely influence appetite and intake. When the site of radiation therapy is the head and neck, side effects such as xerostomia, sore mouth, mucositis, and dysphagia will reduce voluntary food intake. Gastrointestinal symptoms that affect intake and nutrient absorption, such as diarrhea, can occur as a result of radiation of the abdomen and pelvis. Chemotherapy can cause nutritional problems due to a variety of common side effects, including loss of appetite, fatigue, nausea, vomiting, mucositis, taste alterations, xerostomia, dysphagia and changes in bowel function [77]. The use of anti-emetic medications can help to minimize some of the adverse effects of chemotherapy on dietary intake, and several specific diet modification strategies also can be useful. Immunosuppression often occurs in response to chemotherapy, so strategies to ensure food safety and the avoidance of exposure to pathogenic microorganisms via food and beverages are necessary in those cases to reduce risk for infection and illness. General food safety guidelines, such as washing hands before eating, using food preparation techniques that minimize contamination, washing vegetables and fruit

475

thoroughly, cooking foods to proper temperatures, and storing food at temperatures that minimize bacterial growth, are among the general recommendations. Foods at high risk of containing pathogenic microorganisms, such as unpasteurized dairy foods or juice and raw or undercooked meat, fish or eggs should be avoided [89]. Table 26.2 lists examples of nutrition management and counseling strategies for cancer patients experiencing side effects related to treatment modalities that can adversely affect intakes. Several feeding routes may be considered for use in the management of the cancer patient, ranging from strategies that focus on diet modification, enteral nutrition involving feeding tubes, and parenteral nutrition. Overall, oral intake is generally the preferred route, although there are some patients in whom that approach is not optimal or feasible. The usefulness of nutritional counseling and diet modification for cancer patients during initial treatments and recovery has been examined in a few studies. A telephone-based follow-up study of nutrition counseling was reported by Schiller et al. [113] in 400 patients who had been referred for nutrition counseling, of whom 4% of the sample were patients with cancer. Overall, the counseling interaction was found to be well-received by the patients, with 85% reporting at follow-up that they knew what to eat after talking with the dietitian, and 62% reported that they had changed their diets following the counseling while 44% reported health-related changes. In a study of diet modification specifically relevant to patients with cancer, Menashian et al. [79] tested the effect of a modified diet to help control nausea and vomiting in 19 patients receiving cisplatin chemotherapy. Patients in the study group who were advised to consume the modified diet, which consisted of foods observed clinically to be better tolerated during chemotherapy, experienced fewer episodes of emesis when compared to the control subjects and 57% less volume of emesis on the first day of treatment. Liquid dietary supplements are often prescribed to help patients meet energy and nutrient needs in spite of eating problems. These products are theoretically nutritionally complete, with a key determining factor being the amount that is consumed, and proper use is more likely to occur when accompanied by counseling, encouragement and strategies to improve palatability. In a randomized trial [94], effects of individualized dietary counseling focused on regular foods

476

C.L. Rock

Table 26.2 Dietary counseling strategies for treatment-related side effects Nutrition-related side effect Counseling strategies Nausea and vomiting

Diarrhea and bloating

Dysphagia

Pain or dryness (xerostomia)

Taste and odor changes

Fatigue

Eat small, frequent meals and snacks Choose bland-tasting foods and beverages Avoid strong cooking odors Choose foods that are cold or room temperature (rather than hot) Eat salty foods Choose dry foods such as toast or crackers and avoid liquids at mealtimes Drink clear cold beverages Avoid high-fat or greasy foods Avoid high-fiber foods Drink nutrient-dense juices Choose cooked (rather than raw) vegetables and fruit Avoid foods that can cause gas, such as beans, broccoli, cauliflower and cabbage Drink only a small amount of liquid with meals Avoid high-lactose foods (e.g., milk, ice cream, cottage cheese and other cheeses that are not aged) Avoid high-fat or greasy foods Avoid rough-textured foods Choose foods that are cold or room temperature (rather than hot) Eat semisolid or soft foods Drink plenty of fluids and nutrient-dense beverages such as juice Add moisture to foods (e.g., sauces, condiments) Choose soft foods Blenderize foods and have liquid (rather than solid) meals with a straw or from a cup Avoid acid or very salty foods Avoid dry or rough-textured foods cHOOSE foods that are cold or room temperature (rather than hot) Rinse your mouth often Choose foods that are cold or room temperature (rather than hot) Use glass or plastic utensils (rather than metal) utensils and cookware Experiment with new flavors and seasonings Eat small, frequent meals and snacks Keep easy-to-prepare and easy-to-eat foods available Eat energy-dense, high-protein foods and snacks throughout the day Drink nutrient-dense juices and other beverages Ask friends and family members for help with buying and preparing foods to be set aside for meals and snacks

were compared with the effects of prescribing nutrientdense, high-protein liquid dietary supplements or ad libitum intake in 111 colorectal cancer patients treated with radiation therapy. Individualized dietary counseling was found to promote the maintenance of adequate dietary intakes and body weight, resulting in a marked reduction in the incidence and severity of anorexia and diarrhea, and improved quality of life. Notably, the beneficial effects observed in association with dietary counseling were generally maintained three months after the completion of radiation therapy. Although the liquid supplement did facilitate a small increase in energy intake, the other beneficial effects were substantially less than those observed in response to dietary counseling. Enteral nutrition (tube feeding) is indicated when adequate intake cannot be achieved through regular

foods and liquid supplements [80]. Nasogastric tube feeding is typically used when the problem interfering with food intake is likely to be resolved in the shortterm, while more permanent feedings are more acceptable to patients when gastrostomy or jejunostomy is the feeding route utilized. In contrast with the oral diet and enteral approaches, parenteral nutrition, in which energy-producing substrates and nutrients are administered via intravenous access, presents risks for several serious complications and increased risk for adverse effects. This approach, when applied without specific inclusion criteria, has not been shown to improve nutritional measures in the average patient with cancer and is actually associated with increased risk of complications, such as infections. Other complications include fluid overload, hyperglycemia, electrolyte imbalance, and increased serum triglyceride concentrations, and

26 Nutrition in the Management of the Cancer Patient

intensive monitoring of metabolic factors is necessary with this type of nutrition intervention. In 1989, the American College of Physicians [3] published a position paper concluding that parenteral nutrition support was associated with net harm in patients with cancer. In spite of the risk for complications, parenteral nutrition support may be appropriate for some patients with cancer for whom oral intake or enteral nutrition is not an option. The main concern is with the indiscriminate use in patients who are undergoing routine cytotoxic treatments and who do not have pre-existing malnutrition. For example, in the Veterans Affairs Total Parenteral Nutrition Cooperative Study [122], 395 patients who required laparotomy or noncardiac thoracotomy, with the majority having a diagnosis of cancer, were randomly assigned to receive either total parenteral nutrition for 7–15 days prior to surgery and 3 days afterward or no perioperative parenteral nutrition support. Overall, there were more infectious complications in the parenteral nutrition group than in the control group. However, among those who were severely malnourished based on global assessment score, patients who received total parenteral nutrition had fewer noninfectious complications than controls (relative risk [RR] 0.12, 95% confidence interval [CI] 0.02–0.91) with no increase in infectious complications [122]. Another situation in which total parenteral nutrition is currently believed to be beneficial in the management of patients with cancer is in bone marrow transplantation [95]. As summarized by Mercadante [80], the use of parenteral nutrition support should be considered adjuvant treatment and support during therapy for malnourished patients or in those with severely impaired gastrointestinal function who are otherwise expected to survive. Current evidence does not support the concept that specific benefits may be achieved by using high-dose vitamin and mineral supplements during initial treatment and recovery. In fact, some evidence suggests potential harm. High doses of folic acid could interfere with the effectiveness of methotrexate, a chemotherapy drug that targets rapidly proliferating cancer cells by interfering with folate metabolism. Theoretically, high doses of antioxidant vitamins (e.g., vitamin C, vitamin E) also could interfere with the desired effect of cytotoxic cancer treatments such as radiation therapy, in which oxidative damage to cancer cells is among the therapeutic mechanisms [69]. Others have argued that

477

antioxidant nutrients at high doses may improve the efficacy of cancer therapies [93]. Evidence from clinical studies that would help to resolve this controversy has not been reported. Currently, the general consensus is that high doses of vitamins, minerals and other dietary constituents should be avoided during initial treatments because this strategy may increase risk of adverse consequences or interference with treatments [34]. In contrast, possible benefit may be achieved by recommending the use of a multiple vitamin supplement that provides 100% of the recommended dietary intakes. The latter strategy presents negligible risk and will prevent micronutrient deficiencies in patients who are at risk of inadequate intakes from the diet.

26.4 Nutritional Factors and Risk for Recurrence and Survival The majority of patients who are diagnosed with cancer will survive at least five years post-diagnosis, due in part to increased screening efforts, which have resulted in most patients being diagnosed at an earlier stage, and improved initial treatments [23, 59]. In these patients, risk for recurrence or a second primary cancer is an important issue in their long-term management [49]. These patients also are at increased risk for other comorbidities, such as cardiovascular disease, type 2 diabetes, and osteoporosis [6, 10, 11]. For many of these comorbid disorders, the benefit of dietary intervention or weight management has a demonstrated role in prevention and management. The relationships between nutritional factors, recurrence and survival have been examined in several observational studies of breast cancer survivors. In contrast, only a few epidemiological studies have examined the relationship between nutritional factors and survival in patients with a history of other cancers, such as cancer of the prostate, colon or ovary. The subjects examined and followed in these studies were cases who originally participated in case-control studies focused on primary breast cancer risk, were identified in clinical series, or were diagnosed with cancer while being followed within ongoing population-based observational studies or other established cohorts. Several clinical trials have tested the effect of dietary

478

supplements (or diet modification) on progression or recurrence of selected precancerous lesions, and the results of those studies may be relevant to cancer progression in the patient who has had a clinical cancer diagnosis.

26.4.1 Nutritional Factors and Survival in Breast Cancer As described in several reviews [21, 101], epidemiological studies of the association between nutritional factors and survival following the diagnosis of breast cancer have mainly focused on two nutritional factors: relative body weight or other indicators of adiposity or body fat distribution (e.g., BMI, waist-to-hip circumference) and diet composition. The majority of these studies have focused on obesity or relative body weight, with a smaller number of studies in which data on diet composition were collected and examined. Notably, these characteristics are often interrelated. For example, diets that are energy-dense are more likely to promote excess adiposity, although most observational epidemiological studies attempt to separate the effects of these factors. Since 1990, 28 published studies have examined associations between relative body weight and breast cancer recurrence and survival. In 19 of these studies, increased BMI or body weight was found to be a significant risk factor for recurrent disease, decreased survival, or both; in seven studies, no association was evident; and in two studies, a significant inverse association between weight status and survival was identified (reviewed in [101]). The effect of higher (versus lower) relative body weight was fairly substantial in the studies in which an inverse association was observed, with a 30–540% increased risk of death observed in the heavier women across these studies. The relationship between upper body or android obesity and survival following the diagnosis of breast cancer was examined in two of these studies. In a study of both premenopausal and postmenopausal women by Kumar et al. [67], android body fat distribution, as indicated by a higher suprailiac:thigh ratio, was found to be a significant negative prognostic indicator, even though higher BMI status was protective in that study. In contrast, Zhang et al. [132], found no association between android obesity, as indicated by

C.L. Rock

a greater waist-to-hip ratio, and survival, but did detect a significantly greater risk of death among women in the top tertile of BMI. Weight gain often occurs in women after diagnosis of breast cancer, being more prevalent among women who were premenopausal at diagnosis, receive adjuvant chemotherapy, are African-American, and who report higher energy intake [28, 98]. Prediagnosis BMI, age at diagnosis, level of education, and usual exercise level also have been found to be inversely associated with weight gain [98]. There is some evidence, although not consistent, to suggest that weight gain after diagnosis adversely affects disease-free survival. Camoriano et al. [14] followed 646 patients with breast cancer for a median of 6.6 years and found that women who were premenopausal at diagnosis and who gained more than the median amount of weight (5.9 kg) were 1.5 times more likely to relapse and 1.6 times more likely to die of their breast cancer. Results from a study by Chlebowski et al. [20] are similar to these findings. In contrast, other studies have failed to identify an association between post-diagnosis weight gain and prognosis [13, 42, 51]. Increased body fatness, regardless of weight gain, has been noted in five studies that have measured body composition changes in women undergoing adjuvant chemotherapy [101]. A loss of lean body mass that is observed occurs in association with a marked reduction in physical activity [30]. Lean body mass is the major determinant of resting energy expenditure, so these changes in body composition have important implications for long-term weight control. Several mechanisms have been proposed to explain the adverse effect of excess adiposity on prognosis following the diagnosis of breast cancer. One relates to the effect of excess adipose tissue on circulating gonadal hormones, because adipose tissue is an important extragonadal source of estrogens from precursor adrenal androgens [25, 126]. Obesity is associated with increased circulating concentrations of estrone and estradiol in postmenopausal women, and it also is associated with decreased concentrations of sexhormone binding globulin (SHBG), which increases the bioavailable estrogen fraction [124]. Increased circulating estrogen concentrations have been linked to risk for primary breast cancer in postmenopausal women [25, 35, 109] as well as increased risk for recurrence and/or survival recurrence and/or survival among women who have been diagnosed with breast

26 Nutrition in the Management of the Cancer Patient

cancer [102]. Minimizing estrogen stimulation following the diagnosis of breast cancer is a standard management strategy, and antiestrogen therapy has emerged as one of the most effective treatments in the management of endocrine-responsive breast cancers [25]. Another possible mechanism relates to insulin and insulin-like growth factor (IGF) -I, and the interactions of these factors with adiposity and weight gain [60, 90, 107]. Insulin increases the bioactivity of IGF-I by enhancing its synthesis and by altering key binding proteins. In addition to their cellular proliferative effects, insulin and IGF-I both stimulate anabolic processes and can promote tumor development by inhibiting apoptosis [60, 107]. Insulin and IGF-I also stimulate the synthesis of sex steroids and inhibit the synthesis of SHBG, so the effects of these various hormonal factors are biologically related. Fasting insulin concentration has been shown to exhibit an independent effect on survival in a cohort of 512 women without known diabetes who had been diagnosed with early stage breast cancer [44]. Although highly correlated with BMI (r = 0.59, P < 0.001), serum insulin was associated with risk for distant recurrence and death (hazard ratio [HR] 2.1, 95% CI 1.2–3.6, for upper versus lower insulin quartile), adjusted for tumor characteristics and treatment-related variables, in that study. Several studies have examined the link between IGFs and IGF binding proteins and risk for primary breast cancer, and results are not entirely in agreement [60, 90]. The most consistent finding links IGF-I and IGFBP-3 inversely with risk for premenopausal breast cancer [64]. Few studies have examined associations between IGFBP-1 and risk for breast cancer, although this binding protein is inversely related to insulin resistance and hyperinsulinemia [50, 82]. Relationships between IGFs and their binding proteins and prognosis following the diagnosis of breast cancer have been examined in very few studies, with mixed results. Vadgama et al. [125] found IGF-I to be directly associated with risk for recurrence and inversely associated with survival in 130 African-American and Hispanic women diagnosed with breast cancer, but Goodwin et al. [44] did not find an independent association between IGF-I, IGF-II or IGFBP-3 and survival in their cohort. Leptin also may contribute to the link between obesity and breast cancer [55, 104]. Leptin is highly correlated with degree of obesity, increasing in response to insulin secretion and decreasing in response to energy restriction.

479

A few small studies have tested whether diet counseling or prescribing increased physical activity can prevent weight gain in women during the immediate post-diagnosis period, with mixed results. Women provided intensive diet counseling to achieve energyrestricted diets did not exhibit differences in weight gain compared to control subjects in a randomized trial of 104 women with early stage breast cancer [71]. In another small randomized controlled study involving early stage breast cancer patients receiving adjuvant chemotherapy (n = 24), prescribing aerobic exercise did not have a significant effect on weight gain, although significant differences were observed in the change in percent body fat (averaging –0.51% in the treatment group versus +2.19% in the control group) [128]. Both diet and physical activity were the behavioral targets in two small studies that found a significant reduction in body weight (or weight maintenance in those not overweight) in women recently diagnosed with breast cancer [43, 78], and the strongest predictor of the program’s success was increased physical activity [43]. Results from one small study aimed toward promoting weight loss in obese breast cancer survivors (n = 48) after the completion of initial treatments, have been reported. Djuric et al. [33] examined the effect of individualized weight-loss counseling with or without participation in the Weight Watcher’s commercial group-based program versus participation in Weight Watcher’s alone. Subjects were within four years of diagnosis and had a BMI of 30–44 kg/m2 . At 12 months, the average weight change was 0.85 (6.0) kg (mean [SD]) for the control group, –2.6 (5.9) kg for the Weight Watcher’s only group, –8.0 (5.5) kg for the individualized counseling only group, and –9.4 (8.6) kg for the combined treatment group. Compared with the control group, the combined group exhibited statistically significant differences at three, six and 12 months, while the individualized counseling group was significantly different only at 12 months. Other studies examining approaches aimed to promote weight loss and maintenance in overweight or obese breast cancer survivors are currently underway. In an earlier review, results were summarized from 13 studies published between 1985 and 2002 that examined the association between diet composition and recurrence or overall survival following the diagnosis of breast cancer [101]. A variety of approaches to diet assessment were used, all involving self-reported

480

dietary intakes before, during or after the diagnosis of breast cancer, and variable dietary factors were quantified and examined across these studies. Notably, these studies did not consistently or uniformly adjust for important non-dietary factors known to influence survival, such as stage at diagnosis, which likely contributes to the variable findings and interpretation of the results. The relationship between risk for recurrence or survival and intake of fat or high-fat foods was examined in the majority of these studies. In six of the 13 studies that quantified fat intake and examined associations with recurrence or survival, total fat intake was significantly inversely associated with survival or positively related to treatment failure (defined as recurrence or new cancer of the contralateral breast) [48, 53, 85, 111, 132]. When adjusted for energy intake, however, the relationship with total fat intake and recurrence or death was no longer significant in two of these studies [111, 132], and the energy-adjusted relationship was not examined in two others [48, 85]. In the one study that found energy-adjusted total fat intake to be directly associated with risk for treatment failure [53], this relationship was observed only in women who had tumors that were estrogen receptor (ER) positive (but not in those who had ER-negative tumors). As an example of magnitude of effect, the risk for treatment failure in that study was increased by 13% for each percent energy intake from fat in that study. An additional study found a nonsignificant trend for this relationship [105], and another study found energy-adjusted saturated fat (but not total fat) intake associated with reduced likelihood of survival [57]. In one study in which selected foods (but not quantified fat intake) were the focus of the analysis [52], energy-adjusted butter, margarine and lard intake was directly associated with risk for recurrence but not with risk of death. Nine of the 14 follow-up studies of diet composition and breast cancer recurrence or survival examined the associations between intakes of vegetables, fruit or associated micronutrients (e.g., beta-carotene, vitamin C). Three of these studies found a significant positive relationship with survival [56, 57], one found a marginally significant relationship [105], one described a trend for this relationship [36], and one found a protective effect among women with nodenegative disease (who comprised 62% of the total sample) [54]. The magnitude of the effect was a 20–90%

C.L. Rock

reduction in risk for death in those with higher versus lower intakes in the studies that found a beneficial effect for vegetables, fruit and associated micronutrients. Eight of the 14 follow-up studies of diet composition and recurrence or survival reported between 1985 and 2002 specifically examined associations with fiber intake. None of these studies found a significant effect of quantified fiber intake on risk for recurrence or survival, although the point estimates in one study suggest a protective effect [53]. Results from studies that examined relationships between intakes of high-fiber foods (e.g., vegetables, fruit, cereal-grain products) and risk for recurrence or survival are somewhat more supportive. Three (out of a total of four) of these studies found a protective effect of vegetable intake at least at a level of marginal significance in the major subgroups examined [36, 54, 56], and one found bread and cereal intake to be significantly associated with reduced risk for recurrence but not with risk of death [111]. Notably, findings from these observational studies of dietary factors and survival suggest that alcohol intake has no effect on survival. Of the eight of 13 studies that examined this relationship, none found a significant relationship, and a nonsignificant inverse association was observed in only one of them [36]. Several studies have examined selected aspects of dietary intakes and risk for recurrence and survival in women following the diagnosis of breast cancer. Sellers et al. [114] examined the association between folate intake and survival in 177 breast cancer cases treated with chemotherapy, testing the hypothesis that high folate intake could reduce the effectiveness of chemotherapy. Those investigators found no adverse effects of high folate intake on survival through 14 years of follow-up after chemotherapy for breast cancer. Using dietary data collected from 477 women at diagnosis of breast cancer, Goodwin et al. [45] explored whether nonlinear, rather than linear, relationships explained associations between intakes of macronutrients and survival. Indeed, their results suggest an association that may be U-shaped, with midrange intakes of energy-adjusted fat, protein, and carbohydrate intake associated with the most favorable outcomes. Results from studies that have examined the effects of combined dietary and other lifestyle factors indicate potential effects on breast cancer recurrence and/or survival in that context. Kroenke et al. [65] found that

26 Nutrition in the Management of the Cancer Patient

a prudent dietary pattern (high in fruits, vegetables, whole grains, legumes, poultry, and fish) was associated with a 15% reduction in relative risk of overall mortality, and death from causes other than breast cancer (but not breast cancer mortality), when compared with a Western dietary pattern (characterized by refined grains, processed and red meats, desserts, high-fat dairy products, and French fries). In another cohort, the combination of consuming at least five servings/day of fruits and vegetables plus a level of physical activity equivalent to walking 30 minutes six days/week was associated with a 50% reduction in mortality in breast cancer survivors over 7-year follow-up [87], although both of these factors were not significantly protective alone. Women who are breast cancer survivors report a high frequency of use of dietary supplements, with estimates suggesting that the majority (approximately 81%) use dietary supplements regularly [84]. The relationship between use of antioxidant supplements and risk of breast cancer recurrence or survival was examined using data on dietary intakes and supplement use in 385 postmenopausal women who had been diagnosed with breast cancer [39]. Premorbid dietary intakes of vitamin C or vitamin E from diet, supplements or both showed no relationship with risks. During the follow-up period, antioxidant supplement use was reassessed, and use of these supplements was not significantly related to outcome when adjusted for other influencing factors. However, vitamin E supplements had a modest but nonsignificant protective effect when used for more than three years (odds ratio 0.33, 95% CI 0.10–1.07). Given the limitations of diet assessment methodologies and self-reported dietary data [121], follow-up studies based on biomarkers of diet from blood samples collected prior to disease onset and treatment, or following the completion of initial treatments, would be very informative. Only one such study has been reported to date, and the study involved examination of only two biomarkers in plasma samples collected after diagnosis but prior to surgery or adjuvant therapy. In that study [110], 317 cases were followed for a median of eight years post-diagnosis. An increased risk of recurrence was observed in patients with plasma lipoperoxide concentrations, which may be a biomarker for polyunsaturated fat intake, in the highest versus lowest tertile (RR 2.1, 95% CI 1.1–4.0), adjusted for age at diagnosis, menopausal status, and

481

ER and progesterone receptor (PR) status. Adjusted for cholesterol concentration, as an indicator of the size of the plasma pool, plasma alpha-tocopherol concentration >22 umol/L (versus those with lower plasma concentrations) was found to be directly associated with an increased risk for death (adjusted RR 1.7, 95% CI 1.0–3.0) in that study. Thus, findings from observational epidemiological studies provide some evidence, although not entirely consistent, that there may be a relationship between dietary factors and survival following the diagnosis of breast cancer. Several mechanisms have been suggested to explain a possible effect of dietary factors, such as fat, fiber and vegetable intake, on breast cancer progression. Results from several feeding studies and short-term diet interventions involving healthy preand postmenopausal women have suggested that a lowfat diet may reduce serum estrogen concentrations, as summarized in a meta-analysis conducted by Wu et al. [130]. However, weight loss occurred in response to reduced fat intake in those studies in which a reduction in serum estrogen concentrations was observed, so dietary fat intake per se cannot be assumed to be the primary influencing factor. Other proposed mechanisms for an effect on fat intake on breast cancer progression include changes in phospholipid composition and fluidity of tumor cell and/or host immune cell membranes, changes in circulating gonadal hormone bioavailability, altered prostaglandin and leukotriene production, altered dynamics of fatty acid/growth factor interactions, and altered regulatory gene expression [19, 131]. In animals, high-fiber diets have been shown to reduce circulating estrogen concentrations via increased fecal excretion of these hormones [4], and high-fiber foods are good sources of other dietary constituents that may influence mammary carcinogeneis (e.g., indoles, isoflavones) [26]. Vegetables are among the primary dietary sources of carotenoids, and in cell culture studies, both retinoids (a product of carotenoids) and carotenoids have been shown to enhance cellular differentiation and to have marked inhibitory effects on mammary cell growth [95]. Both ER-positive and ER-negative mammary cancer cell lines are highly responsive to the beneficial cell growth regulatory effects of both vitamin A precursor and nonvitamin A precursor carotenoids [92, 119]. Another possible effect of dietary intakes on breast cancer progression relates to oxidative stress, because a diet

482

with large amounts of antioxidants could theoretically reduce the risk for breast cancer by protecting against DNA damage and other free-radical-induced cellular changes that would promote mammary carcinogenesis. Vegetables and fruit provide numerous antioxidants, including flavonoids, vitamin C, and carotenoids. Two large randomized controlled trials have tested whether diet modification following the diagnosis of early stage breast cancer affects cancer outcomes. The Women’s Intervention Nutrition Study (WINS) tested a low-fat diet (<15% of kcal) in 2,437 postmenopausal women with early stage breast cancer [22]). With a median follow-up of five years, the WINS intervention resulted in a difference in dietary fat intake (33.3 versus 51.3 g fat/day in the intervention versus control groups at year one), which was associated with modest weight loss (averaging 2.7 kg) and 24% reduction in new breast cancer events in the intervention group, although a stronger protective effect (42% reduction) was observed in the subgroup of women with estrogen receptor-negative tumors. The Women’s Healthy Eating and Living (WHEL) Study tested the effect of a diet very high in vegetables, fruit, and fiber and low in fat (20% of kcal) on prognosis in 3,088 preand postmenopausal breast cancer survivors who were followed for an average of 7.3 years [86, 88]. At baseline, the WHEL Study participants reported an average intake of 7.3 servings/day of vegetables and fruit, which averaged 9.2 in the intervention group and 6.2 in the control group at six years. Recurrence-free survival did not differ across the two study arms. In that study, serum estrogen at baseline was found to be independently associated with poor prognosis [102], and a protective effect of the diet was observed in the subgroup of women who did not report hot flashes at enrollment [41]. These findings suggest that reproductive hormonal status may determine whether a highvegetable, fruit and fiber diet may improve prognosis. Another interesting finding from the WHEL Study was that total exposure to carotenoids over the course of the study, which was largely determined by the level at enrollment, was associated with breast cancer-free survival regardless of study group assignment [103]. Thus, diet over the long-term and prior to the diagnosis of cancer, rather than a marked change after diagnosis, may be the more important factor that influences risk for recurrence and likelihood of survival.

C.L. Rock

26.4.2 Nutritional Factors and Survival in Prostate Cancer Two follow-up studies of nutritional factors and survival after the diagnosis of prostate cancer have been conducted, and the relationships between survival and relative body weight and selected dietary factors were addressed in these studies. Meyer et al. [81] prospectively followed 384 men diagnosed with prostate cancer, with a median duration of follow-up of 5.2 years. Adjusted for known prognostic factors and energy intake, saturated fat consumption was significantly inversely associated with disease-specific survival in that study (RR 3.1, 95% CI 1.3–1.7 for men in the highest tertile compared with those in the lowest tertile of saturated fat intake). BMI and intakes of total, monounsaturated and polyunsaturated fat were not found to be related to risk of dying from prostate cancer in that study, and relationships with survival and other dietary factors were not examined or reported. In a group of 408 men diagnosed with prostate cancer who were followed for a median of 4.9 years, Kim et al. [62] found an inverse association between intake of monounsaturated fat and risk of death for prostate cancer (RR 0.3, 95% CI 0.1–0.7), but no significant relationships between survival and intakes of total fat, saturated fat, polyunsaturated fat, vitamin A or beta-carotene, or BMI, were observed. More recently, Chan et al. [16] found protective effects of intakes of fish (HR 0.73, 95% CI 0.52–1.02) and tomato sauce (HR 0.56, 95% CI 0.38 – 0.82) in the post-diagnostic dietary intakes in a cohort of men with prostate cancer. Although obesity has not been linked with risk of cancer death in men diagnosed with prostate cancer, obesity was linked with increased risk of biochemical recurrence in 1,106 men treated with radical prostatectomy [40]. The effects of supplemental vitamin E and selenium, singly or in combination, on the incidence of primary prostate cancer has been tested in a randomized controlled trial [63], the Selenium and Vitamin E Cancer Prevention Trial (SELECT). The rationale for this study was based in part on protective effects of vitamin E and selenium supplementation on risk for primary prostate cancer that were observed in prior studies that were designed to focus on the prevention of other cancers [24, 121]. In the study in

26 Nutrition in the Management of the Cancer Patient

which vitamin E supplementation was associated with a reduced risk for primary prostate cancer, the survival of the men in whom prostate cancer developed during the study was not affected by the use of vitamin E supplements (The Alpha Tocopherol, Beta Carotene Prevention Study Group 1994). SELECT was designed to test whether selenium (200 ug/d l-selenomethionine) and/or vitamin E (400 mg/d dl-αtocopherol) on prostate cancer incidence in >35,000 men enrolled at >400 sites in the U.S. In 2008, the active treatment (supplementation) in this trial was halted because the supplements, taken alone or together for an average of five years, did not prevent prostate cancer. The study was designed to detect a 25% reduction in prostate cancer, and it was evident that effect was unlikely to be achieved even with continuation of treatment, based on the data examined at the five-year time point. Further, there were two findings that caused some concern, although these findings were not statistically significant. Slightly more cases of prostate cancer in men taking only vitamin E and slightly more cases of diabetes in men taking only selenium were observed. Most of the men enrolled in SELECT are to be followed for about three more years, so that their health status can be monitored. In a few small studies, the short-term effects of selected dietary constituents on various metabolic factors have been examined in men who had been diagnosed with prostate cancer. In response to three weeks of daily tomato sauce feeding (which provided 30 mg lycopene/day), a reduction in prostate tissue oxidative DNA damage and serum prostatespecific antigen (PSA) concentration was observed in 32 men with localized prostate adenocarcinoma preceding their scheduled radical prostatectomy [17]. In a small randomized clinical trial involving 26 men with clinically localized prostate cancer, the effect of administering 15 mg lycopene/day for three weeks prior to radical prostatectomy on biomarkers of cellular differentiation and apoptosis was examined [66]. Changes in the various biomarkers were not significantly different in the intervention versus control groups in that study. The effects of dietary fat restriction (<20% of energy) and flaxseed supplementation were examined in another study involving 25 patients with prostate cancer, and results were compared with matched historic cases [30]. A reduction in serum

483

testosterone concentration was observed in the intervention group, and cellular proliferation rate and apoptosis were significantly associated with the number of days on the diet. Findings from these small studies involving patients with prostate cancer are interesting, but the small sample sizes and limitations in study design constrain the interpretation of these observations. Similar to breast cancer, prostate cancer is a hormone-related cancer, and the proposed mechanisms by which nutritional factors may influence disease progression are similar to those suggested for breast cancer. A reduction in circulating testosterone and/or improved antioxidant status, via increased tissue lycopene and alpha-tocopherol concentrations, are the primary mechanisms that have been suggested. Available data from epidemiological studies do not suggest that obesity is associated with prognosis in prostate cancer, and the evidence for a relationship with fat intake is inconsistent. However, the data are very limited at this time, which limits the ability to develop recommendations or conclusions. Notably, however, cardiovascular disease is a major cause of death for prostate cancer survivors, so a prudent recommendation for this target population to reduce saturated fat intake and increase intake of vegetables and fruit [10].

26.4.3 Nutritional Factors and Survival in Colorectal Cancer The relationship between selected nutritional factors and survival following the diagnosis of colorectal cancer has been examined in two epidemiological studies. Tartter et al. [120] conducted a retrospective review of 279 patients who had undergone resection for newly diagnosed adenocarcinoma of the color or rectum. Adjusted for stage at diagnosis, patients at or below the median weight for the group had significantly lower risk for recurrence than patients who were above the median weight (53% versus 75%, respectively, P < 0.01). The relationship with BMI and survival was similar, although not statistically significant. Dietary data were not collected or analyzed in that study. In a more recent and larger study, Slattery et al. [116] examined the relationship between survival and

484

BMI and selected dietary factors in a group of 815 postmenopausal women who had been diagnosed with colon cancer in an analysis that was focused on the effect of using hormone replacement therapy (HRT). Women with a low BMI were less likely to die of colon cancer during the follow-up period if they used HRT than were those with higher BMI (hazard rate ratio [HRR] 0.5, 95% CI 0.4–1.0). Also, women who used HRT had a lower probability of dying from colon cancer if they reported high levels of dietary folate intake (HRR 0.5, 95% CI 0.3–0.9). Significant relationships with intakes of energy, fiber, and alcohol and disease-specific survival were not observed in that study. Several randomized studies have tested whether various nutritional factors can modify the risk for recurrence of colorectal adenoma, which is an established and relevant preneoplastic lesion. Results of these studies are summarized in Table 26.3. Based on the strength of the early epidemiological evidence linking higher intakes of beta-carotene and antioxidant vitamins to lower risk for primary colorectal cancer, two large randomized controlled trials tested the effect of beta-carotene supplementation (with or without vitamin E and vitamin C, or modified fat and fiber intakes) on the risk for recurrence of adenomatous polyps [47, 73]. A significant beneficial effect of beta-carotene supplementation or other dietary factors that were targeted for modification was not observed in either of these trials. Results of three studies that examined whether fiber supplementation (wheat bran, ispaghula fiber, or high-wheat bran fiber cereal) could influence colorectal adenoma recurrence consistently identified no beneficial effect [2, 7, 73]. In contrast, calcium supplementation at a dose of 1200 mg elemental calcium/day was shown to result in a modest reduction in risk for adenoma recurrence (RR 0.81, 95% CI 0.67– 0.99) in one randomized clinical trial [5]. Although not achieving statistical significance, similar beneficial findings were observed in another randomized trial involving calcium supplementation [7]. The Polyp Prevention Trial (PPT) was a large multicenter study that aimed to test the effect of multifaceted diet modification on the recurrence of colorectal adenomas. In the PPT, 2,079 men and women with a history of adenomatous polyps were randomized to the diet intervention arm or control arm [112]. The goals of the intervention were a diet low in fat (<20% of energy), high in fiber (18 g/1000 kcal/day), and high

C.L. Rock

in vegetables and fruit (3.5 servings/1000 kcal/day). At study end, the intervention group had increased vegetable and fruit intake by an average of 1.1 servings/1000 kcal/day, and average reported intake of total carotenoids increased on average approximately 50% [112]. However, total plasma carotenoids were increased by only 5% on average in the intervention group at study end, which is considerably lower than has been observed in response to high-vegetable and fruit diet interventions in other studies [97, 100], including a high vegetable and fruit diet intervention study aimed toward a similar population [117]. No effect on adenoma recurrence was observed in the PPT, when analyzed on the basis on study group assignment. However, the limited effect of the intervention on circulating carotenoids suggests that this study may not have adequately tested the effect of a high-vegetable and fruit intake. The mechanisms by which dietary fiber has been proposed to influence colorectal cancer progression include increased fecal bulk (which dilutes the concentrations of carcinogens in the feces), altered bacterial composition in the colon, promotion of structural and functional changes in the gut mucosa, and decreased fecal bile acid concentration [91]. Fecal secondary bile acids have a tumor-promoting effect in the large bowel, and certain fibers can bind cytotoxic bile acids and also reduce the concentration of these tumor promoters. Other dietary constituents exhibit other potentially beneficial effects on colon tissue. For example, calcium reduces epithelial cell proliferation, folate affects DNA methylation, and antioxidant constituents of vegetables and fruit may reduce oxidative damage to DNA and lipids [91, 118]. Based on limited epidemiological data, evidence suggests the possibility that obesity or overweight may be associated with reduced likelihood of survival in patients who have been diagnosed with colorectal cancer. However, more epidemiological and clinical studies are needed to confirm this observation. Although data from calcium supplementation trials suggest the possibility of beneficial effects of this strategy at the preneoplastic stage of colon carcinogeneis, the relevance of studies targeting adenoma recurrence may or may not be applicable to long-term survival in the individual who has been diagnosed with a clinical colorectal cancer. Most adenomas do not develop into colon cancer, and the point at which the most important and modifiable molecular changes relevant to the

3 years

4 years

3 years

2000 mg/day elemental calcium, 3–5 g/day ispaghula husk

Reduced fat (20% energy), increased fiber (18 g/1000 kcal), and increased fruits and vegetables (3.5 svgs/1000 kcal)

13.5 g/day or 2 g/day wheat bran fiber

Random assignment to three treatment arms, including placebo, in parallel design

Randomly assigned to two groups: diet intervention group or standard care with advice to follow usual diet

Randomly assigned to receive high-fiber or low-fiber cereal supplement

2–4 years

4 years

4 years

25 mg/day beta-carotene, 1 g/day vitamin C, 400 mg/day vitamin E 20 mg/day beta-carotene, reduce fat to <25% energy, 25 g/day wheat fiber

1200 mg/day elemental calcium

Randomly assigned to receive calcium carbonate or placebo

Factorial design (2 × 2, dietary fat reduction, wheat bran fiber, and beta-carotene)

Factorial design (2 × 2, beta-carotene, vitamin C and vitamin E)

confidence interval, OR odds ratio, RR risk ratio

1429 men and women with a history of colorectal adenomas

Alberts et al. [2]

a CI

2079 men and women with a history of colorectal adenomas

930 men and women with a recent history of colorectal adenomas 665 patients with a history of colorectal adenomas

864 men and women with an adenomatous polyp diagnosed within 3 months and removed 306 men and women with a history of adenomatous polyps that were removed

Schatzkin et al. [112]

Bonithon-Kopp et al. [7]

Baron et al. [5]

MacLennan et al. [73]

Greenberg et al. [47]

No difference in incident adenomas in high-fiber versus low-fiber cereal group

Adjusted RR for new adenoma was 0.81 (95% CI 0.67 – 0.99) in the calcium arm Adjusted OR for recurrence was 0.66 (95% CI 0.38 – 1.17, P = 0.03) for calcium group and 1.67 (95% CI 1.01 – 2.76, P = 0.042) for ispaghula husk group No treatment effect on recurrence

No treatment effect of beta-carotene, vitamin C or vitamin E on incidence of new adenomatous polyps No treatment effect of beta-carotene, fat reduction or wheat bran fiber on total incidence of new adenomatous polyps; wheat bran plus low-fat diet reduced incidence of large adenomas (P = 0.03)

Table 26.3 Randomized controlled trials testing the effect of nutritional factors on recurrence of colorectal adenomatous polypsa Subjects and key Years of Study characteristics Intervention Dosage or dietary goals follow-up Key findings

Self-reported dietary data suggest that goals were nearly achieved (averaging 24% energy from fat, 17 g/1000 kcal fiber, 3.4 svgs/1000 kcal fruits and vegetables), dietary biomarker (serum carotenoids) changed minimally in the intervention group

Supplementation with fiber as ispaghula husk may have adverse effects, while calcium effect was modestly beneficial but not statistically significant

Beta-carotene associated with nonsignificant higher incidence of new polyps (OR 1.5, 95% CI 0.9–2.5) and large adenomas (OR 2.4, 95% CI 0.8–7.0), and fewer adenomas with moderate or severe dysplasia (OR 0.6, 95% CI 0.2–1.6)

Comments

26 Nutrition in the Management of the Cancer Patient 485

486

biological activities of the various dietary constituents that have been tested has not been established.

26.4.4 Nutritional Factors and Survival in Other Cancers Based on consistent evidence from laboratory animal studies, and clinical studies that have demonstrated beneficial effects on preneoplastic lesions for cancers of the oral cavity, pharynx and larynx, beta-carotene has been the primary dietary factor considered to have a potentially protective effect on progression of these cancers (reviewed in [74]). The primary proposed mechanisms include antioxidant activity and promotion of normal cell growth regulation. To date, one placebo-controlled trial testing the effect of betacarotene supplementation on recurrence and survival in 264 men and women with a recent history of head and neck cancer has been conducted [75]. Study participants received 50 mg beta-carotene/day or placebo and were followed for a median of approximately four years. The intervention had no effect on risk for the primary outcome, which was second primary tumors plus local recurrences (RR 0.90, 95% CI 0.56–1.45), and no effect on total mortality was observed (RR 0.86, 95% CI 0.52–1.42). Other endpoints examined were second head and neck cancer (RR 0.69, 95% CI 0.39–1.25) and lung cancer, a common site of second primary cancer in these individuals (RR 1.44, 95% CI 0.62–3.39). Although the point estimate for head and neck cancer was in the direction of benefit, the effect was not statistically significant. Results from early observational epidemiological studies have suggested that carotenoids could have a role in the prevention of skin cancer, so a trial testing the effect of beta-carotene on skin cancer recurrence was conducted [46]. The randomized placebocontrolled trial tested the effect of beta-carotene supplementation on recurrent nonmelanoma skin cancer in 1,805 men and women with a history of basal cell and squamous cell cancers of the skin. Study subjects were administered 50 mg/day beta-carotene or placebo and were followed for five years, but no beneficial effects of supplementation were observed. The relationship between nutritional factors and survival following the diagnosis of cervical cancer has

C.L. Rock

not been reported or investigated in epidemiological or clinical studies. However, evidence from laboratory and epidemiological studies have suggested that dietary factors, especially carotenoids, vitamin C and folate, could contribute to the risk for persistent human papilloma virus (HPV) infection and progression of neoplasia to cervical cancer through many mechanisms, including effects on immune function and the promotion of normal cell growth regulation (reviewed in [99]. Several studies have examined the effect of intervention on progression of cervical dysplasia, an established and relevant preneoplastic lesion. Based on the strength and consistency of earlier observational studies, five randomized controlled trials testing whether beta-carotene supplements could increase the rate of regression of cervical dysplasia were conducted [31, 38, 61, 72, 106]. As shown in Table 26.4, none of these studies found a beneficial effect of betacarotene and/or vitamin C supplementation compared with placebo. Additionally, two randomized placebocontrolled studies tested whether folic acid supplementation could promote regression of cervical dysplasia, and neither of these studies demonstrated any benefits [12, 18]. A better test of the associations observed in epidemiological studies, in which the nutrients that are consumed are from food rather than supplements, involves testing the effect of a high vegetable and fruit diet, which would provide the various carotenoids in addition to other micronutrients (e.g., vitamin C, folate). In a randomized clinical trial testing this strategy, 150 women with cervical dysplasia were enrolled and randomized to a diet intervention arm or control arm and followed for one year [100]. The diet intervention efforts resulted in a substantial increase in plasma carotenoid and peripheral tissue concentrations, with plasma concentrations of total carotenoids increasing nearly two-fold in the intervention group. This study was recently completed, and analysis of response is currently underway. An important issue in the interpretation of clinical trials targeting women with cervical dysplasia is that the stage at which carotenoids may influence the progression of cervical cancer is unknown. In vitro studies suggest that carotenoids can induce growth retardation in cervical dysplasia cell lines and apoptosis in HPVinfected cells [83]. However, diet may have a more meaningful clinical effect earlier in the HPV exposure and infection process, and thus, the earlier part of the

103 women diagnosed with CIN II and III

Keefe et al. [61]

Compared placebo to beta-carotene

Factorial design (2 × 2, beta-carotene and vitamin C)

hazard ratio, HPV human papillomavirus, NS not significant

141 women diagnosed with atypia, CIN I

a HR

Compared placebo to beta-carotene

Compared placebo to folic acid

Compared placebo to folic acid

Compared placebo to beta-carotene

69 women diagnosed Compared placebo to with CIN I, II and III beta-carotene

331 women with atypia, mild or moderate CIN 111 women diagnosed with atypia, HPV, CIN I and II

278 women diagnosed with CIN I, II, and III 235 women diagnosed with CIN I or II

Mackerras et al. [72]

Romney et al. [106]

Fairley et al. [38]

Childers et al. [18]

Butterworth et al. [12]

De Vet et al. [31]

30 mg/day beta-carotene

30 mg/day betacarotene, 500 mg/ day vitamin C

30 mg/day beta-carotene

30 mg/day beta-carotene

5 mg/day folic acid

10 mg/day folic acid

10 mg/day beta-carotene

2 years

2 years

9 months

12 months

6 months

6 months

3 months

Overall regression rate was similar between treatment groups

Regression rate was nonsignificantly higher in those randomized to beta-carotene (HR 1.58, 95% CI 0.86, 2.93, P = 0.14)

No difference in the regression rate, cervical cytology or the amount of HPV DNA present No effect on regression and progression

No difference in study groups for dysplasia status, biopsy results, or HPV type 16 infection No effect on regression or progression

No effect on regression and progression

Table 26.4 Randomized controlled trials of nutritional factors and regression of cervical intraepithelial neoplasia (CIN)a Months or Subjects and key years of Study characteristics Intervention Dosage follow-up Key findings Comments

Outcome analysis adjusted for severity of CIN and type-specific persistent HPV infection and continual HPV infection with a high viral load at baseline and 9 months Possible interaction effect of beta-carotene and vitamin C (P = 0.052), with 7 of the progressed lesions in those receiving both supplements versus a total of 6 in the other three study groups CIN regression was negatively correlated with serum retinol concentrations

Dietary beta-carotene included in secondary analysis (NS)

26 Nutrition in the Management of the Cancer Patient 487

488

C.L. Rock

Table 26.5 American cancer society recommendations for practice [68] Clinical recommendation Maintain a healthy weight throughout life • Balance caloric intake with physical activity • Avoid excessive weight gain throughout the lifecycle • Achieve and maintain a healthy weight if currently overweight or obese Adopt a physically active lifestyle. • Adults: engage in at least 30 minutes of moderate-to-vigorous physical activity, above usual activities, on five or more days of the week (45–60 min of intentional physical activity are preferable). • Children and adolescents: engage in at least 60 min/day of moderate-to-vigorous physical activity at least 5 days/week. Limit screen time (TV, computer, games) to no more than 2 h per day. Consume a healthy diet, with an emphasis on plant sources • Choose foods and beverages in amounts that achieve and maintain a healthy weight. • Eat five or more servings of a variety of vegetables and fruits each day. • Choose whole grains in preference to processed (refined) grains. • Limit consumption of processed and red meats. If you drink alcoholic beverages, limit consumption (no more than one drink/day for women or two drinks/day for men).

Table 26.6 World cancer research fund/American institute for cancer research persona recommendations [129] Guideline Personal recommendations Be as lean as possible within the normal range of body weight Be physically active as part of everyday life

Limit consumption of energy-dense foods; avoid sugary drinks Eat mostly foods of plant origin

Limit intake of red meat and avoid processed meat Limit alcoholic drinks Limit consumption of salt; avoid mouldy cereals (grains) or pulses (legumes) Aim to meet nutritional needs through diet alone Mothers to breastfeed; children to be breastfed Cancer survivors should follow the recommendations for cancer prevention

Ensure that body weight through childhood and adolescent growth projects toward the lower end of the normal BMI range at age 21 Maintain body weight within the normal range from age 21 Avoid weight gain and increases in waist circumference throughout adulthood Be moderately physically active, equivalent to brisk walking, for at least 30 min each day As fitness improves, aim for 60 min or more of moderate, or for 30 min or more of vigorous, physical activity every day Limit sedentary habits such as watching television Consume energy-dense foods sparingly Avoid sugary drinks Consume fast foods sparingly, if at all Eat at least five portions/servings (at least 400 g or 14 oz) of a variety of non-starchy vegetables and of fruits every day Eat relatively unprocessed cereals (grains) and/or pulses (legumes) with every meal Limit refined starchy foods People who consume starchy roots or tubers as staples also to ensure intake of sufficient non-starchy vegetables, fruits, and pulses (legumes) People who eat red meat to consume less than 500 g (18 oz) a week, very little if any to be processed If alcoholic drinks are consumed, limit consumption to no more than two drinks a day for men and one drink a day for women Avoid salt-preserved, salted, or salty foods; preserve foods without using salt Limit consumption of processed foods with added salt to ensure an intake of less than 6 g (2.4 g sodium) a day Do not eat mouldy cereals (grains) or pulses (legumes) Dietary supplements are not recommended for cancer prevention Aim to breastfeed infants exclusively up to six months and continue with complementary feeding thereafter All cancer survivors to receive nutritional care from an appropriately trained professional If able to do so, and unless otherwise advised, aim to follow the recommendations for diet, healthy weight, and physical activity

26 Nutrition in the Management of the Cancer Patient

continuum may be a more appropriate target for intervention. Also, the spontaneous regression rate for this condition typically falls in the range at which the number of subjects needed to detect a treatment effect is very high. Several epidemiological studies have examined the relationships between nutritional factors and risk for ovarian cancer, and results have suggested the possibility that dietary factors may influence risk for primary cancer [108]. To date, one epidemiological study has examined the relationship between dietary intakes and survival following the diagnosis of ovarian cancer. In a cohort of 609 women with invasive ovarian cancer, improved five-year survival was observed for women who reported a higher intake of vegetables (hazard ratio [HR] 0.75, 95% CI, 0.57–0.99 for highest versus lowest tertile). Cruciferous vegetables, in particular, were associated with greater likelihood of survival (HR 0.0.76, 95% CI 0.57–0.98 for highest versus lowest tertile). As a hormone-related cancer, ovarian cancer progression could theoretically be influenced by several constituents of vegetables that influence the metabolism of reproductive gonadal hormones, including dietary fiber and factors that influence activities of P450s and other metabolizing enzymes (e.g., indole-3carbinol). Given the limited data that are available, the general consensus is that the nutritional recommendations for cancer prevention are appropriate for post-diagnosis cancer survivors, as a strategy that may reduce risk for recurrence and comorbid diseases [34, 101]. These recommendations, as summarized in Tables 26.4, 26.5 and 26.6 are to achieve and maintain a healthy body weight, and to eat a diet that emphasizes vegetables, fruit, whole grains, legumes and other plant foods. The diet should include low-fat (rather than high-fat) dairy foods and protein-rich foods that are low in saturated fat (such as nuts, legumes, and fish) rather than high-saturated fat choices from beef, pork and other animal foods [68]. Also, these guidelines are consistent with the current guidelines for the prevention and treatment of other common comorbid diseases, such as cardiovascular disease and type 2 diabetes. With the exception of calcium supplementation to prevent the recurrence of adenomatous polyps, studies to date that have involved dietary supplements have not generally demonstrated beneficial effects on cancer progression, so that particular strategy of nutrition intervention is not well-supported by current evidence.

489

26.5 Summary and Conclusions Nutritional care and guidance are important aspects of the management of the cancer patient across the continuum from the immediate post-diagnosis period of initial treatment and recovery through long-term survival. Cancer is a major health problem around the world, and currently, one of every four deaths in the U.S. is due to cancer [59]. Nutritional assessment and monitoring of patients across the continuum of care is a first step toward identifying individuals and circumstances for which evidence suggests potential benefits of nutrition intervention. Incorporating nutritional care into the management of the cancer patient contributes to increased quality and/or quantity of life for the millions of individuals who are diagnosed with cancer each year. The specific advice and modality of nutrition intervention utilized varies considerably across patients, situations and in consideration of other influencing factors. In the initial phases of treatment and recovery, meeting nutritional needs and maintaining good nutritional and functional status are usually the primary areas of focus. Following completion of initial treatments, nutritional strategies that may reduce risk for recurrence and increase likelihood of survival become important priorities. Current dietary recommendations for cancer survivors are the same as those for cancer prevention, which emphasize achieving and maintaining a healthy weight through diet and exercise, and eating a diet rich in vegetables, fruit and whole grains, with limited intakes of processed and red meat and alcohol.

References 1. Adachi Y, Suematsu T, Shiraishi N, Katsuta T, Morimoto A, Kitano S et al (1999) Quality of life after laparoscopyassisted Billroth I gastrectomy. Ann Surg 229:49–54 2. Alberts DS, Martinez ME, Roe DJ, Guillen-Rodriguez JM, Marshall JR, van Leeuwen JB, et al (2000) Lack of effect of a high-fiber cereal supplement on the recurrence of colorectal adenomas. N Engl J Med 342:1156–1162 3. American College of Physicians (1989) Parenteral nutrition in patients receiving cancer chemotherapy. Ann Intern Med 110:734–736 4. Arts CJ, Thijssen JH (1992) Effects of wheat bran on blood and tissue hormone levels in adult female rats. Acta Endocrinologica 127:271–278

490 5. Baron JA, Beach M, Mandel JS, van Stolk RU, Haile RW, Sandler RS et al (1999) Calcium supplements for the prevention of colorectal adenomas. N Engl J Med 340:101–107 6. Bines J, Gradishar WJ (1997) Primary care issues for the breast cancer survivor. Comprehensive Therapy 23: 605–611 7. Bonithon-Kopp C, Kronborg O, Glacosa A, Rath U, Faivre J, for the European Cancer Prevention Organisation Study Group (2000) Calcium and fibre supplementation in prevention of colorectal adenoma recurrence: a randomized intervention trial. Lancet 356:1300–1306 8. Branda RF, Nigels E, Lafayette AR, Hacker M (1998) Nutritional folate status influences the efficacy and toxicity of chemotherapy in rats. Blood 92:2471–2476 9. Brody JJ (1999) The syndrome of anorexia-cachexia. Curr Opin Oncol 11:255–260 10. Brown BW, Brauner C, Minnotte MC (1993) Noncancer deaths in white adult cancer patients. J Natl Cancer Inst 85:979–997 11. Brown ML, Riley GF, Potosky AL, Etzioni RD (1999) Obtaining long-term disease specific costs of care: application to medicare enrollees diagnosed with colorectal cancer. Med Care 37:1249–1259 12. Butterworth CE, Hatch KD, Soon SJ, Cole P, Tamura T, Sauberlich HE et al (1992) Oral folic acid supplementation for cervical dysplasia: a clinical intervention trial. Am J Obstet Gynecol 166:803–809 13. Caan BJ, Emond JA, Natarajan L, Castillo A, Gunderson EP, Habel L et al (2006) Post diagnosis weight gain and breast cancer recurrence in women with early stage breast cancer. Breast Cancer Res Treat 99:47–57 14. Camoriano JK, Loprinzi CL, Ingle JN, Therneau T, Krook J, Veeder M (1990) Weight change in women treated with adjuvant therapy or observed following mastectomy for node-positive breast cancer. J Clin Oncol 8:1327–1334 15. Cangiano C, Laviano A, Muscaritoli M, Meguid MM, Cascino A, Fanfelli FR (1996) Cancer anorexia: new pathogenic and therapeutic insights. Nutrition 2(suppl):S41–S51 16. Chan JM, Holick CN, Leitzmann MF, Rimm EB, Willett WC, Sampfer MJ et al (2006) Diet after diagnosis and the risk of prostate cancer progression, recurrence, and death (United States). Cancer Causes Control 17:199–208 17. Chen L, Stacewicz-Sapuntzakis M, Duncan C, Sharifi R, Ghosh L, van Breemen R et al (2001) Oxidative DNA damage in prostate cancer patients consuming tomato sauce-based entrees as a whole-food intervention. J Natl Cancer Inst 93:1872–1879 18. Childers JM, Chu J, Voigt LF, Feigl P, Tamimi HK, Franklin EW et al (1995) Chemoprevention of cervical cancer with folic acid: a phase III southwest oncology group intergroup study. Cancer Epidemiol Biomarkers Prevent 4:155–159 19. Chlebowski RT, Rose D, Buzzard IM, Blackburn GL, Insul W, Grosvenor M et al (1991) Adjuvant dietary fat intake reduction in postmenopausal breast cancer patient management. Breast Cancer Res Treat 20:73–84 20. Chlebowski RT, Blackburn GL, Buzzard IM, Rose DP, Martino S, Khandekar D et al (1993) Adherence to a dietary fat intake reduction program in postmenopausal

C.L. Rock

21.

22.

23.

24.

25. 26. 27.

28.

29.

30.

31.

32.

33.

34.

35.

women receiving therapy for early breast cancer. The women’s intervention nutrition study. J Clin Oncol 11:2072–2080 Chlebowski RT, Aiello E, McTiernan A (2002) Weight loss in breast cancer patient management. J Clin Oncol 20:1128–1143 Chlebowski RT, Blackburn GL, Thomson CA, Nixon DW, Shapiro A, Hoy MK et al (2006) Dietary fat reduction and breast cancer outcome: interim efficacy results from the women’s intervention nutrition study. J Natl Cancer Inst 98:1767–1776 Chu K, Tarone R, Kessler LG, Ries LA G, Hankey BF, Miller BA et al (1996) Recent trends in U.S. breast cancer incidence, survival, and mortality rates. J Natl Cancer Inst 88:1571–1579 Clark LC, Combs GF, Turnbull BW, Slate EH, Chalker DK, Chow J et al (1996) Effects of selenium supplementation for cancer prevention in patients with carcinoma of the skin. A randomized controlled trial. J Am Med Assoc 276:1957–1963 Clemons M, Goss P (2001) Estrogen and the risk of breast cancer. N Engl J Med 344:276–285 Cohen LA (1999) Dietary fiber and breast cancer. Anticancer Res 19:3685–3688 Copeland EM (1998) Historical perspective on nutritional support of cancer patients. CA A Cancer J Clinicians 48:67–68 Demark-Wahnefried W, Rimer BK, Winer EP (1997) Weight gain in women diagnosed with breast cancer. J Am Dietetic Assoc 97:519–529 Demark-Wahnefried W, Peterson B, McBride C, Lipkus I, Clipp E (2000) Current health behaviors and readiness to pursue life-style changes among men and women diagnosed with early stage prostate and breast carcinomas. Cancer 88 674–684 Demark-Wahnefried W, Price DT, Polascik TJ, Robertson CN, Anderson EE, Paulson DF et al (2001) Pilot study of dietary fat restriction and flaxseed supplementation in men with prostate cancer before surgery: exploring the effects on hormonal levels, prostatespecific antigen, and histopathologic features. Urology 58: 47–52 De Vet HC W, Knipschild PG, Willebrand D, Schouten HJ, Sturmans FJ (1991) The effect of beta-carotene on the regression and progression of cervical dysplasia: a clinical experiment. Clin Epidemiol 44:273–285 DeWys WD, Begg C, Lavin PT, Band PR, Bennett JM, Bertino JR et al (1980) Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern cooperative oncology group. Am J Med 69:491–497 Djuric Z, DiLaura NM, Jenkins I, Darga L, Jen CK L, Mood D et al (2002) Combining weight-loss counseling with the Weight Watchers plan for obese breast cancer survivors. Obesity Res 10:657–665 Doyle C, Kushi LH, Byers T, Courneya KS, DemarkWahnefried W, Grant B et al (2006) Nutrition and physical activity during and after cancer treatment: an American cancer society guide for informed choices. CA: A Cancer J Clinicians 56:323–353 Endogenous Hormones and Breast Cancer Collaborative Group (2002) Endogenous sex hormones and breast

26 Nutrition in the Management of the Cancer Patient

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

cancer in postmenopausal women: reanalysis of nine prospective studies. J Natl Cancer Inst 94:606–616 Ewertz M, Gillanders S, Meyer L, Zedeler K (1991) Survival of breast cancer patients in relation to factors which affect the risk of developing breast cancer. Int J Cancer 49:526–530 Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults (1998) Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Am J Clin Nutr 68:899–917 Fairley CK, Tabrizi SN, Chen S, Baghurst P, Young H, Quinn M et al (1996) A randomized clinical trial of beta carotene vs placebo for the treatment of cervical HPV infection. Int J Gynecol Cancer 6:225–230 Fleischauer AT, Simonsen N, Arab L (2003) Antioxidant supplements and risk of breast cancer recurrence and breast cancer-related mortality among postmenopausal women. Nutr Cancer 46:15–22 Freedland SJ, Aronson WJ, Kane CJ, Presti JC, Amling CL, Elashoff D et al (2004) Impact of obesity on biochemical control after radical prostatectomy for clinically localized prostate cancer: a report by the shared equal access regional cancer hospital database study group. J Clin Oncol 22:446–453 Gold EB, Pierce JP, Natarajan L, Stefanick ML, Laughlin GA, Caan BJ et al (2009) Dietary pattern influences breast cancer prognosis in women without hot flashes: the women’s healthy eating and living trial. J Clin Oncol 27:352–359 Goodwin PJ, Panzarella T, Boyd NF (1988) Weight gain in women with localized breast cancer – a descriptive study. Breast Cancer Res Treat 11:59–66 Goodwin P, Esplen MJ, Butler K, Winocur J, Pritchard K, Brazel S et al (1998) Multidisciplinary weight management in locoregional breast cancer: results of a phase II study. Breast Cancer Res Treat 48:53–64 Goodwin PJ, Ennis M, Pritchard KI, Trudeau ME, Koo J, Madarnas Y et al (2002) Fasting insulin and outcome in early-stage breast cancer: Results of a prospective cohort study. J Clin Oncol 20:42–51 Goodwin PJ, Ennis M, Pritchard KI, Koo J, Trudeau ME, Hood N (2003) Diet and breast cancer: evidence that extremes in diet are associated with poor survival. J Clin Oncol 21:2500–2507 Greenberg ER, Baron JA, Stukel TA, Stevens MM, Mandel JS, Spencer SK et al (1999) A clinical trial of betacarotene to prevent basal cell and squamous-cell cancers of the skin. N Engl J Med 343:789–795 Greenberg ER, Baron JA, Tosteson TD, Freeman DH, Beck GJ, Bond JH et al (1994) A clinical trial of antioxidant vitamins to prevent colorectal adenoma. N Engl J Med 331:141–147 Gregorio DI, Emrich LJ, Graham S, Marshall JR, Nemoto T (1985) Dietary fat consumption and survival among women with breast cancer. J Natl Cancer Inst 75: 37–41 Hayes DF, Kaplan W (1996) Evaluation of patients after primary therapy. In Harris JR, Lippman ME, Morrow M et al (eds) Diseases of the breas. Lippincott-Raven, Philadelphia, pp 629–648

491 50. Heald AH, Cruickshank JK, Riste LK, Cade JE, Anderson S, Greenhalgh A et al (2001) Close relation of fasting insulin-like growth factor binding protein-1 (IGFBP-1) with glucose tolerance and cardiovascular risk in two populations. Diabetologia 44:333–339 51. Heasman KZ, Sutherland HJ, Campbell JA, Elhakim T, Boyde NF (1985) Weight gain during adjuvant chemotherapy for breast cancer. Breast Cancer Res Treat 5: 195–200 52. Hebert JR, Hurley TG, Ma Y (1998) The effect of dietary exposures on recurrence and mortality in early stage breast cancer. Breast Cancer Res Treat 51:17–28 53. Holm LE, Nordevang E, Hjalmar ML, Lindbrink E, Callmer E, Nilsson B (1993) Treatment failure and dietary habits in women with breast cancer. J Natl Cancer Inst 85:32–36 54. Holmes MD, Stampfer MJ, Colditz GA, Rosner B, Hunter DJ, Willett WC (1999) Dietary factors and the survival of women with breast carcinoma. Cancer 86:826–835 55. Hu, X, Juneja SC, Maihle NJ, Cleary MP (2002) Leptin – a growth factor in normal and malignant breast cells and for normal mammary gland development. J Natl Cancer Inst 94:1704–1711 56. Ingram D (1994) Diet and subsequent survival in women with breast cancer. Br J Cancer 69:592–595 57. Jain M, Miller AB, To T (1994) Premorbid diet and the prognosis of women with breast cancer. J Natl Cancer Inst 86:1390–1397 58. Jebb SA, Osborne RJ, Dixon AK, Bleehen NM, Elia M (1994) Measurements of resting energy expenditure and body composition before and after treatment of small cell lung cancer. Ann Oncol 5:915–919 59. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ (2009) Cancer statistics 2009. CA: A Cancer J Clinicians 59: 225–249 60. Kaaks R, Lukanova A (2001) Energy balance and cancer: the role of insulin and insulin-like growth factor-I. Proc Nutr Soc 60:91–106 61. Keefe KA, Schell MJ, Brewer C, McHale M, Brewster W, Chapman JA et al (2001) A randomized, double blind, Phase III trial using oral beta-carotene supplementation for women with high-grade cervical intraepithelial neoplasia. Cancer Epidemiol Biomarkers Prevent 10:1029–1035 62. Kim DJ, Gallagher RP, Hislop TG, Holowaty EJ, Howe GR, Jain J et al (2000) Premorbid diet in relation to survival from prostate cancer. Cancer Causes Control 11:65–77 63. Klein EA, Lippman SM, Thompson IM, Goodman PJ, Albanes D, Taylor PR et al (2003) The selenium and vitamin E cancer prevention trial. World J Urol 21:21–27 64. Krajcik RA, Borofsky ND, Massardo S, Orentreich N (2002) Insulin-like growth factor I (IGF-I), IGF-binding proteins, and breast cancer. Cancer Epidemiol Biomarkers Prevent 11:1566–1573 65. Kroenke CH, Fung TT, Hu FB, Holmes MD (2005) Dietary patterns and survival after breast cancer diagnosis. J Clin Oncol 23:9295–9303 66. Kucuk O, Sarkar FH, Sakr W, Djuric Z, Pollak MN, Khachik F et al (2001) Phase II randomized clinical trial of lycopene supplementation before radical prostectomy. Cancer Epidemiol Biomarkers Prevent 10:861–868

492 67. Kumar NB, Cantor A, Allen K, Cox CE (2000) Android obesity at diagnosis and breast carcinoma survival: evaluation of the effects of anthropometric variables at diagnosis, including body composition and body fat distribution and weight gain during life span, and survival from breast carcinoma. Cancer 88:2751–2757 68. Kushi LH, Byers T, Doyle C, Bandera EV, McCullough M, Gansler T et al (2006) American Cancer Society guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clinicians 56:254–81 69. Labriola D, Livinston R (1999) Possible interactions between dietary antioxidants and chemotherapy. Oncology (Williston Park) 13:1003–1008; discussion 1008, 1011–1002 70. Langstein H, Norton J (1991) Mechanisms of cancer cachexia. Hematol Oncol Clin N Am 5:103–123 71. Loprinzi CL, Athmann LM, Kardinal CG, O’Fallon JR, See JA, Bruce BK et al (1996) Randomized trial of dietician counseling to try to prevent weight gain associated with breast cancer adjuvant chemotherapy. Oncology 53:228–232 72. Mackerras D, Irwig L, Simpson JM, Weisberg E, Cardona M, Webster F et al (1999) Randomized double-blind trial of beta-carotene and vitamin C in women with minor cervical abnormalities. Br J Cancer 79:1448–1453 73. MacLennan R, Macrae F, Bain C, Battistutta D, Cahpuis P, Gratten H et al (1995) Randomized trial of fat, fiber, and beta carotene to prevent colorectal adenomas. J Natl Cancer Inst 87:1760–1766 74. Mayne ST, Lippman SM (2001) Cancer prevention: diet and chemopreventive agents. Retinoids, carotenoids and micronutrients. In: DeVita VT, Hellman S, Rosenberg SA (eds) Principles and practice of oncology, 6th edn. Lippincott Williams and Wilkins, Philadelphia, pp 575–590 75. Mayne ST, Cartmel B, Baum M, Shor-Posner G, Fallon BG, Briskin K et al (2001) Randomized trial of supplemental beta-carotene to prevent second head and neck cancer. Cancer Res 61:1457–1463 76. McMahon K, Decker G, Ottery F (1998) Integrating proactive nutritional assessment in clinical practices to prevent complications and cost. Semin Oncol 25: 20–27 77. McMahon K, Brown JK (2000) Nutritional screening, assessment, and planning for patients receiving cancer treatment. Semin Oncol Nurs 16:106–112 78. McTiernan A, Ulrich C, Kumai C, Bean D, Schwartz R, Mahlock J et al (1998) Anthropometric and hormone effects of an eight-week exercise-diet intervention in breast cancer patients: results of a pilot study. Cancer Epidemiol Biomarkers Prevent 7:477–481 79. Menashian L, Flam M, Douglas-Paxton D, Raymond J (1992) Improved food intake and reduced nausea and vomiting in patients given a restricted diet while receiving cisplatin chemotherapy. J Am Diet Assoc 92: 58–61 80. Mercadante S (1998) Parenteral versus enteral nutrition in cancer patients: indications and practice. Support Care Cancer 6:85–93

C.L. Rock 81. Meyer F, Bairati I, Shadmani R, Fradet Y, Moore L (1999) Dietary fat and prostate cancer survival. Cancer Causes Control 10:245–251 82. Mogul HR, Marshall M, Frey M, Burke HB, Wynn PS, Wiilker S et al (1996) Insulin like growth factorbinding protein-1 as a marker for hyperinsulinemia in obese menopausal women. J Clin Endocrinol Metabol 81:4492–4495 83. Muto Y, Fujii J, Shidoji Y, Moriwaki H, Kawaguchi T, Noda T (1995) Growth retardation in human cervical dysplasia-derived cell lines by beta-carotene through down regulation of epidermal growth factor receptor. Am J Clin Nutr 62(suppl) 1535S–1540S 84. Newman V, Rock CL, Faerber S, Flatt SW, Wright FA, Pierce JP (1998) Dietary supplement use by women at risk for breast cancer recurrence. J Am Dietetic Assoc 98: 285–292 85. Nomura AM, Marchand LL, Kolonel LN, Hankin JH (1991) The effect of dietary fat on breast cancer survival among Caucasian and Japanese women in Hawaii. Breast Cancer Res Treat 18(suppl), S135–S141 86. Pierce JP, Faerber S, Wright F, Rock CL, Newman V, Flatt SW et al (2002) A randomized trial of the effect of a plant based dietary pattern on breast cancer recurrence: the women’s healthy eating and living (WHEL) study. Controlled Clin Trials 23:728–756 87. Pierce JP, Natarajan L, Caan BJ, Parker BA, Greenberg ER, Flatt SW et al (2007) Influence of a diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer: the women’s healthy eating and living (WHEL) randomized trail. J Am Med Assoc 298:289–298 88. Pierce JP, Stefanick ML, Flatt SW, Natarajan L, Sternfeld B, Madlensky L et al (2007) Greater survival after breast cancer in physically active women with high vegetablefruit intake regardless of obesity. J Clin Oncol 25: 2345–2351 89. Pizzo PA, Purvis DS, Waters C (1982) Microbiological evaluation of food items. J Am Dietetic Assoc 82:272–279 90. Pollak M (2000) Insulin-like growth factor physiology and cancer risk. Eur J Cancer 36:1224–1228 91. Potter JD (1992) Reconciling the epidemiology, physiology, and molecular biology of colon cancer. J Am Med Assoc 268:1573–1577 92. Prakash P, Krinsky NI, Russell RM (2000) Retinoids, carotenoids, and human breast cell cultures: a review of differential effects. Nutr Rev 58:170–176 93. Prasad KN, Cole WC, Kumar B, Prasad KC (2001) Scientific rationale for using high-dose multiple micronutrients as an adjunct to standard and experimental cancer therapies. J Am Coll Nutr 20:450S–463S 94. Ravasco R, Monteiro-Grillo I, Vidal PM, Camilo ME (2005) Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. J Clin Oncol 23:1431–1438 95. Rivadeneira DE, Evoy D, Fahey TJ, Lieberman MD, Daly JM (1998) Nutritional support of the cancer patient. CA A Cancer J Clinicians 48:69–80 96. Rock CL, Kusluski RA, Galvez MM, Ethier SP (1995) Carotenoids induce morphological changes in human

26 Nutrition in the Management of the Cancer Patient

97.

98.

99.

100.

101.

102.

103.

104.

105.

106.

107.

108.

109.

110.

111.

112.

mammary epithelial cell cultures. Nutr Cancer 23: 319–333 Rock CL, Flatt SW, Wright FA, Faerber S, Newman V, Kealey S et al (1997) Responsiveness of carotenoids to a high vegetable diet intervention designed to prevent breast cancer recurrence. Cancer Epidemiol Biomarkers Prevent 6:617–623 Rock CL, Flatt SW, Newman V, Caan BJ, Haan MN, Stefanick ML et al (1999) Factors associated with weight gain in women after diagnosis of breast cancer. J Am Dietetic Assoc 99:1212–1218 Rock CL, Michael CW, Reynolds RK, Ruffin MT (2000) Prevention of cervix cancer. Crit Rev Oncol/Hematol 33:169–185 Rock CL, Moskowitz A, Huizar B, Saenz CC, Clark JT, Daly TL et al (2001) High vegetable and fruit diet intervention in premenopausal women with cervical intraepithelial neoplasia. J Am Dietetic Assoc 101: 1167–1174 Rock CL, Demark-Wahnefried W (2002) Nutrition and survival after the diagnosis of breast cancer: a review of the evidence. J Clin Oncol 20:3302–3316 Rock CL, Flatt SW, Laughlin GA, Gold EB, Thomson CA, Natarajan L (2008) Reproductive steroid hormones and recurrence-free survival in women with a history of breast cancer. Cancer, Epidemiol Biomarkers Prevent 17:614–620 Rock CL, Natarajan L, Pu M, Thomson CA, Flatt SW, Caan BJ et al (2009) Longitudinal biological exposure to carotenoids is associated with breast cancer-free survival in the women’s healthy eating and living study. Cancer, Epidemiol Biomarkers Prevent 18:486–494 Rose DP, Giolhooly EM, Nixon DW (2002) Adverse effects of obesity on breast cancer prognosis, and the biological actions of leptin (Review). Int J Oncol 21: 1285–1292 Rohan TE, Hiller JE, McMichael AJ (1993) Dietary factors and survival from breast cancer. Nutr Cancer 20:167–177 Romney SL, Ho GY F, Palan PR, Basu J, Kadish AS, Klein S et al (1997) Effects of β-carotene and other factors on outcome of cervical dysplasia and human papillomavirus infection. Gynecol Oncol 65:483–492 Rosfjord EC, Dickson RB (1999) Growth factors, apoptosis, and survival of mammary epithelial cells. J Mammary Gland Biol Neoplasia 4:229–237 Runnebaum IB, Stickeler E (2001) Epidemiological and molecular aspects of ovarian cancer risk. J Cancer Res Clin Oncol 127:73–79 Russo J, Russo IH (1994) Toward a physiological approach to breast cancer prevention. Cancer Epidemiol Biomarkers Prevent 3:353–364 Saintot M, Mathieu-Daude H, Astre C, Grenier J, SimonyLafontaine J, Gerber M (2002) Oxidant-antioxidant status in relation to survival among breast cancer patients. Int J Cancer 97:574–579 Saxe GA, Rock CL, Wicha MS, Schottenfeld D (1999) Diet and risk for breast cancer recurrence and survival. Breast Cancer Res Treat 543:241–253 Schatzkin A, Lanza E, Corle D, Lance P, Iber F, Caan B et al (2000) Lack of effect of a low-fat, high-fiber diet

493

113.

114.

115.

116.

117.

118.

119.

120.

121.

122.

123.

124. 125.

126.

on the recurrence of colorectal adenomas. N Engl J Med 342:1149–1155 Schiller MR, Miller F, Moore C, Davis E, Dunn A, Mulligan K et al (1998) Patients report positive nutrition counseling outcomes. J Am Dietetic Assoc 98:977–982 Sellers TA, Alberts SR, Vierkant RA, Grabrick DM, Cerhan JR, Vachon CM et al High-folate diets and breast cancer survival in a prospective cohort study. Nutr Cancer 44:139–144 Shaw JH, Humberstone DM, Douglas RG, Korea J (1991) Leucine kinetics in patients with benign disease, nonweight-losing cancer, and cancer cachexia: studies at the whole-body and tissue level and the response to nutritional support. Surgery 109:37–50 Slattery ML, Anderson K, Samowitz W, Edwards SL, Curtin K, Caan B et al (1999) Hormone replacement therapy and improved survival among postmenopausal women diagnosed with colon cancer. Cancer Causes Control 10:467–473 Smith-Warner SA, Elmer PJ, Tharp TM, Fosdick L, Randall B, Gross M et al (2000) Increasing vegetable and fruit intake: randomized intervention and monitoring in an at-risk population. Cancer Epidemiol Biomarkers Prevent 9:307–317 Steinmetz KA, Potter JD (1996) Vegetables, fruit, and cancer prevention: a review. J Am Dietetic Assoc 96:1027–1039 Sumantran VN, Zhang R, Lee DS, Wicha MS (2000) Differential regulation of apoptosis in normal versus transformed mammary epithelium by lutein and retinoic acid. Cancer Epidemiol Biomarkers Prevent 9: 257–263 Tartter PI, Slater G, Papatestas AE, Aufses AH (1984) Cholesterol, weight, height, Quetelet’s Index, and colon cancer recurrence. J Surg Oncol 27:232–235 The Alpha-Tocopherol Beta Carotene Cancer Prevention Study Group (1994) The effect of Vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med 330:1029–1035 The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group (1991) Perioperative total parenteral nutrition in surgical patients. N Engl J Med 325:525–532 Thomson CA, Giuliano A, Rock CL, Ritenbaugh CK, Flatt SW, Faerber S et al (2003) Measuring dietary change in a diet intervention trial: comparing food frequency questionnaire and dietary recalls. Am J Epidemiol 157:73–84 Torosian MH, Donoway RB (1991) Total parenteral nutrition and tumor metastasis. Surgery 109:597–601 Vadgama JV, Wu Y, Datta G, Khan H, Chillar R (1999) Plasma insulin-like growth factor-I and serum IGFbinding protein 3 can be associated with the progression of breast cancer, and predict the risk of recurrence and the probability of survival in African-American and Hispanic women. Oncology 57:330–340 Verkasalo PK, Thomas HV, Appleby PN, Davey GK, Key TJ (2001) Circulating levels of sex hormones and their relation to risk factors for breast cancer: a cross-sectional study in 1092 pre- and postmenopausal women (United Kingdom). Cancer Causes Control 12:47–59

494 127. Warren S (1932) The immediate cause of death in cancer. Am J Med Sci 184:610 128. Winningham ML, MacVicar MG, Bondoc M, Anderson JI, Minton JP (1989) The effect of aerobic exercise on body weight and composition in patients with breast cancer on adjuvant chemotherapy. Oncol Nurs Forum 16:683–689 129. Wiseman M (2008) The second World cancer research fund/American institute for cancer research expert report. Food, nutrition, physical activity and the prevention of cancer: a global perspective. Proc Nutr Soc 67:253–256

C.L. Rock 130. Wu AH, Pike MC, Stam DO (1999) Meta-analysis: dietary fat intake, serum estrogen levels, and risk of breast cancer. J Natl Cancer Inst 91:529–534 131. Wynder EL, Cohen LA, Muscat JE, Winters B, Dwyer JT, Blackburn GL (1997) Breast cancer: weighing the evidence for a promoting role of dietary fat. J Natl Cancer Inst 89:766–775 132. Zhang S, Folsom AR, Sellers IA, Kushi LH, Potter JD (1995) Better breast cancer survival for postmenopausal women who are less overweight and eat less fat. The Iowa women’s health study. Cancer 76:275–283

Chapter 27

γ-Induced Indoleamine Predictive Value of IFN-γ 2,3-Dioxygenase (IDO) Expression in Cancer Patients G. Brandacher, A. Amberger, K. Schroecksnadel, R. Margreiter, and Dietmar Fuchs

27.1 Introduction Serotonin

Recent work has provided new support to the idea that the interaction between immune system and tumor tissue can lead to the development of specific escape mechanisms of certain tumor cells which might predict outcome in cancer patients. These findings are summarized by the cancer immunosurveillance hypothesis that takes a broader view of immune systemtumor interactions. Basically tumor cells are either rejected due to tumor associated antigens (TAA) or they can induce immunological resistance by secretion of anti-inflammatory cytokines such as transforming growth factor-ß (TGF-β) and finally tumors can induce T-cell anergy and thereby leading to immunological tolerance. Indoleamine 2,3-dioxygenase (IDO) is the key enzyme in the extrahepatic degradation of the essential amino acid tryptophan via the kynurenine pathway. IDO has been implicated in the pathophysiology of inflammation, host immune defence and maternal tolerance. Recently it has been shown that local tryptophan depletion upon IDO activation by proinflammatory cytokines such as interferon-γ (IFN-γ) is an important mechanism for suppressing T-cell responses and ultimately leading to T-cell unresponsiveness. However, the role of IDO in tumor immunology and its role in tumorigenesis and tumor growth has not been clarified yet (Fig. 27.1).

D. Fuchs () Department of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria e-mail: [email protected]

T5H CO2 O

N

OH

O NH3+

Proteins

Tryptophan

IDO

TDO

NH3+

O

CH NH2

O O

Kynurenine

Fig. 27.1 Essential amino acid tryptophan is precursor for 3 major biochemical pathways: (1) for the biosynthesis of proteins, (2) for the biosynthesis of neurotransmitter 5-hydroxytryptamin (serotonin) by enzyme tryptophan 5-hydroxylase (T5H) and (3) for the conversion to N-formyl-kynurenine and kynurenine by hepatic tryptophan 2,3-dioxygenase (TDO, tryptophan pyrrolase) and by its extrahepatic isoform indoleamine 2,3dioxygenase (IDO). Kynurenine serves as a precursor for further catabolites such as quinolinic acid and the end products NAD/NADH

Recent studies from our laboratory have shown that colon-cancer cells are able to express IDO upon stimulation with exogenous IFN-γ and thereby lead to profound inhibition of T-cell activation in the tumor microenvironment. In tissue specimens from patients with colorectal cancer, analysed by immunohistochemistry, a high IDO expression score correlated significantly with the invasiveness and the frequency of liver metastasis and poor overall survival. In addition IDO expression showed an inverse correlation with the number of CD3+ T-cells within the tumor stroma. IDO overexpression was found to be associated with a significant reduction of CD3+ tumor-infiltrating T-cells. In conclusion, IDO over-expression within colorectal cancer specimens results in impaired local

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, DOI 10.1007/978-90-481-9704-0_27, © Springer Science+Business Media B.V. 2011

495

496

T-cell infiltration and thereby contributes to different pattern of invasiveness and the prevalence of metastasis, by actively reducing the number and power of anti-tumoral T-cell attacks. IDO-high expression by certain colorectal tumor subtypes enables such tumors to initially avoid immune attack and to defeat the invasion of T-cells via local tryptophan depletion and the production of pro-apoptotic tryptophan catabolites. Thus, IDO significantly contributes to and predicts disease progression, frequency of metastases and overall survival in colorectal cancer patients.

27.2 Basic Immunological Principles of Tumor and Host Interactions In the context of tumor immunology, the survival of a malignant cell, after its generation from the benign precursor due to genetic alteration or transformation, strongly depends on the interaction of this cell with various components of the immune system. Generally, three basic mechanisms govern how the immune system interacts with tumor cells. A malignant cell can be eliminated either by cytotoxic T-cells or natural killer cells (NK cells) because of the recognition of tumor associated antigens (TAA). Second, a tumor can be resistant to immune attack due to the loss of major histocompatibility complex (MHC) class I molecules or the production of anti-inflammatory cytokines like transforming growth factor-β (TGF-β). Or finally, some tumors are able to induce T-cell anergy, ultimately leading to tumor antigen-specific tolerance. The tumor microenvironment, which is composed of malignant cells, immune cells, stromal cells and the extracellular matrix, is the main scene of action during the neoplastic process. Crosstalk between the players in this field, which are normal and tumor cells, is increasingly recognized to influence various stages of carcinogenesis [1]. During the initial stages of tumor formation, stromal cells can provide signals that determine tumor-cell growth and differentiation, whereas later in tumor progression, stromal-cell-derived cues can modulate cancer-cell invasion, metastasis or propagate conditions that favor tumor immune tolerance leading malignant cells to escape from tumor immunity [2]. One variable of particular importance for tumor-host interaction is the mixture of cytokines produced within this microenvironment; among these

D. Fuchs et al.

cytokines, interferons have been identified as one of the key players [3, 4]. Human cancer development is a slow process that, like chronic infection, can occur over several years. In addition, tumorigenesis and malignant disease expose patients to a high risk for opportunistic infections and the development of sepsis and multiple organ failure [5]. Impaired immune responsiveness, in particular of effector T-cells, is considered a crucial factor for the development of an immunocompromised status in these patients. T-cell anergy appears to be mostly due to a deficient production of forward-regulatory cytokines such as interleukin-2 and IFN-γ [6]. During the initiation of cellular anti-tumor immune activation IFN-γ increases T-cell activity, supporting the development of a Th1-type immune response.

27.2.1 Immunological Mechanisms Facilitating Tumor Immune Escape Recent findings, however, have challenged this hypothesis since some tumors develop strategies to bypass IFN-γ-mediated anti-tumor responses. However, there are a number of such different mechanisms by which tumors may actively evade or silence immune responses and thereby create a state of immunological tolerance towards their own antigens [2]. Tumor antigen-specific immune tolerance is initiated by a constitutive interaction between tumors and the patient’s immune system and controlled by various modifications to the immune response present in the tumor environment [7]. The expression of apoptosis-inducing Fas ligand causes deletion of tumor-reactive T-cells and immune evasion [8]. Secretion of immunosuppressive cytokines like IL-10 or TGF-β is important for direct tolerization [9, 10]. Another mechanism responsible for the shutdown of T-cell responses against tumors might be the presence of regulatory CD4+ CD25+ T-regulatory cells [11]. Some tumors are localized so that they are not accessible to circulating T-cells, which therefore are unable to detect the presence of such tumors [12]. And finally, cross-presentation of tumor antigens by APCs is also a major feature inducing T-cell tolerance [13]. Despite the various ways in which tumors can evade or subvert immune responses, the exact mechanisms,

27 Predictive Value of IFN-γ -Induced IDO Expression

by which such unresponsiveness to malignant cells is generated or maintained, are not fully understood. Recently an additional mechanism during tumor immunosurveillance has been proposed for IFN-γ via induction of the immunomodulatory enyzme indoleamine 2,3-dioxygenase (IDO). IDO is the extrahepatic rate-limiting enzyme in the degradation of the essential amino acid tryptophan via the kynurenine pathway to form N-formyl kynurenine, which – depending on the cell type and species [38] – is subsequently converted to niacin. IDO is widely distributed in mammals and is induced in various cell types particularly by IFN-γ [14]. For many years IDO has been considered as an innate defence mechanism limiting growth of viruses, bacteria, intracellular pathogens and malignant cells by withdrawing tryptophan from the microenvironment [15]. Recently, it has been shown that activation of IDO is also critically involved in the regulation of immune responses [16], in establishing immune tolerance in pregnant mice upon their fetuses, and in inducing T-cell unresponsiveness [17, 18]. Proliferation of alloreactive T-cells is thereby arrested via local tryptophan deprivation and possibly also by the accumulation of toxic, proapoptotic catabolites such as kynurenine and quinolinic acid [19]. Insufficient availability of tryptophan seems to be of particular relevance for the development of immune deficiency and infection because of its multiple important roles in regulating monocytes, macrophages, and T-cells, in response to inflammation and infection (Fig. 27.2). Insufficient T-cell responses together with inadequate production of IFN-γ in cancer patients would result in insufficient killing of pathogens. As a consequence, bacterial overgrowth and sepsis develop, which increases the risk of death in these patients and has substantial implications on long term outcome. As discussed above, IFN-γ is an important mediator of innate and adaptive immune responses that play many critical roles in promoting both protective immune responses and immunopathologic processes and influences a remarkable range of distinct cellular programs [20]. In addition to its forwardregulatory role in T-cell activation, within Th1-type immune response IFN-γ initiates several antimicrobial and antitumoral biochemical pathways in certain target cells. For example, in various cells, but especially in monocyte-derived macrophages, IFN-γ, together with

497

T IFN-γ

MΦ IDO Iron

ROS GCH iNOS Biopterin Neopterin

Tumor tissue

Fig. 27.2 Interaction between tumor tissue and immunocompetent cells leads to activation of T-cells and macrophages (M). Among various regulatory molecules, Th1-type cytokine interferon-γ (IFN-γ) stimulates macrophages to a number of tumoricidal activities, which include the formation of reactive oxygen species (ROS) mainly via NADPH oxidase, the expression of indoleamine 2,3-dioxygenase (IDO), of nitric oxides synthase (iNOS) and of GTP-cyclohydrolase I (GCH). IDO degrades tryptophan and thus causes deprivation of this essential amino acid as well as the production of toxic tryptophan catabolites. iNOS produces nitric oxide and together with reactive oxygen species, cytotoxic peroxynitrite (ONOO- ) is formed. Nitric oxide formation is also involved in the withdrawal of iron from the tumor cells. GCH gives rise for the production of tetrahydrobiopterin, the necessary cofactor of iNOS. However, due to distinct repertoire of subsequent enzymes, human macrophages produce neopterin at the expense of biopterin derivatives. Neopterin contributes to amplification of ROS effects, it superinduces the production of pro-inflammatory cytokine as well as apoptosis in tumor cells

tumor necrosis factor-α (TNF-α), induces enzymes like nitric oxide synthase (iNOS), GTP cyclohydrolase I (GCH) and IDO and triggers the formation of reactive oxygen species (ROS) [21]. iNOS produces nitric oxide which, upon reaction with superoxide anion, produces highly toxic peroxynitrite. IDO converts the essential amino acid tryptophan into kynurenine and subsequent degradation products in various cells [22]. Thereby, growth of microbes and tumor cells is affected, because deprivation of essential amino acid tryptophan limits protein biosynthesis. Increased IDO activity is indicated by an elevated ratio of kynurenine to tryptophan concentrations (kyn/trp) [23]. Activation of GCH in human macrophages and dendritic cells (DC) leads to the increased formation of neopterin, which is a sensitive marker of immune activation in humans [24]. Both enzymatic pathways are induced in parallel in peripheral blood mononuclear cells (PBMC) upon stimulation with mitogens (Fig. 27.3).

498

D. Fuchs et al. 15 p <0.01

p <0.01

Kynurenine [µmol/L]

Tryptophan [µmol/L]

25 20 15 10 5

p <0.01

9 6 3 0

0

Co

Con A

PHA

Co

1000000

Con A

PHA

40

p <0.01

p <0.01

100000 10000 1000 100

Neopterin [nmol/L]

Kynurenine/tryptophan [µmol/mmol]

p <0.01 12

p <0.01

p <0.01

30 20 10 0

Co

Con A

PHA

Co

Con A

PHA

Fig. 27.3 When human peripheral blood mononuclear cells are stimulated with mitogens such as phytohemagglutinin (PHA) and concanavalin A (con A), T-cells release Th1-type cytokine interferon-γ (IFN-γ), which in turn stimulates tryptophan degradation by indoleamine 2,3-dioxygenase (IDO). Due to IDO activation, significant decline of tryptophan concentrations in culture supernatants is observe, at the same

time kynurenine concentrations increase. Increased IDO activity is reflected by an increased kynurenine to tryptophan ratio in stimulated cells (note: log-scale) and goes in parallel to enhanced neopterin formation in stimulated cells. IFN-γ also induces enzyme GTP-cyclohydrolase I and thus, the degradation of tryptophan is paralleled by increased neopterin formation

Like IDO activity, several other IFN-γ-mediated biochemical effects aim to affect growth of cells carrying non-self-surface structures after infection with viruses, parasites or mycobacteria or after malignant transformation. Such data have given rise to the generally accepted concept that IFN-γ is critically involved and plays a physiologically relevant role in promoting host resistance to tumor development and microbial infection. Taking into account that NO and tryptophan metabolism are non-redundant, alternative systems that control T-cell responses, current data obtained largely in murine models and in vitro suggest that a temporal relay between both pathways could be beneficial in tolerance induction. Recently, Hill et al. demonstrated that the interplay between NO and IDO is an important determinant in the clinical efficacy of the costimulatory blocking molecule cytotoxic T lymphocyte-associated antigen 4 immunoglobulin (CTLA4Ig) to induce immunological tolerance upon fully MHC mismatched murine heart allografts [25]. The proposed mechanism for this potent pro-tolerogenic action was, that both, IDO and iNOS

together, are responsible for the impaired capacity of DCs from CTLA4Ig-treated animals to stimulate allogeneic T-cells. These data substantiate the fact that the NO and IDO pathways are cross-regulated, since certain tryptophan catabolites can inhibit IFN-γinduced iNOS transcription in murine macrophages by inhibition of NF-κB activation and tryptophan starvation also inhibits IFN-γ-induced iNOS expression in these cells [26].

27.3 Role of IFN-γ During Innate and Adaptive Anti-tumor Immune Responses Since the introduction of the cancer immunosurveillance concept by Burnet and Thomas in 1957, the idea that the immune system plays a protective role in the development of malignant disease and might be able to control or eliminate cancer cells has been a subject of controversy [27]. In general an immune

27 Predictive Value of IFN-γ -Induced IDO Expression

response towards tumor cells can be broadly divided into innate and adaptive components, with intense crosstalk between the two. Innate immunity, including components such as complement proteins, granulocytes, macrophages and NK cells, serves as the first line of defense against infection orchestrating inflammatory reactions [28]. NK cells thereby do not employ classical antigen receptors to recognize their cellular target, they rather use pattern-recognition receptors and other cell-surface molecules such as NKG2D, Ly-49 and KIRs to directly detect tumor cells [29]. Activation of NK cells subsequently increases their production of IFN-γ and thus helps establish an appropriate cytokine milieu that favours the generation of further protective cell-mediated immune responses towards tumor cells. The adaptive immune system acts via an indirect pathway, which is mediated through cross-priming by dendritic cells (DCs) to achieve initial recognition of cancer. Malignant cells do not express co-stimulatory molecules like B7 family members that are essential for full T-cell activation and hence are insufficient to prime cellular immune responses [30]. By contrast, DCs, the key antigen-presenting cells (APC) for initiating immune responses, capture tumor antigens and process the material for MHC presentation following increased expression of costimulatory molecules such as B7-1 and B7-2 within the regional lymph nodes. DCs thereby activate both CD4+ and CD8+ T-cells, which represent the major source of IFN-γ during the adaptive phase of immune responses for tumor clearance [31]. Taken together, IFN-γ exerts significant features in regulating tumor development in several animal models. The major issues thereby are activation of the innate and adaptive immune response against tumors (Fig. 27.2), anti-proliferative and pro-apoptotic actions of IFN-γ and its signaling system as well as inhibition of angiogenesis. In humans there are also several hints for a similar existing role of IFN-γ in cancer immunosurveillance. First, transplant recipients requiring life-long immunosupp-ressive therapy display a higher incidence of malignancies as compared to immunocompetent individuals [32]. Second, cancer patients may spontaneously develop specific adaptive immune responses toward tumor antigens [33] and third, there have been several reports showing that the presence of tumor-infiltrating lymphocytes

499

(TILs) correlates with clinical outcome and patient survival [34].

27.3.1 Effects of Sustained IFN-γ γ Production in Cancer Patients As discussed so far, IFN-γ is probably the most important anti-proliferative cytokine which is released in large amounts during tumor development. It induces several biochemical pathways and mechanisms in order to stop growth of microbes and tumor cells. However, if the immune system is unable to eliminate the malignant tumor cells, immune activation may persist, which causes overproduction of IFN-γ. Because of its outstanding potency it is not surprising to find side-effects, especially during such clinical conditions of continuous immune system stimulation and IFN-γ production which may exert a strong negative impact on host cells [35]. One underlying mechanism for these detrimental IFN-γ effects appears to be the increased tryptophan depletion, which can affect T-cell responses and thus contribute to the development of immunodeficiency in cancer patients. IFN-γ may also provide a key to understand how the complex interplay between tumor and stroma is affected by IDO activity. First evidence for such a tumoral immune resistance mechanism based on tryptophan degradation was provided by Uyttenhove et al. in a murine model, where they showed that IDO reduces anti-tumoral T-cell attack [36]. They observed that expression of IDO by immunogenic mouse tumor cells prevented their rejection in preimmunized mice. This effect was accompanied by a lack of accumulation of T-cells at the tumor site and was partly reverted by systemic treatment of mice with a pharmacological IDO inhibitor.

γ Induces IDO-Mediated 27.4 IFN-γ Tryptophan Catabolism The release of IFN-γ is the main stimulus for activating IDO in monocyte-derived macrophages, DCs, fibroblasts and various other cell types [37]. However, other cytokines like IFN-α, IFN-β, TNF-α or lipopolysaccharides are also able to induce IDO, although to a much lesser extent [38]. IDO, a 42kDA

500

hem- containing enzyme, degrades the essential amino acid L-tryptophan to form N-formyl kynurenine which sets free a 1-carbon unit and kynurenine is produced. Thus, also the production of formaldehyde and formate during, e.g. malignant disease [39] may relate to IDO activity. Kynurenine, depending on cell type and enzymatic repertoires, is subsequently converted to finally form niacin [40]. This process involves the cleavage of the five-membered indole ring. Once cleaved, the indole ring cannot be resynthesized by human metabolism. L-tryptophan is therefore an essential amino acid which is required for the biosynthesis of proteins and is the precursor for several biologically important compounds such as 5-hydroxytryptamine (serotonin), formed by tryptophan (5)-hydroxylase following decarboxylation, or melatonin. Raised IFN-γ concentrations during immune responses have been shown to lead to robust and sustained tryptophan depletion [41]. In recent years, a clear association has been made between tryptophan catabolism and inflammatory reactions in a wide array of different diseases with much of the focus centering on the kynurenine pathway of tryptophan degradation occurring in the immune system [42]. IFN-γ-mediated tryptophan breakdown acts to reduce substrate availability for certain intracellular pathogens, bacteria or cancer cells and contributes substantially to its antimicrobial and antitumor response [43]. Consequently, tryptophan depletion is regarded as a natural defense mechanism of immunocompetent cells, which is induced by IFN-γ during immune response. Furthermore, local tryptophan depletion has recently been hypothesized to be a mechanism for suppressing T-cell responses. Activation of IDO inhibits responsiveness of T-cells to mitogenic stimulation in vitro and in vivo [44]. This is especially true when the enzyme is induced by IFN-γ in macrophages and DCs. It appears that not only tryptophan deprivation is important to arrest T-cells within the G1 phase of the cell cycle, but also the pro-apoptotic effect of certain tryptophan catabolites like kynurenine is of relevance [45]. In addition, tryptophan depletion is also critically involved in DC functions. DCs are known as APCs that prime T helper cells and are also involved in tolerance induction towards self and non-pathogenic foreign antigens [46]. Dependent on the state of DC maturation, these cells can activate lymphocytes to respond to a certain antigen or to induce tolerance to the presented antigen (Fig. 27.4). IFN-γ is one of the primary cytokines that cause

D. Fuchs et al. TLR

IDO iNOS

IFNs

NK Cytokines

DC

T

Regulation

GCH IDO

IFN-γ

iNOS TLR

Killing

GCH

MΦ Fig. 27.4 Monocyte-derived macrophages (M) and dendritic cells (DC) stimulated via pro-inflammatory cytokines or via Toll like receptor (TLR) share several biochemical pathways including the expression of indoleamine 2,3-dioxygenase (IDO), of nitric oxides synthase (iNOS) or of GTP-cyclohydrolase I (GCH). In stimulated M, these enzymatic pathways appear to preferentially contribute to the killing repertoire of cells, whereas in DC their main task is immunoregulation

DC maturation and hence induction of effector T-cell responses. Recently it has been shown that CTLA4-Ig is able to upregulate IDO expression in DCs via an IFN-γ-dependent mechanism [47]. CTLA4 is a T-cell surface receptor that plays an important role in mediating immune tolerance. Thus, these data indicate that IDO-mediated tryptophan depletion is involved in the development and maintenance of tolerance. IDO+ DCs have also been identified in breast tumor tissue and tumor-draining lymph nodes of patients with melanoma and patients with colon, lung and pancreatic cancers, and it is conceivable that such DCs contribute to tumor-mediated immunosuppression or immune evasion. [48]. All these observations together support the view that activation of IDO together with other biochemical pathways induced by IFN-γ is an important anti-proliferative mechanism of monocytederived macrophages and DCs which however can also decrease the responsiveness of stimulated T-cells and thus contribute to the development of immunodeficiency. In general IFN-γ-mediated metabolic activation of IDO during prolonged disease stages can be regarded as harmful to the host by slowing down T-cell responses.

27.5 IDO-Mediated Tryptophan Catabolism in Patients with Malignant Disease – A Predictive Marker In patients with malignant tumors, significantly accelerated degradation of tryptophan with lowered serum concentrations of tryptophan and increased kynurenine

27 Predictive Value of IFN-γ -Induced IDO Expression

as well as an increased kyn/trp was recognized earlier by our group and others [49, 50]. Recently, significantly lower tryptophan levels and higher kyn/trp as compared to healthy volunteers were observed in colorectal cancer patients, and the lower tryptophan levels were associated with reduced quality of life and poor outcome [51]. A concomitant increase in kynurenine suggested that the observed tryptophan deficiency is related to IDO-mediated tryptophan degradation. Such a phenomenon can be best explained by IFN-γ-mediated IDO expression within the tumors. This conclusion is also supported by a correlation found between neopterin concentrations, an established marker of cellular immune responses, and kyn/trp, which suggests that under these conditions endogenous production of IFN-γ is increased, and by the finding of an increased expression of IFN-γ in cancer patients reported earlier [52]. In several other malignant diseases, including various solid tumors as well as hematological neoplasias, accelerated tryptophan catabolism has been described as well [53, 54]. Lower tryptophan concentrations and increased kyn/trp are associated with more advanced stages of the disease, and in patients with adult T-cell leukemia [55] or with colorectal carcinoma [51], lower tryptophan concentrations are predictive for shorter survival. In addition, in patients with colon carcinoma enhanced IDO expression and increased tryptophan degradation were suggested to be an intrinsic immunoescape mechanism of tumor cells [36]. In a very recent study we tested the expression of IDO protein in vivo in human tumor samples by means of semiquantitative immunostaining [55]. We detected colorectal tumor cells expressing IDO in all 143 cases analyzed. These results are in line with previous studies indicating that human tumors frequently express IDO [36]. However, 39.2% of tumor specimens revealed IDO-high expression, whereas in 60.8% of cases the staining was scored as IDO-low expression, indicating certain colon cancer subsets that differ in their ability to express IDO in vivo. Apart from malignant cells, we identified a number of IDO positive cells within the tumor stroma morphologically classified as antigen-presenting cells. IDO-expressing cells have been deemed to create a state of immunological unresponsiveness towards tumor-derived antigens [56]. However, which cells in particular, either tumor cells themselves or host APCs expressing IDO, are responsible for tolerance induction is still unclear. The observation of IDO expression in tumor cells of

501

colorectal cancer patients with distinct expression patterns provides for the first time also a link to the clinical outcome, since IDO expression significantly correlated with the frequency of metastases and overall survival in this study, which implicates the importance of the tumor itself as the primary tolerizing agent. Similar conclusions can be deduced from recent findings in patients with malignant melanoma, which presented with significantly accelerated tryptophan degradation, and the lowering of plasma tryptophan concentrations turned out to be strongest predictor of poor survival [57]. Conceptually, tumor cells in the early stage may be recognized by the host’s immune system which is accompanied by formation of IFN-γ. As a consequence, IDO is activated and tryptophan deprivation and formation of pro-apoptotic, downstream catabolites restrict T-cell proliferation and T-cell numbers decline. This may cause a selective survival benefit of IDO-high-expressing malignant cells. In addition, the suppressive effects of IDO might be mediated by tryptophan depletion within the tumor microenvironment resulting in a local milieu that is rendered immunosuppressive. We hypothesize that IDO-high-expressing tumor cells enable certain cancer subsets to initially avoid immune attack and then reduce T-cell priming and defeat the invasion of effector T-cells via local tryptophan depletion and the production of proapoptotic tryptophan catabolites. Almost 20 years ago it has been already shown that IDO can be drastically induced in most but not all human cells and tumor cell lines by IFN-γ, whereas the same cells, with the exception of one T24, a bladder carcinoma cell lien, did not spontaneously degrade tryptophan to a relevant extent [38]. Once induced, it is unclear for how long IDO activity can be detected in these cells. One may speculate that IDO may continue to degrade tryptophan for long time, even if the initial stimulus has already disappeared. These in vitro findings are well in line with more recent studies indicating that the therapeutic efficacy of IFN-γ in tumor models critically depends on the ability of the tumor cells themselves to respond to IFN-γ [58]. However, correlation found between kyn/trp and neopterin concentrations favours the view that IDO activation in monocytederived macrophages, DCs and/or tumor cells is due to enhanced endogenous formation of IFN-γ during the host’s response against the tumor and may suppress T-cell proliferation, thus acting immunosuppressive. Reduced immunoresponsiveness may thereby develop

502

as a consequence of the antiproliferative mechanism induced by this particular cytokine [59]. This gives rise to the conclusion that in patients with malignant disease experiencing chronic states of immune activation, systemically increased IFN-γ is no longer antigenspecific and is associated with the development of immunodeficiency.

27.6 Enhanced Tryptophan Depletion Due to IDO Results in Immunodefiency Immunodeficiency with reduced cell-mediated immune response (CMI) occurs in a number of chronic infectious diseases, including tuberculosis, leishmaniasis and human immunodeficiency virus (HIV) infection [60]. More recently, it has become increasingly apparent that CMI is also suppressed in virtually all malignant diseases, including melanoma, colorectal and prostate cancer and this becomes even more evident as the disease progresses [61]. However, the mechanisms underlying the immune defects noticed in cancer patients have not been fully elucidated. In cancer patients, analogous to patients with HIV infection, higher neopterin concentrations and kyn/trp, reflecting increased IFN-γ levels (Fig. 27.3), predict a more rapid disease progression and shorter survival time, and both are associated with the development of immunodeficiency. Enhanced degradation of tryptophan has been demonstrated earlier in several diseases which go hand-in-hand with or are even characterized by acquired immunodeficiency. This is especially true for patients with HIV infection, but also for various other mostly chronic diseases like autoimmune disorders, in which immunodeficiency develops as disease progresses and is a sign of poor prognosis [62]. Acquired immunodeficiency is the hallmark of progressing HIV infection. In parallel, activation of several immune compartments has been observed including activation of B-cells, T-cells and macrophages. Several parameters of immune activation were found to predict disease development in patients with HIV infection, and data show that immune activation coexists with immune deficiency in such patients [63]. Activation of IDO by IFN-γ could be involved in diminishing T-cell responsiveness in patients with HIV infection and reduced T-cell

D. Fuchs et al.

proliferative response to soluble antigens in vitro has been found to be associated with the immune activation status in these patients [64]. Similar relationships also appear to exist in cancer patients and result in reduced CMI. Decreased blood tryptophan in cancer patients indicates significant depletion of tryptophan in the microenvironment of activated cells, and the enhanced IDO activity is most likely driven by endogenously formed cytokines like IFN-γ. Because tryptophan is essential for the production and function of rapidly proliferating cells and tissues in general, tryptophan degradation may also suppress T-cell proliferation. Expression of IDO by antigen-stimulated macrophages inhibits proliferation of T cells co-cultured with macrophages. Such a nutrient-depleting role of competing cells was recently extended to include novel regulatory pathways for IDO in immunosuppression. The restriction of available tryptophan in microenvironment such as within the tumor stroma could be crucial for a sufficient immune response to tumorassociated antigens and contribute to immune evasion by influencing the quality and quantity of local T-cell responses. T-lymphocytes and natural killer cells (NKcells), in contrast to almost all other cell types, in particular tumor cells, stop proliferation under conditions of tryptophan deprivation because of a specific tryptophan-sensitive checkpoint which arrests their cell cycle in the G1 phase, whereas at the same tryptophan concentrations malignant cell growth is not affected [65]. In addition, cancer patients have significantly lower absolute numbers of both B and T lymphocytes (CD4+ and CD8+ subsets) in peripheral blood than do healthy subjects, which can seriously affect immune functions [66]. Thus, immunodeficiency in cancer patients may result from the enhanced long-term production of IFN-γ in response to malignant transition and tumor formation as part of the immune defense reaction. Antimicrobial and cytocidal biochemical consequences of IFN-γ not only restrict bacterial growth, but may also impair T-cell development and proliferation via a negative feedback loop and contribute to the development of immunodeficiency. This raises the possibility that, as a tumor develops, cancer cells evolve to subvert the CMI response via IFN-γ to increase IDO activity. Consequently, tryptophan deprivation is one of several anti-proliferative events mediated by IFN-γ in tumor patients that might exert detrimental effects in

27 Predictive Value of IFN-γ -Induced IDO Expression

the host. Moreover, the reduced CMI response as seen in colorectal cancer patients is completely reversed following curative surgery, strongly supporting the idea that tumors themselves can suppress the systemic immune response [61]. Notably, paralleling neopterin concentrations, kyn/trp in cancer patients exhibits a steady increase over time and those patients with higher kyn/trp tended to have the greatest impairment in immune function and hence the highest incidence of sepsis and death [67].

27.7 Sustained IDO Activity Accounts for Several Symptoms Such as Cachexia, Anemia, Organ Failure and Depression of the Terminally ILL Cancer Patient About 50–80% of all advanced-stage cancer patients experience a wasting syndrome called cachexia, in which the tumor induces metabolic changes in the host leading to loss of adipose tissue, skeletal muscle mass and anemia [68]. These effects are not a local phenomenon of a tumor but are thought to be a type of paraneoplastic syndrome. The process appears to be mediated by circulatory tumor-produced catabolic factors acting either alone or in concert with certain cytokines such as IFN-γ [69]. No effective treatment is currently available for the cancer cachexia syndrome and it must therefore be regarded as a strong independent risk factor. As previously mentioned, tryptophan is essential for many cellular functions, including protein biosynthesis and cell proliferation, and an intracellular tryptophan deficiency alters these cellular functions substantially. Increased neopterin levels and kyn/trp were found to be associated with cachexia and weight loss [53] as well as anemia [70]. Enhanced tryptophan degradation appears to be involved in the development of these symptoms as well (Fig. 27.5). Likewise, in patients with hematological neoplasias, low tryptophan concentrations were found to be associated with low serum albumin concentrations and weight loss [71], this association was apparent at study entry and during patient follow-up. IFN-γ-mediated tryptophan deprivation may be one important underlying mechanism to cause slow-down of protein biosynthesis and in turn accelerate breakdown of muscle proteins.

503 Immune activation Immunodeficiency IDO

Anemia

Tryptophan

Cachexia Depression ?

Fig. 27.5 Th1-type immune activation is associated with the induction of numerous biochemical pathways including the expression of indoleamine 2,3-dioxygenase (IDO) in various cells and tissues. Due to IDO activity, tryptophan degradation takes place and reduces the availability of tryptophan. This initially antitumoral and antimicrobial activity of immunocompetent cells can also affect proliferation of T-cells, which increases the risk of immunodeficiency, but also of erythroid progenitor cells, which increases the risk of anemia in patients. Insufficient availability of tryptophan will also reduce protein biosynthesis in the whole organism. Moreover, tryptophan-deprived cells begin to break-down protein to recruit tryptophan for their necessary biochemical functions. Both these consequences of tryptophan degradation are involved in the development of weight-loss and cachexia in patients. Subnormal availability of tryptophan also slows down biosynthesis of serotonin and its subsequent metabolite melatonin. Serotonin deficiency can increase the risk for depression in patients, when exposed to unfavorable experiences

Cytokines affect the homeostatic loop of body weight regulation in cancer patients either by their involvement in the brain’s serotonergic system or by mimicking leptin, a member of the helical cytokine family and one of the key targets for neuropeptidergic effector molecules that regulate food intake and energy expenditure via the sympathetic nervous system [72]. More direct evidence of cytokine involvement comes from experiments in which specific neutralization of cytokines can relieve cachexia in experimental animal models. Examples are the anti-TNF-α, antiIL-1 and anti-IFN-γ antibodies, although no single antibody could reverse all of the features seen in cancer cachexia. These studies revealed that cachexia is associated with cytokine activation and other cachectic factors that are orchestrated to induce major metabolic abnormalities [73]. Anemia is another frequent complication in cancer, occurring in more than half of all patients with malignancies. However, in a considerable number of patients, no cause other than malignant disease itself can be implicated. Cancer-related anemia is similar to the anemia observed in other chronic diseases, characterized by a hyporegenerative, normocytic,

504

normochromic anemia associated with reduced serum iron and transferrin saturation. Recently, accelerated catabolism of tryptophan was proposed to also be in important in the pathogenesis of anemia in states of chronic inflammation [70]. It is currently well established that pro-inflammatory cytokines IFN-γ and TNF-α suppress growth and differentiation of erythroid progenitor cells, and these cytokines are crucially important in the pathogenesis of anemia. Thus, IFN-γ-induced tryptophan deprivation appears to be involved in hematopoietic suppression in cancer patients in the same way as iron withdrawal [74], and the limitation of tryptophan availability may be a key mechanism in cytokine-mediated inhibition of erythroid progenitor cells. IFN-γ has been furthermore implicated in the pathogenesis of bone marrow failure. In vitro, bone marrow stromal cells genetically engineered to constitutively express IFN-γ markedly suppressed the proliferative capacity of erythrocyte, granulocyte, and monocyte precursors [75]. Such impaired bone marrow function may also contribute to the development of multiple organ dysfunction syndrome and multiple organ failure in cancer patients. Other distressing symptoms that debilitate patients with malignant disease and contribute to their profound fatigue are severe mood changes, subtle cognitive changes and depression. Insufficient availability of tryptophan reduces the biosynthesis of neurotransmitter 5-hydroxytryptamine (serotonin), which in turn can increase the susceptibility to develop mood disturbance and depression and which may also impair cognitive function [76]. Furthermore, downstream products of tryptophan – kynurenine metabolism such as 3-hydroxy-anthranilic acid and quninolinic acid can cause neuronal damage and dysfunction [77]. The latter is a potent neurotoxin which interferes with the N-methyl-D-aspartate (NMDA) receptor and may thereby influence the neuroendocrine system in addition to the neuropathologic effects of tryptophan deprivation. Immune-mediated tryptophan degradation by means of IDO may thus elicit neuropsychiatric symptoms when the availability of tryptophan is insufficient for normal serotonin biosynthesis [78]. In patients with major depression decreased serum tryptophan concentrations are found, correlating with increased concentrations of immune activation markers [79]. On the one hand, reduced concentrations of 5-hydroxyindoleacetic acid, the main catabolite of

D. Fuchs et al.

serotonin, are observed and confirm insufficient availability of serotonin. On the other hand, treatment with selective serotonin-reuptake inhibitors (SSRIs) can be very effective in patients with depression. Thus, several indirect evidences are in support of the view that enhanced degradation of tryptophan due to immune stimulation could underlie the increased risk for development of mood disturbances and susceptibility to depression in cancer patients, especially when undergoing prolonged disease. In several types cancer, enhanced degradation of tryptophan was found to coincide with impaired quality of life [51, 80]. Moreover during treatment with IFN-α, a relationship between lower tryptophan levels and increased susceptibility of depression was reported recently in malignant melanoma patients [81].

27.8 Nutrition and Tryptophan Availability As an essential amino acid, the tryptophan concentration is influenced by diet. However, dietary changes influence serum/plasma tryptophan levels only to a minor extent, when compared to the dramatic changes, which are induced during an inflammatory response. Notably, all the supplemented tryptophan is degraded within 24–48 h, when cultures of PBMC are stimulated (Fig. 27.3) [82]. In vitro it is observed that antioxidant vitamins possess some anti-inflammatory activity, which includes the suppression of IFN-γ production by stimulated PBMC. As a consequence also neopterin production and tryptophan degradation is diminished by compounds like vitamin C and E, but also aspirin. Thus, a so-called “healthy diet” could indeed have some benefit to slow-down inflammation and thus reduce the cancer risks in the community. In conclusion, it is apparently becoming clear that increased and sustained immune activation and IFN-γ levels and hence increased IDO activity in the course of malignant diseases are an integral mechanism in initiating long-term, aforementioned side-effects of chronic immune activation and may even aggravate severity of tumor burden in this patient population. IDO expression in certain cancer subtypes has been demonstrated to predict disease progression and overall survival. Recent data revealed a dual role for the immune system in general and for IFN-γ in particular

27 Predictive Value of IFN-γ -Induced IDO Expression

in suppressing and promoting cancer formation. In this context, the interplay of chronic infection, inflammation and cancer immunity helps to determine the outcome of the host response. There is also compelling evidence that the IFN-γ induced IDO pathway is critically involved in the pathogenesis of various diseases composing the cancer-cachexia syndrome, including also the impaired quality of life, which is almost generally observed in the alter course of the disease.

505

13.

14.

15. Acknowledgements This work was supported by the European Community, Project #019031 BAMOD. 16.

References 17. 1. Hanahan D, Weinberg RA (2000) The hallmarks of cancer. Cell 100:57–70 2. Mapara MY, Sykes M (2004) Tolerance and cancer: mechanisms of tumor evasion and strategies for breaking tolerance. J Clin Oncol 22:1136–1151 3. Dranoff G, Mulligan RC (1995) Gene transfer as cancer therapy. Adv Immunol 58:417–454 4. Ikeda H, Old LJ, Schreiber RD (2002) The roles of IFN gamma in protection against tumor development and cancer immunoediting. Cytokine Growth Factor Rev 13:95–109 5. Faist E (1996) The mechanisms of host defense dysfunction following shock and trauma. Curr Top Microbiol Immunol 216, 259–274 6. Murphey ED, Lin CY, McGuire RW, Toliver-Kinsky T, Herndon DN, Sherwood ER (2004) Diminished bacterial clearance is associated with decreased IL-12 and interferon-gamma production but a sustained proinflammatory response in a murine model of postseptic immunosuppression. Shock 21:415–425 7. Zou W (2005) Immunosuppressive networks in the tumour environment and their therapeutic relevance. Nat Rev Cancer 5:263–274 8. Gastman BR, Atarshi Y, Reichert TE, Saito T, Balkir L, Rabinowich H, Whiteside TL (1999) Fas ligand is expressed on human squamous cell carcinomas of the head and neck, and it promotes apoptosis of T lymphocytes. Cancer Res 59:5356–5364 9. Stevens SR, Shibaki A, Meunier L, Cooper KD (1995) Suppressor T cell-activating macrophages in ultravioletirradiated human skin induce a novel, TGF-beta-dependent form of T cell activation characterized by deficient IL-2r alpha expression. J Immunol 155:5601–5607 10. Gorelik L, Flavell RA (2001) Immune-mediated eradication of tumors through the blockade of transforming growth factor-beta signaling in T cells. Nat Med 7:1118–1122 11. Woo EY, Yeh H, Chu CS, Schlienger K, Carroll RG, Riley JL, Kaiser LR, June CH (2002) Regulatory T cells from lung cancer patients directly inhibit autologous T cell proliferation. J Immunol 168:4272–4276 12. Ochsenbein AF, Klenerman P, Karrer U, Ludewig B, Pericin M, Hengartner H, Zinkernagel RM (1999) Immune

18.

19.

20. 21.

22.

23.

24.

25.

26.

27. 28.

surveillance against a solid tumor fails because of immunological ignorance. Proc Natl Acad Sci USA 96:2233–2238 Ochsenbein AF, Sierro S, Odermatt B, Pericin M, Karrer U, Hermans J, Hemmi S, Hengartner H, Zinkernagel RM (2001) Roles of tumour localization, second signals and cross priming in cytotoxic T-cell induction. Nature 411:1058–1064 Byrne GI, Lehmann LK, Kirschbaum JG, Borden EC, Lee CM, Brown RR (1986) Induction of tryptophan degradation in vitro and in vivo: a gamma-interferon-stimulated activity. J Interferon Res 6:389–396 Ozaki Y, Edelstein MP, Duch DS (1988) Induction of indoleamine 2,3-dioxygenase: a mechanism of the antitumor activity of interferon gamma. Proc Natl Acad Sci USA 85:1242–1246 Hwu P, Du MX, Lapointe R, Do M, Taylor MW, Young HA (2000) Indoleamine 2,3-dioxygenase production by human dendritic cells results in the inhibition of T cell proliferation. J Immunol 164:3596–3599 Munn DH, Zhou M, Attwood JT, Bondarev I, Conway SJ, Marshall B et al (1998) Prevention of allogeneic fetal rejection by tryptophan catabolism. Science 281:1191–1193 Mellor AL, Munn DH (2003) Tryptophan catabolism and regulation of adaptive immunity. J Immunol 170: 5809–5813 Munn DH, Shafizadeh E, Attwood JT, Bondarev I, Pashine A, Mellor AL (1999) Inhibition of T cell proliferation by macrophage tryptophan catabolism. J Exp Med 189: 1363–1372 Billiau A, Matthys P (1992) Interferon-gamma, more of a cachectin than tumor necrosis factor. Cytokine 4:259–263 Nathan CF, Murray HW, Wiebe ME, Rubin BY (1983) Identification of interferon-gamma as the lymphokine that activates human macrophage oxidative metabolism and antimicrobial activity. J Exp Med 158:670–689 Wirleitner B, Neurauter G, Schröcksnadel K, Frick B, Fuchs D (2003) Interferon-γ-induced conversion of tryptophan: immunologic and neuropsychiatric aspects. Curr Med Chem 10:1581–1591 Fuchs D, Moeller AA, Reibnegger G, Stoeckle E, Werner ER, Wachter H (1990) Decreased serum tryptophan in patients with HIV-1 infection correlates with increased serum neopterin and with neurologic/psychiatric symptoms. J Acquir Immune Defic Syndr 3:873–876 Murr C, Widner B, Wirleitner B, Fuchs D (2002) Neopterin as a marker for immune system activation. Curr Drug Metabol 3:175–187 Hill M, Zagani R, Voisine C, Usal C, Anegon I (2007) Nitric oxide and indoleamine 2,3-dioxygenase mediate CTLA4Ig-induced survival in heart allografts in rats. Transplantation 84:1060–1063 Sekkaï D, Guittet O, Lemaire G, Tenu JP, Lepoivre M (1997) Inhibition of nitric oxide synthase expression and activity in macrophages by 3-hydroxyanthranilic acid, a tryptophan metabolite. Arch Biochem Biophys 340: 117–123 Burnet FM (1957) Cancer – a biological approach. Br Med J 1:841–847 Janeway CA Jr (2001) How the immune system works to protect the host from infection: a personal view. Proc Natl Acad Sci USA 98:7461–7468

506 29. Diefenbach A, Raulet DH (2002) The innate immune response to tumors and its role in the induction of T-cell immunity. Immunol Rev 188:9–21 30. Sharpe AH, Freeman GJ (2002) The B7-CD28 superfamily. Nat Rev Immunol 2:116–126 31. Banchereau J, Briere F, Caux C, Davoust J, Lebecque S, Liu YJ, Pulendran B, Palucka K (2000) Immunobiology of dendritic cells. Annu Rev Immunol 18:767–811 32. Sheil AGR (2001) Cancer in dialysis and transplant patients. In: Morris PJ (ed) Kidney transplantation, principles and practice, 54th edn. Philadelphia, PA, WB Saunders, pp 558–570 33. Boon T, van der Bruggen P (1996) Human tumor antigens recognized by T lymphocytes. J Exp Med 183: 725–729 34. Zhang L, Conejo-Garcia JR, Katsaros D, Gimotty PA, Massobrio M, Regnani G, Makrigiannakis A, Gray H, Schlienger K, Liebman MN, Rubin SC, Coukos G (2003) Intratumoral T cells, recurrence, and survival in epithelial ovarian cancer. N Engl J Med 348:203–213 35. Schroecksnadel K, Pellegrin K, Winkler C, Fuchs D (2005) Antimicrobial activity of interferon-γ involved in impaired T-cell function. Proceedings of the 6th European congress of trauma and emergency surgery – EATES, September 9–12, 2004 Rotterdam, Medimond S r.l., Bologna, The Netherlands, pp 41–47 36. Uyttenhove C, Pilotte L, Theate I, Stroobant V, Colau D, Parmentier N, Boon T, Van den Eynde BJ (2003) Evidence for a tumoral immune resistance mechanism based on tryptophan degradation by indoleamine 2,3-dioxygenase. Nat Med 9:1269–1274 37. Werner ER, Bitterlich G, Fuchs D, Hausen A, Reibnegger G, Szabo G, Dierich MP, Wachter H (1987) Human macrophages degrade tryptophan upon induction by interferon-gamma. Life Sci 41:273–280 38. Werner-Felmayer G, Werner ER, Fuchs D, Hausen A, Reibnegger G, Wachter H (1989) Characteristics of interferon induced tryptophan metabolism in human cells in vitro. Biochim Biophys Acta 1012:140–147 39. Ebeler SE, Clifford AJ, Shibamoto T (1997) Quantitative analysis by gas chromatography of volatile carbonyl compounds in expired air from mice and human. J Chromatogr B Biomed Sci 702:211–215 40. Bender DA (1986) The relative importance of dietary tryptophan and preformed nicotinic acid and nicotinamide as precursors of nicotinamide nucleotide coenzymes. In: Bender DA, Joseph MH, Kochen W, Steinhart HW (eds) Progress in tryptophan and serotonin research. de Gruyter, Berlin, pp 159–164 41. Hayaishi O (1996) Utilization of superoxide anion by indoleamine oxygenase-catalyzed tryptophan and indoleamine oxidation. Adv Exp Med Biol 398:285–289 42. Schroecksnadel K, Wirleitner B, Winkler C, Fuchs D (2006) Monitoring tryptophan metabolism in chronic immune activation. Clin Chim Acta 364:82–90 43. Aune TM, Pogue SL (1989) Inhibition of tumor cell growth by interferon-gamma is mediated by two distinct mechanisms dependent upon oxygen tension: induction of tryptophan degradation and depletion of intracellular nicotinamide adenine dinucleotide. J Clin Invest 84: 863–875

D. Fuchs et al. 44. Grohmann U, Fallarino F, Puccetti P (2003) Tolerance, DCs and tryptophan: much ado about IDO. Trends Immunol 24:242–248 45. Frumento G, Rotondo R, Tonetti M, Damonte G, Benatti U, Ferrara GB (2002) Tryptophan-derived catabolites are responsible for inhibition of T and natural killer cell proliferation induced by indoleamine 2,3-dioxygenase. J Exp Med 196:459–468 46. Thompson AG, Thomas R (2002) Induction of immune tolerance by dendritic cells: implications for preventative and therapeutic immunotherapy of autoimmune disease. Immunol Cell Biol 80:509–519 47. Grohmann U, Orabona C, Fallarino F, Vacca C, Calcinaro F, Falorni A, Candeloro P, Belladonna ML, Bianchi R, Fioretti MC, Puccetti P (2002) CTLA-4-Ig regulates tryptophan catabolism in vivo. Nat Immunol 3:1097–1101 48. Munn DH, Sharma MD, Lee JR, Jhaver KG, Johnson TS, Keskin DB, Marshall B, Chandler P, Antonia SJ, Burgess R, Slingluff CL Jr, Mellor AL (2002) Potential regulatory function of human dendritic cells expressing indoleamine 2,3-dioxygenase. Science 297:1867–1870 49. Rose DP (1967) Tryptophan metabolism in carcinoma of the breast. Lancet 1:239–241 50. Brandacher G, Schroecksnadel K, Winkler C, Margreiter R, Fuchs D (2006) Antitumoral activity of interferon-γ involved in impaired immune function in cancer patients. Curr Drug Metabol 7:599–612 51. Huang A, Fuchs D, Widner B, Glover C, Henderson DC, Allen-Mersh TG (2002) Serum tryptophan decrease correlates with immune activation and impaired quality of life in colorectal cancer. Br J Cancer 86:1691–1696 52. Denz H, Fuchs D, Huber H, Nachbaur D, Reibnegger G, Thaler J, Werner ER, Wachter H (1990) Correlation between neopterin, interferon-gamma and haemoglobin in patients with haematological disorders. Eur J Haematol 44:186–189 53. Denz H, Orth B, Weiss G, Herrmann R, Huber P, Wachter H, Fuchs D (1993) Weight loss in patients with hematological neoplasias is associated with immune system stimulation. Clin Invest 71:37–41 54. Giusti RM, Maloney EM, Hanchard B, Morgan OS, Steinberg SM, Wachter H, Williams E, Cranston B, Fuchs D, Manns A (1996) Differential patterns of serum biomarkers of immune activation in human T-cell lymphotropic virus type I-associated myelopathy/tropical spastic paraparesis, and adult T-cell leukemia/lymphoma. Cancer Epidemiol Biomarkers Prev 5:699–704 55. Brandacher G, Perathoner A, Ladurner R, Schneeberger S, Obrist P, Winkler C, Werner ER, Werner-Felmayer G, Weiss HG, Goebel G, Margreiter R, Koenigsrainer A, Fuchs D, Amberger A (2005) Prognostic value of indoleamine 2,3-dioxygenase expression in colorectal cancer: impact on tumor-infiltrating T-cells. Clin Cancer Res 12:1144–1151 56. Mellor AL, Munn DH (1999) Tryptophan catabolism and T-cell tolerance: immunosuppression by starvation? Immunol Today 20:469–473 57. Weinlich G, Murr C, Richardsen L, Winkler C, Fuchs D (2007) Decreased serum tryptophan concentration predicts poor prognosis in malignant melanoma patients. Dermatology 214:8–14

27 Predictive Value of IFN-γ -Induced IDO Expression 58. Tannenbaum CS, Hamilton TA (2000) Immuneinflammatory mechanisms in IFNgamma-mediated anti-tumor activity. Semin Cancer Biol 10: 113–123 59. Fuchs D, Malkovsky M, Reibnegger G, Werner ER, Forni G, Wachter H (1989) Endogenous release of interferon-gamma and diminished response of peripheral blood mononuclear cells to antigenic stimulation. Immunol Lett 23:103–108 60. Delobel P, Launois P, Djossou F, Sainte-Marie D, Pradinaud R (2003) American cutaneous leishmaniasis, lepromatous leprosy, and pulmonary tuberculosis coinfection with downregulation of the T-helper 1 cell response. Clin Infect Dis 37:628–633 61. Dalgleish AG, O’Byrne KJ (2002) Chronic immune activation and inflammation in the pathogenesis of AIDS and cancer. Adv Cancer Res 84:231–276 62. Widner B, Ledochowski M, Fuchs D (2000) Interferongamma-induced tryptophan degradation: neuropsychiatric and immunological consequences. Curr Drug Metab 1:193–204 63. Fahey JL, Taylor JM, Detels R, Hofmann B, Melmed R, Nishanian P, Giorgi JV (1990) The prognostic value of cellular and serologic markers in infection with human immunodeficiency virus type 1. N Engl J Med 322: 166–172 64. Fuchs D, Hausen A, Reibnegger G, Werner ER, WernerFelmayer G, Dierich MP, Wachter H (1991) Immune activation and the anaemia associated with chronic inflammatory disorders. Eur J Haematol 46:65–70 65. Kudo Y, Boyd CA (2000) Human placental indoleamine 2,3-dioxygenase: cellular localization and characterization of an enzyme preventing fetal rejection. Biochim Biophys Acta 1500:119–124 66. Caras I, Grigorescu A, Stavaru C, Radu DL, Mogos I, Szegli G, Salageanu A (2004) Evidence for immune defects in breast and lung cancer patients. Cancer Immunol Immunother 53:1146–1152 67. Pellegrin K, Neurauter G, Wirleitner B, Fleming AW, Peterson VM, Fuchs D (2005) Enhanced enzymatic degradation of tryptophan by indoleamine 2,3-dioxygenase contributes to the tryptophan-deficient state seen after major trauma. Shock 23:209–215 68. Bruera E (1997) ABC of palliative care. Anorexia, cachexia, and nutrition. Br Med J 315: 1219–1222 69. Moldawer LL, Copeland EM 3rd (1997) Proinflammatory cytokines, nutritional support, and the cachexia syndrome: interactions and therapeutic options. Cancer 79: 1828–1839

507 70. Weiss G, Schroecksnadel K, Mattle V, Winkler C, Konwalinka G, Fuchs D (2004) Possible role of cytokineinduced tryptophan degradation in anaemia of inflammation. Eur J Haematol 72:130–134 71. Iwagaki H, Hizuta A, Uomoto M, Takeuchi Y, Saito S, Tanaka N (1997) Cancer cachexia and depressive states: a neuro-endocrine-immunological disease? Acta Med Okayama 51:233–236 72. Billington CJ, Briggs JE, Harker S, Grace M, Levine AS (1994) Neuropeptide Y in hypothalamic paraventricular nucleus: a center coordinating energy metabolism. Am J Physiol 266:1765–1770 73. Kurzrock R (2001) The role of cytokines in cancer-related fatigue. Cancer 92:1684–1688 74. Weiss G, Wachter H, Fuchs D (1995) Linkage of cellmediated immunity to iron metabolism. Immunol Today 16:495–500 75. Selleri C, Maciejewski JP, Sato T, Young NS (1996) Interferon-gamma constitutively expressed in the stromal microenvironment of human marrow cultures mediates potent hematopoietic inhibition. Blood 87:4149–4157 76. Owens MJ, Nemeroff CB (1994) Role of serotonin in the pathophysiology of depression: focus on the serotonin transporter. Clin Chem 40:288–295 77. Heyes MP (1993) Quinolinic acid and inflammation. Ann NY Acad Sci 679:211–216 78. Murr C, Widner B, Sperner-Unterweger B, Ledochowski M, Schubert C, Fuchs D (2000) Immune reaction links disease progression in cancer patients with depression. Med Hypotheses 55:137–140 79. Maes M, Scharpe S, Meltzer HY, Okayli G, Bosmans E, D’Hondt P, Vanden Bossche BV, Cosyns P (1994) Increased neopterin and interferon-gamma secretion and lower availability of L-tryptophan in major depression: further evidence for an immune response. Psychiatry Res 54:143–160 80. Schroecksnadel K, Fiegl M, Winkler C, Denz HA, Fuchs D (2007) Diminished quality of life in patients with cancer correlates with tryptophan degradation. J Cancer Res Clin Oncol 133:477–485 81. Capuron L, Neurauter G, Musselman DL, Lawson DH, Nemeroff CB, Fuchs D, Miller AH (2003) Interferon-alphainduced changes in tryptophan metabolism, relationship to depression and paroxetine treatment. Biol Psychiatry 54:906–914 82. Jenny M, Klieber M, Zaknun D, Schroecksnadel S, Kurz K, Ledochowski M, Schennach H, Fuchs D (2010) In vitro testing for anti-inflammatory properties of compounds employing peripheral blood mononuclear cells freshly isolated from healthy donors. Inflamm Res (in press)

Subject Index

A AbraxaneTM , 41 Absorption of folate antagonists, 127 of oral busulfan, 420 of paclitaxel, 45, 50 of topotecan, 112 of vinorelbine, 29 ABVD (adriamycin, bleomycin, vinblastine and dacarbazine), 195, 200, 425 Acetaminophen, 439, 441–442 Achilles tendon, 32 ACNU, 68 Acquired drug resistance, 221 Acquired immunodeficiency syndrome (AIDS), 7–8, 13, 93, 180, 240, 242, 273, 332, 448 AcroContin system, 444 Acrolein, 62, 64, 77 Actinomycin, 28, 129, 200 Acute lymphoblastic leukemia (ALL) in adults, 412–413 different sources of HSCT in, 414 Acute lymphoblastic lymphoma (ALL), 125 Acute myeloid leukemia (AML), 350, 414–417 consolidation therapy, 415 prognostic factors, 415 source of HSCT, 415–416 strategies, 416–417 unrelated donor cells, uses, 416 Adaptive immune responses, 241, 497, 499 Adaptive immune system, 499 Adenine, 62, 64, 150, 153 Adenocarcinoma, 149, 259–260, 265, 288, 297, 324, 350, 483 Adenovirus, 72, 262, 266–267, 269, 295–296, 300–307 Adoptive immunotherapy (AIT), 285–292 clinical trials/translational research, 292 effector lymphocytes, 286–290 LAK cells and TILs, 287 problems of, 290–291 rationale of, 286 Adriamycin, 27, 48, 128, 145, 195, 199, 355, 423 Adult and childhood acute leukemias, 92 Adverse reactions, 31–32, 253

Aggressive lymphoma allogeneic transplantation for, 425 autologous transplantation for, 424–425 Agitation, 388 AICARFT, 126, 128, 136, 138 AIDS-related Kaposi’s sarcoma, 8, 13 Albumin, 12, 16, 29, 41, 44, 46, 109, 127, 241, 269, 301, 390, 503 Aldoketoreductases, 91 Alkaloids, vinca, see Vinca alkaloids Alkylating agents ADEPT, 71–72 alkyl sulfonate, 67 aziridines, 63–66 epoxides, 66 glutathione S-transferase-activated prodrug, 70–71 mechanism of action, 61–62 nitrogen mustards, 62–63 nitrosoureas, 67–69 resistance and modulation, 73–76 steroid conjugates, 72 toxicity, 76–78 triazene compounds, 69–70 Alkyl sulfonates, 67 Allergic reactions, 78, 182, 385, 394 Allogeneic BMT, 392, 395 Allogeneic transplantation ablative, 410 for aggressive lymphoma, 425 for indolent lymphoma, 424 using unrelated donors, 411 Alopecia, 7, 45–46, 77, 92, 94, 96, 115–117, 132, 411, 461 AMD473, 148, 154 American cancer society recommendations for practice, 488 American Cyanamid Laboratories, 88 American institute for cancer research persona recommendations, 488 American Society of Clinical Oncology (ASCO), 333, 463 Amines, secondary, 446 9-Aminocamptothecin (IDEC-132), 17 Aminopterin (4-Aminopteroic Acid, AMT), 134 Amitriptyline, 446 Analogs of cisplatin, 146–149

B.R. Minev (ed.), Cancer Management in Man: Chemotherapy, Biological Therapy, Hyperthermia and Supporting Measures, Cancer Growth and Progression 13, c Springer Science+Business Media B.V. 2011 DOI 10.1007/978-90-481-9704-0,

509

510 Anaphylactic reaction, 253 Androgens breast cancer therapy, 175 deprivation therapy, 180–181 Anemia, sustained IDO activity, 503–504 Angiofibromas, 346 Angiogenesis, 331–337 activators/inhibitors, 332 metronomic dosing of chemotherapy, 337 VEGF signaling, 331–336 Angiography, 341–342 Anorexia, 115–116, 179–180, 409, 474, 476 Anthracenediones, see Anthracyclines and anthracenediones Anthracyclines and anthracenediones antibiotics, 3 clinical uses, 91–93 drug interactions, 96–97 grading criteria for, 95 mechanism of action, 88–90 pharmacokinetics, 90–91 reduction of doxorubicin, 89 resistance, 93–94 structure of, 87–88 toxicity, 94–96 Anti-androgens, 182 Antibiotics, 3, 28, 127, 253 Antibodies -based therapies for solid tumors, 245–254 antibodies targeting VEGF, 246 bevacizumab, 246–248 to EGFR, 250 antibody vs. tyrosine kinase inhibitor, 250 biology/expression in cancer, 250 Antibody-directed abzyme prodrug therapy (ADAPT), 72 Antibody-directed enzyme prodrug therapy (ADEPT), 71–72 Anticancer agents, see Plant-derived natural products as anticancer agents Antidepressants, 438, 444–446 Antidiuretic hormone (ADH), 32 Antiemetic drugs, 76 Antiepileptic drugs (AED), 438, 445–446 Antifolates, 132 Antifungal macrolides, 50 Antigen presenting cells (APC), 110, 118, 237, 239–241, 265, 267, 273, 496, 499–501 Antigens melanoma, 258–259 TAA, 257–260 Antihistamines, 385 Antimetabolites, 125, 128, 133, 193–194, 198 Antimitotic agent, 4 Antitumoral potency activity, 303–304 chemotherapy and radiotherapy, 305 immune responses, 304 therapeutic genes, 304 Antitumor antibiotics, 16, 31, 46, 69–70, 147 Aplastic anemia, 388, 396 Aromatase inhibitors (AI), 165–173, 203 Ascites, 46, 109, 112, 130

Subject Index Assisted reproductive techniques (ART) for men semen cryopreservation, 201–202 TESE, 202 testicular germ cell transplantation, 202–203 for women cryopreservation of oocytes, 203 embryo cryopreservation, 203 ovarian tissue cryopreservation and transplantation, 203–204 Astrocytoma, 272 Ataxia, 32, 53 ATP, 93, 153, 250, 257, 319 ATP-binding cassette (ABC), 27–28, 70, 93–94, 108, 154, 351, 356 Autologous stem cell transplantation, 407–408, 417, 422 Autologous transplantation for aggressive lymphoma, 424–425 for indolent lymphoma, 423–424 Aziridines, 63–66 B BBR3464, 148–149 B cell lymphocytes, 218–220, 245, 352 lymphomas, 224, 226–227, 267, 271 BCNU, 67–69, 73, 75 Bevacizumab (avastin), 332–335 breast cancer, 247 colorectal carcinoma, 247 malignant glioma, 248 non-small-cell lung cancer, 247 ovarian cancer, 248 renal cell carcinoma, 247–248 side effects, 248 Bile, 30, 127–128, 342, 484 Bioavailability, 7, 12, 17, 29, 70, 112, 133, 148, 445, 481 Biotherapy, 332 Bladder cancer, 93, 130, 297, 388 Blast crisis, 320–321, 355 Bleeding, 171, 246, 248, 321, 334, 346, 387–390, 392, 439–441 Bleomycin, 3, 32, 145, 195, 427, 456 Blood brain barrier (BBB), 30, 32, 63–64, 70, 90, 94, 127, 448 Blood component therapy, 382–393 granulocyte transfusion, 390–392 plasma transfusion and coagulation factor, 392–393 platelet transfusion, 387–390 red cell transfusion, 382–387 Blood transfusion adverse effects of, 394 risks, 393–395 BMS-310705, 50, 53 Body mass index (BMI), 369, 474, 478–479, 482–484, 488 Body weight, 51, 474, 476, 478–479, 482, 488–489, 503 Bone fractures, 166 Bone marrow failure, 504 Bone marrow transplantation (BMT), 407–428 autologous stem cell transplantation, 407–408 disease indications, 412–428 myeloablative and NST, 410–412

Subject Index stem cell mobilization/collection, 408–410 transplants, statistics of, 412 Brain atrophy, 445 metastases, 247–248, 426 receptors (D1/D2/D3/D4), 461 stem, 447, 455 tumor, 7, 68–70, 248, 268, 272 Breast cancer, 13, 47–48, 427–428 androgens, 175 aromatase inhibitors, 167–173 cancer cells, 43, 73, 203, 303 estrogens, 167, 175–176 MX1 xenograft, 70 nutritional factors and survival in, 478–482 OFS with/without SERMs in premenopausal women, 173–174 progestational agents, 174 progesterone receptor antagonists, 174 SERM, 166–167 stem cells, 350 Breast cancer resistance protein (BCRP), 94, 108, 112, 155, 356 Bronchial carcinoma, 178 Buffy coat, 385 Buprenorphine, 444–445 Burkitt’s lymphoma, 129, 138, 221, 413, 423 Busulfan, 61, 67, 73, 76–77, 196–198, 202, 419–420 Butorphanol, 445 C Cachexia, 179–180, 474, 503–504 Camptothecin analogs biochemical effects, 14 in clinical use/trial, 15–17 irinotecan, 16 mechanism of action, 14–15 resistance, 15 supply, 15 topoisomerase I, 14 topotecan, 15–16 Cancer stem cells (CSC), 305–306, 350–351, 353, 356 Canertinib, 325 Cannabinoids, 462, 466–467 Capecitabine (Xeloda), 133–134, 138 Carboplatin, 13, 46, 49, 51–53, 112, 146, 149–151, 154, 158, 194–195, 247, 249, 323–324, 326–327, 333, 426, 456 Carcinogenesis, 78, 218, 221, 296, 482, 496 Carcinoid, 178, 248, 342 Carcinomas, 3, 5, 49, 64, 70, 94, 130, 133, 178, 248, 259, 286, 344 Cardiomyopathy, 92, 95 Cardiotoxicity, 87, 89–96, 249, 446 Carmustine, 67–68 Casopitant, 454–455, 460–461 Caspases, 153, 157 CCNU (lomustine), 67–68 CD45, 353 CD46, 297 Celecoxib Long Term Arthritis Safety Study (CLASS), 442

511 Cell adhesion-mediated drug resistance (CAM-DR), 217, 221, 354 Cell cycle, 5, 9–10, 14, 39, 41–42, 62, 75, 105, 113, 136, 152, 192, 198, 216, 218, 220, 222, 224, 227, 298, 319, 327, 349, 356, 500, 502 Cell-mediated immune response (CMI), 502 Cellular immunity therapy, 237, 240 toxicity, 496–498 transformation, 496 Central nervous system (CNS), 29–30, 129 Cerebrospinal fluid (CSF), 6, 109, 112, 127, 448, 453 Cervical cancer, 16, 107–108, 113, 266, 268, 297, 383, 486 Cervical intraepithelial neoplasia (CIN), 487 Cervix, 367–369 Cetuximab, 251–252 colorectal cancer, 252 head and neck cancer, 251–252 Chemo-radiotherapy, 382–383 Chemoresistance, 355 Chemotherapy effects in men animal studies, 192 clinical assessment, 192–193 combination/disease-specific considerations, 194–196 on spermatogenesis, 193–194 effects in women animal studies, 197 combination/disease-specific considerations, 199–201 germ cells toxicity, 197–199 on ovarian function, 197 in hematologic malignancies, 215–228 drug sensitivity/resistance, 217, 221–225 microenvironment-mediated drug resistance, 226 tumorigenesis/tumor cell survival, 217–221 tumor-stroma interaction/pathways, 225–227 Chemotherapy-induced nausea/vomiting (CINV), 455–456 clinical agents for treatment of, 456–462 cannabinoids, 462 casopitant, 460–461 corticosteroids, 461 dopamine-serotonin receptor antagonists, 458 fosaprepitant, 459–460 gabapentin, 462 olanzapine, 461–462 palonosetron, 457–458 serotonin (5-HT3) receptor antagonists, 456–457 substance P (NK-1) receptor antagonists aprepitant, 458–459 clinical management of multiple-day chemotherapy, 463–464 principles in management of CINV, 463 refractory therapy, 464 rescue therapy, 464 single day-chemotherapy, 463 Childhood acute leukemia, 8 Cholangiocarcinoma, see Hepatocellular carcinoma (eHCC) Cholinergic syndrome, 117 CHOP (cytoxan, hydroxyrubicin (adriamycin), oncovin (vincristine), prednisone), 27, 423 Choriocarcinoma, 129, 132

512 Chromatin, 89 Chronic lymphocytic leukemia (CLL), 417–419 allo-HSCT/auto-HSCT in, 418–419 auto-HSCT vs. allo-HSCT in, 419 Chronic myeloid leukemia (CML), 419–420 Cingulotomy, 447 Circulating tumor cells, 243, 496 Cirrhosis, 30, 128, 131, 445 Cisplatin, 145–149 carboplatin, 146 oxaliplatin and DACH complexes, 146–147 structures of, 146 CKD-602, 17 Clearance, 117, 251, 329 Cleavable complex, 6, 14, 89, 105 Clonidine, 446–448 Coagulation abnormalities, 388 Codeine, 439, 442–443 Coenzyme, 126, 128 Colon cancer, 7–8, 28, 50, 52, 68, 105–106, 135, 138, 147, 157, 246–247, 252–254, 268, 270, 301, 336, 351, 474, 484, 495, 500–501 Colorectal adenomatous polyps, 485 Colorectal cancer bevacizumab, 332–333 irinotecan, 106, 113 karenitecin (BNP-1350), 17 leukovorin, 134 metastatic, 106, 133, 252, 254, 325, 332–335, 372 nutritional factors and survival in, 483–486 oxaliplatin, 147 panitumumab, 245 Colorectal tumor cells, 501 Coma, 131, 439 Combination chemotherapy and disease-specific considerations, 194–196 in men high dosage chemotherapy and BMT, 196 lymphoma, 194–195 testicular cancer, 195 in women breast cancer, 199 high dosage chemotherapy and BMT, 200–201 lymphoma, 199–200 ovarian germ cell tumors, 200 Complementarity-determining regions (CDR), 245 Concanavalin A (Con A), 498 Constipation, 32, 442–443, 446, 461 COPP, 27, 194–195 Coronary artery disease, 409 Corticosteroids, 33, 107, 180, 183, 391, 445–446, 457, 461, 464 Cough, 33, 77, 131 Coxsackievirus A21, 302 Creatinine, 93, 114, 128, 130 R Cremophor -EL, 41, 44–46, 51, 53 Crigler-Najjar syndrome, 110 Cross link, 63–68 Cryopreservation of oocytes, 203 Cushing’s syndrome, 178 CXCR4, 303, 408–410 Cyclooxygenase 2 (COX-2), 301

Subject Index Cyclophosphamide immunosuppression, 78 metabolism, 64 myelosupression, 76 prodrug, 70 urotoxicity, 77 Cyclosporine, 33, 94, 97, 112, 306, 392, 396, 411, 418, 422 Cysteine, 73, 75, 240, 259 Cystitis, haemorrhagic, 62, 77 Cytarabine (ara C), 7, 223 Cytochrome P450, 33, 45, 62, 64, 70, 72, 75, 117, 183 Cytokines, 237–244 biomarkers, 243 categories of, 238 challenges associated with, 242–244 interferon-alpha, 241–242 interleukin-2 (IL-2), 239–241 to stimulate immunity, 240 Cytomegalovirus, 395 Cytosine arabinoside, 97, 130, 196 Cytoskeleton, 72 Cytotoxicity, 17, 27, 31, 41–43, 50, 67–68, 72, 74, 76–77, 128, 133, 135–136, 145, 147–153, 156, 249, 261–262, 272, 291 Cytotoxic T lymphocytes (CTL), 257 Cytoxan, 27 D Dacarbazine, 69–70, 195, 327, 456 DACH complexes, 146–147 Dactinomycin, 28 Dasatinib, 321–322 Daunorubicin, 3, 87–88, 90–92, 95–97 Dehydration, 117 Dendritic cell-based vaccines, 269–273 Depression sustained IDO activity, 503–504 Diflomotecan (BN-80915), 17 Dihydrofolate reductase (DHFR), 125–126 Diuresis, 130 DNA adducts, 64, 75, 78, 150–151, 155–156 alkylations, 64, 68 -based vaccines, 267–269 binding, 220 ability, 109 to anthracyclines, 89 cleavage, 89, 94 crosslinking, 62, 64, 72 damage, 10, 62, 72, 75, 105, 148, 151–154, 156–158, 482–484 polymerase, 68, 156–157 replication, 109, 152, 156, 240, 300 synthesis, 14, 125–126, 128, 130, 133, 150, 156 viruses, 300 Docetaxel (TaxotereTM ), 3, 8 and anthracycline, 47 for lung cancer, 13 for metastatic lung cancer, 49 for NSCLC, 108 and paclitaxel, 12–13, 41–47, 49 plus prednisone, 48

Subject Index plus ZD6474, 336 side effects, 46 vandetanib, 326 Donor lymphocytes, 396 Dopamine, 179, 453–455, 458, 461 Dose limiting toxicity (DLT), 115 Dose-response effects, 365–368 Double-minute chromosomes, 133 Doxorubicin, 87, 89–92, 94–96, 194, 198, 249, 342 Droperidol, 454 Drug clearance combination, 16, 72–73, 136, 156, 447 delivery, 13, 77, 438, 444, 448 interactions, 33, 96, 110, 117–118, 128, 446 resistance, 93–94, 153–154, 222, 224 Drug effects on spermatogenesis, 193–194 high toxicity to germinal epithelium, 193–194 low toxicity to male germ cells, 194 Drug sensitivity/resistance, 221–225 acquired drug resistance, 224–225 de novo drug resistance, 222–224 Dual antibody therapy, 253–254 Ductal carcinoma, 350 Dyspnea, 33, 46, 77, 131, 462 E E1A, 301–302, 305–306 Early breast cancer, neo-adjuvant treatment, 48 E1B-55kD gene, 295 Ectopic ACTH syndrome, 165, 171, 178 Edatrexate (10-Ethyldeazaaminopterin), 134 Edema, 46, 241, 321, 328, 394 Edmonston vaccine strain, 297 Effector cells, 257, 285–291 Effector lymphocytes first generation LAK cells, 286 TILs, 286–287 novel effector cells, 289–290 γ δT cells, 290 NKT cells, 289–290 second generation tumor cell engineering, 288 in vitro tumor sensitization technique, 287–288 whole tumor cells, 287–288 third generation peptide/DC system, 288 tumor lysate/fusion on DC system, 288–289 tumor RNA/DC system, 289 use of DCs, 288–289 Effects of nutritional support on chemotherapy, see Nutrition in management of cancer patient EGFR and HER2 tyrosine kinase inhibitors, 322 EIF4E, 303 Embryo cryopreservation, 203 Emesis, mechanisms of, 453–455 anatomy, 453 antiemetic/dopamine receptor antagonists, 453–454 dopamine-serotonin receptor antagonists, 455 neurotransmitters and receptors, 453–454 pathways of, 454

513 patient-related risk factors, 456 risk groups with agents, 456 serotonin (5-HT3) receptor antagonists, 455, 457 substance P receptor antagonists, 455 Encephalopathy, 131, 334, 342 Endometrial cancer, 176–177 Enhanced tryptophan degradation, 502–503 Enteral nutrition (tube feeding), 476 Enzyme-inducing anti-epileptic drugs (EIAED), 107 Enzyme-linked immunosorbent assay (ELISA), 28–29 Epistaxis, 334, 346 Epothilones BMS-310705, 53 clinical activity, 51 ixabepilone (ixempra), 51–52 KOS-862 (Epothilone D), 53–54 microtubules, 39–40 patupilone (EPO906), 52–53 phase I studies of, 53 sagopilone (ZK-EPO), 54 Epoxides, 66 Erlotinib, 323–325 Erythema, 33 Erythrocytes, 76 Esophagus, 369 Estrogen therapy breast cancer, 166–167, 175–176 prostate cancer, 181 receptor down-regulators, 167 SERM, 166–167 Etopohos, 5 Etoposide (VP16-213), 3–4 Eukaryotic cells, 39 European Organization for Research and Treatment of Cancer (EORTC), 416 Ewing’s sarcoma, 27 Exactecan, 17 F Febrile transfusion reactions, 384, 389, 393 Fentanyl, 442–444, 447 Fibroblast growth factor (FGF), 218–219 Fibronectin (FN), 222–223, 354 Fibrosis, 77, 95, 128, 131–132, 197 Flavoprotein, 89 Flt3 ligandmobilized DC (FLDC), 269 5-Fluorouracil (5-FU, Efudex), 16, 42, 105–106, 115, 126, 129–130, 133–134, 138, 147, 173, 192, 198–199, 247, 251, 305, 332–333, 335 Folates, 125–127, 129, 133–135 antifolate resistance, 132 aquired resistance, 132–133 distribution, 127 drug interactions, 128 excretion, 128 intrinsic resistance, 132 mechanism of action, 126–127 metabolism, 125–128, 137 and MTX, 130–132, 138 neoplastic treatments, 128–130 new antagonists, 134–136

514 Folates (cont.) pharmacokinetics, 127 -related agents, 133–134, 138 Folic acid, 32, 125, 127–128, 135, 477, 486–487 Folylpolyglutamyl synthase (FPGS), 126 Formaldehyde, 500 Fosaprepitant, 459–460 Fragmentation of DNA, 260 Free radical, 89–90, 94, 482 Frozen blood, 386 G G92A, 301 Gabapentin, 446, 462, 467 GARFT, 126, 128, 134–136, 138 Gastric cancer, 8, 50, 130, 246, 248, 253, 287, 366, 371–372, 385, 474 Gastrointestinal (GI) tract, 453 bleeding, 439–440 cancer, 68, 130, 134 disturbances, 7 toxicity, 76, 130–132, 146 Gefitinib, 322–323 Gene-directed abzyme/enzyme prodrug therapy (GDEPT), 71–72 Gene gun, 267 Genome, 237, 264, 298, 302 Germ cell tumor (GCT), 426 Germinal epithelium toxicity, 193–194 Gilbert syndrome, 110, 113–114 Gimatecan, 17, 103 Glioblastoma, 107, 268, 272, 306, 323–324, 367 Glioma, 248 Glucocorticoid receptors, 178 Glutamine, 50 Glutathione S-transferase-activated prodrug, 70–71 GLV-1h68, 298–300 Gonadal function, chemotherapy on animal models, 192 counseling patients, 201–206 hormonal manipulation to prevent infertility, 204–205 hormone replacement therapy, 205 in men, 191–196 mutagenic potential of, 205–206 in women, 196–201 Gonadotropin-releasing hormone, 180, 204 Graft-vs.-host disease (GVHD), 395–396, 408, 411–414, 416–420, 422, 424, 426–427 Granulocyte-macrophage colony stimulating factor (GM-CSF), 238, 268, 273 Granulocyte transfusion, 390–392 components/administration, 391–392 guidelines, 391 neutropenic infection, 390–391 Granulosa cells, 196 Gruppo Italiano Malattie Ematologiche Maligne dell’ Adulto (GIMEMA), 416 GTP cyclohydrolase I (GCH), 497–498, 500 Guanosine 5-triphoshpate (GTP), 26 Gynecology Oncology Group (GOG), 49, 176–177

Subject Index H H101, 296, 305, 308 Hageman factor (FXII), 393 Hairy cell leukemia (HCL), 240, 242 Hand-foot syndrome, 95, 133, 325, 335–336 Headache, 117, 131, 273, 325, 409, 446, 455, 457 Head and neck cancers, 54, 93, 130, 134, 136, 138, 248, 251, 253, 305, 345–346, 351, 486 Healthy diet, 504 Heart allografts, 498 disease, 179 failure, 95–96 Heat shock protein (HSP) 70, 270 Hematological malignancy, 412–414 ALL in adults, 412–413 graft vs. leukemia effect in ALL, 413–414 HSCT in ALL, 413–414 patients support, 381–397 blood component therapy, 382–393 cytomegalovirus infection, 395 physician’s role in transfusion safety, 396 TA-GVHD, 395–396 transfusion risks, 393–395 tumors, 217–221 See also Chemotherapy Hematologic tumorigenesis and tumor cell survival, 217–221 B cell activating-factor, 220–221 interleukin-6, 219–220 transforming growth factor-β, 218 VEGF and FGF, 218–219 Hematopoietic recovery, 179–180 Hematopoietic stem and progenitor cells (HPC) collection, 409–410 mobilization, mechanism of, 408–409 Hematopoietic stem cells (HSC), 67, 76, 349–352, 396, 407, 411, 419, 464 Hematopoietic stem cell transplantation (HSCT), 407 in ALL, 413 different sources in ALL, 414 Hematopoietic suppression, 76 Hemoglobin, 328, 382–384, 386–387 Hemoglobin oxygen carrier (HBOC), 386 Hemolysis, 382, 388 Heparin, 96, 306 Hepatic artery embolization, 178, 342 Hepatic neoplasms, 341–344 Hepatic stem cells, 349 Hepatitis, 241, 341, 393, 395, 397 Hepatobiliary system, 30 Hepatoblastoma, 27 Hepatocellular carcinoma (eHCC), 341 Hepatocytes, 30, 241, 302 Hepatoma, 133, 305, 307, 341 Hepatotoxicity, 131 HER-2/neu proto-oncogene, 248 Herpes simplex virus-1 (HSV-1), 266, 295, 300–303, 305–306 Heterogeneity of cancer, 438 Hexitol derivatives, see Epoxides

Subject Index High-dose chemotherapy (HDT) for primary therapy of high risk disease, 426–427 for relapsed refractory disease, 426 High pressure liquid chromatography (HPLC), 28 HLA compatible donors, 390 Hodgkin’s disease, 425–426 Hormonal therapy breast cancer, 165–176 cancer anorexia and cachexia, 179–180 ectopic ACTH syndrome, 178 endometrial cancer, 176–177 hematopoietic recovery, 179–180 meningioma, 178 neuroendocrine tumors, 178–179 ovarian cancer, 176 pituitary adenoma, 179 prostate cancer, 180–183 uterine sarcomas, 177–178 Hormone-refractory prostate cancer (HRPC), 48, 273 Hormone replacement therapy (HRT), 484 estrogen deficiency, 205 Leydig cell dysfunction, 205 Host immune response, 306–307 Human epithelioma, 250 Human immunodeficiency virus (HIV) infection, 242, 393–394, 396, 502 Human telomerase reverse transcriptase (hTRT), 258, 271, 301 Hybrid-systems, 373 Hydrocodone, 439, 442 Hydromorphone, 442–444, 447 3-Hydroxy-anthranilic acid, 504 Hypercalcemia, 351 Hyperglycemia, 328, 476 Hyperthermia, 365–374 chemoperfusion, 370–372 intraperitoneal/vesical perfusion, 372 isolated perfusion of limb/liver/lung, 370–371 clinical application, 366 thermal dose and dose-response correlation, 365–366 Hyperthermia-induced gene therapy (HIGT), 373 Hyperventilation, 439 Hypocalcemia, 393, 409 Hypogonadism, 179 Hyponatremia, 32, 53 Hypotension, 32, 46, 112, 241, 444, 446 Hypothalamus, 32, 181, 197 Hypothermia, 394 Hypoxia, 105, 246, 332, 349 I Ibuprofen, 439, 441–442 ICP4, 300–302 IDO-mediated tryptophan catabolism, 499–502 Ifosfamide, 62–63, 77, 129, 193–194, 369, 413, 426 Imatinib, 320–321, 420 Immune thrombocytopenic purpura (ITP), 390 Immunoconjugates, 423 Immunodeficiency, 499–500, 502–503 Immunoglobulin, 220, 246, 252, 271, 352–354, 417–418, 498 Immunomodulator, 227, 298, 306–307, 351, 384, 497 Immunostimulating agents, 260

515 Immunosuppressed hosts, 265, 269 Immunosuppression, 78, 264, 411–412, 417, 422, 427, 475, 499–500, 502 Immunotherapy, 285–292 Impaired immune responsiveness, 496 Indoleamine IFN-γ, role of, 498–500 immunodeficiency, 502–503 -mediated tryptophan catabolism, 499–502 IFN-≈ inducing, 499–500 in patients with malignant disease, 500–502 nutrition and tryptophan availability, 504–505 role of, 495 sustained activity, 503–504 tumor and host interactions, 496–498 tumor immune escape, 496–498 Indolent lymphoma allogeneic transplantation for, 424 autologous transplantation for, 423–424 Induced hyperthermia, 365–374 chemoperfusion, 370–372 classification, 365–366 local hyperthermia, 366–367 locoregional hyperthermia, 369 regional radiofrequency hyperthermia, 367–369 whole-body hyperthermia (WBH), 370 Infection cytomegalovirus, 395 HIV, 242, 393–394, 396, 502 neutropenic, 390–391 NST, 411–412 respiratory failure, 300 risk factors of, 393–397, 422, 448, 475–476 Inflammatory breast carcinoma, 350 Influenza, 295, 301, 307 Infusion bolus, 27, 29, 133 hepatic artery, 307 intravenous, 16–17, 44, 51, 109, 113, 133, 240–241 ixabepilone, 51 KOS-862, 53 Nab-paclitaxel, 46–47 oxaliplatin, 150 paclitaxel, 45–47 transcatheter, 346 Intercellular adhesion molecule ICAM-1, 257 Interferon (IFN), 328, 332, 496 -α (IFN-α), 241–242 -γ (IFN-γ), 499–500 Interleukin -2 (IL-2), 239–241, 285 -3 (IL-3), 271 Internal ribosomal entry site (IRES), 301 International Germ Cell Cancer Collaborative Group (IGCCCG), 426 Intestine, 110, 127 Intra-arterial chemoembolization, 345 Intra-arterial infusion chemotherapy, 90, 92, 345 Intrathecal pump, 448 Invariant TCR+ NKT cells, 289 Invasive lobular carcinoma, 350

516 Irinotecan, 16 clinical use, 105–107 dose adjustments, 114–115 drug interactions, 118 pharmacokinetics, 109–112 toxicity, 117 Iron, 89, 382, 393, 497, 504 Irradiation, 96, 117, 127, 179, 196, 201, 205, 367, 382, 394, 396, 417, 420 Ixabepilone (Ixempra), 11, 50–53 K Kaposi’s sarcoma, 7–8, 13, 92–93, 240, 332 Karenitecin (BNP-1350), 17, 103 Karnofsky performance, 328 Ketamine, 445 KOS-862 (Epothilone D), 50, 53–54 Kynurenine metabolism, 504 L L1210, 5, 14, 67, 94, 145 Lapatinib, 325 Lethargy, 335 Leucopenia, 32, 96, 116 Leucovorin, 105–106, 115, 127, 134, 147, 195, 247, 333 Leukapheresis, 273, 391 Leukemia acute, 128 acute lymphoblastic, 7–8, 128, 196, 223, 412–413 acute lymphocytic, 27, 92, 218, 387 acute myelogenous, 7, 92, 305, 381 acute nonlymphocytic, 96, 128, 474 adult, 92, 412–413, 501 childhood acute, 8 chronic lymphocytic, 218, 223, 417–418 chronic myelocytic, 125 chronic myelogenous, 222, 242, 410 chronic myeloid, 67, 320, 355, 419–420 hairy cell, 240, 242 L1210, 5, 14, 145 lymphocytic, 92, 96, 128, 218, 223, 387, 417–418 meningeal, 128 monocytic, 7–8 myelogenous, 7, 92, 222, 242, 295, 305, 381, 410 myelomonocytic, 7–8 P388, 93 Lewis lung carcinoma, 336 Leydig cell dysfunction, 192, 205 Limb perfusion, 365–366, 370–371 Lipids, 319, 484 Liposomes, 93, 260, 306, 373–374, 390 Liver cyclophos-phamide, activation of, 62 dysfunction, 93 enzymes, 131, 179 hyperthermic isolated perfusion, 370–371 metastases, 30, 114, 246, 495 toxicity, 174, 302 transplantation, 178, 384, 394 uptake of vinca alkaloids, 30, 33

Subject Index Local hyperthermia, 366–367 Locoregional hyperthermia, 369 Lometrexol (5–10-Dideazatetrahydrofolate, DDTHF, LMTX), 135 Lomustine, 67–68 L-threonine, 50–51, 328 Lung cancer, 13, 49, 130 carcinoma, 5, 259 lymph node metastases, 366–367, 371 melanoma, 387 NSCLC, 247 SCLC, 7–8, 16, 91, 107, 113, 136, 154, 260, 326 Lurotecan, 17 Lymphoblasts, 126 Lymphocyte function antigens (LFA-1/LFA-3), 257 Lymphocytes autologous, 285–292 B cell, 218–220, 245, 352 donor, 396 effector, see Effector lymphocytes splenic, 220 T lymphocytes, see T lymphocytes Lymphokine-activated killer (LAK) cells, 285–286 Lymphoma Burkitt’s, 129, 221 non Hodgkin’s, 3, 8, 27, 138, 191, 195, 200, 218, 222, 408, 423, 473–474 Lymphoproliferative disease, 226 Lysine, 68 M Macromolecules, 66, 78 Macrophages, 95, 263, 268, 273, 497–502 Macular papular rash, 46 Magnetic fluid hyperthermia (MFH), 373 Magnetic resonance image (MRI), 178, 272, 341–342 Major histocompatibility complex (MHC), 239–240, 257–266, 269–270, 300, 496, 498–499 Male germ cells toxicity, 194 Malignant mesothelioma, 135, 287 Malnutrition, 473–474, 477 Mammalian target of rapamycin kinase (mTOR) inhibitor, 327 Mammals, 218, 265, 267, 327, 455, 497 Mammary gland cancer, 481 epithelial, 303 MX1, 70 Marrow infusion, 407, 409–410 Matched unrelated donor (MUD) transplants, 414, 416–419 Maximum tolerated dose (MTD), 46, 52–54, 149, 251, 307, 331, 336, 461 Measles virus, 266, 296–297, 303–307 Measles virus Edmonston strain (MV-Edm), 266–267 Melanoma, 51, 54, 69–70, 73, 94, 220, 240–244, 257–273, 286–289, 291, 307, 327, 336, 341, 356–357, 366–367, 370–371, 387, 500–502, 504 Meningioma, 178 Meperidine, 443, 445 Metaphase arrest, 6

Subject Index Metastases, 32, 92, 114, 129, 176, 178, 181, 217, 238–239, 246–248, 250, 261, 266–269, 271, 274, 287, 297, 304, 307, 331, 334–335, 341, 344–346, 366–367, 371–372, 385, 426, 440, 446, 495–496, 501 Metastatic breast cancer (MBC), 12–13, 27, 43, 45, 47–48, 51–52, 129, 133, 148, 168, 171, 247, 249–250, 272, 333–334, 336–337, 427–428 Metastatic renal cell cancer (RCC), 286, 427 Methadone, 443, 445 Methotrexate metabolism of, 127–128 monoglutamate, 125 MTX, 125–139, 192, 194–195, 199, 412–413, 418 Methylenetetrahydrofolate dehydrogenase (MTHFD), 126 Metronomic therapy, 337 Microfilaments, 39–41 Micrometastases, 191 Microsomes, 110 Microtubule-binding proteins (MAP), 42, 152, 157, 219 Microtubules, 5, 9–12, 25–27, 29, 32, 39–42, 44, 50–51, 72 Minimal residual disease, 216–217, 221, 225–226, 228, 423–424 miRNAs, 302 Mitogens, 497–498, 500 Mixed lymphocyte tumor culture (MLTC), 287–288 Modified vaccinia virus Ankara (MVA), 265 Monoclonal antibody (MAb), 29, 95, 106, 219, 227–228, 242, 245–246, 249–250, 254, 303, 319–320, 332, 373–374, 396, 423, 425, 428 Monocytic leukemia, 7–8 Mononucleosis-like syndrome, 395 Morphine, 442–448, 455 Morphine-3-glucuronide (M3G), 445 Morphine-6-glucuronide (M6G), 445 MTX toxicities bone, 132 CNS, 131 gastrointestinal, 131 hematologic, 130 hepatotoxicity, 131 pulmonary, 131–132 renal, 130–131 skin, 132 teratogenic and mutagenic, 132 Multidrug resistance-associated protein (MRP), 28, 70–71, 73, 94, 108, 154 Multidrug resistance protein (MDR), 12, 15, 17, 27–28, 42, 74, 93–94, 96–97, 157, 355 MDR1, 28, 32 -related proteins (MRP), 94 Multinational Association Supportive Care in Cancer (MASCC), 463 Multiple-day chemotherapy, 463–464, 466–467 Multiple myeloma (MM), 351–352, 421–422 allogeneic transplantation, 422 characteristics of early vs. late cells, 354 clonal B cells in, 352–353 differentiation, 353–354

517 other cancer stem cells, 356 pathological characteristics of early cells, 354–355 single auto transplant vs. conventional dose therapy alone, 421 tandem vs. single auto transplant, 421–422 Murine mastocytoma, 5 Muscle pain, 32 Myeloablative and NST, 410–412 ablative allogeneic transplant, 410 acute myeloid leukemia, 414–417 allogeneic transplantation, 411 breast cancer, 427–428 CLL, 417–419 CML, 419–420 comparison, 411–412 graft-vs.-host disease (GVHD), 411 hematological malignancy, 412–414 Hodgkin’s disease, 425–426 multiple myeloma (MM), 421–422 NHL and Hodgkin disease, 423–425 renal cell cancer, 427 solid tumors, 426–427 Myelodysplatic syndrome, 75, 107–108 Myelogenous leukemia, 7, 92, 222, 242, 295, 305, 381 Myeloid cells, 270, 414–416, 419 Myelomonocytic leukemia, 8 Myelosuppression, 6–7, 31–32, 52, 62, 69, 90, 92–94, 97, 110, 112, 114–115, 117, 150, 321, 421, 423 Myelotoxicity, 69, 115 Myxoma virus (MYXV), 296, 306 N Nab-paclitaxel, 41–42, 44–49 NADPH oxidase, 43, 72, 89, 497 Naproxen, 128, 440–441 Narcotic analgesics, 447 National Comprehensive Cancer Network (NCCN), 273, 462–463 Natural killer cells (NKC), 285, 416, 496, 502 CINV, 458–459 NKT cells, 289–290 Nausea/vomiting in cancer patients, 453–467 CINV, 455–456 mechanisms of emesis, 453–455 opioid-induced chronic nausea and emesis, 464–465 radiation-induced emesis, 464 Neoplastic treatments acute leukemia, 128 breast cancer, 129 choriocarcinoma, 129 gastrointestinal cancer, 130 genitourinary cancer, 130 head and neck cancer, 130 lung cancer, 130 lymphoma, 128–129 neoplastic meningitis, 130 osteogenic sarcoma, 129 Nephrectomy, 344–345 Nephron-sparing surgery, 344 Nephrotoxicity, 127, 146, 149–150

518 Nervous system, 438 central nervous system (CNS), 30, 32, 70, 76, 129, 272, 334, 439, 442, 445, 447, 453 sympathetic nervous system, 503 Neural stem cells, 349 Neuroblastoma cells, 105, 118, 306 Neuroendocrine tumors, 165, 178–179, 341 Neurologic deficits, toxicity, 53 Neuropathy, peripheral, 7, 29, 31–32, 46–47, 51–53, 446 Neurotoxicity, 27, 31–33, 46, 54, 127, 129, 131, 146–147, 149–150 Neutropenia, 16, 29, 44–49, 51–53, 92, 107, 111, 113–118, 130, 135, 148–150, 321–322, 381, 387–388, 390–391, 408, 461 Newcastle disease virus (NDV), 296–297, 304, 307 NHL and Hodgkin disease, 423–425 allogeneic transplantation for indolent lymphoma, 424 allogeneic transplant for aggressive lymphoma, 425 autologous transplantation for aggressive lymphoma, 424–425 autologous transplantation for indolent lymphoma, 423–424 Nilotinib, 322 Nitric oxide synthase (NOS), 497–498, 500 9-Nitrocamptothecin (Rubitecan), 17, 103 Nitrogen mustards, 62–63 Nitrosoureas, 67–69 BCNU activation and guanine alkylation, 69 structures of, 68 N-methyl-D-aspartate (NMDA) receptor, 445, 447, 504 Nociceptors, 438 Nolatrexed (Thymitaq, AG337), 136, 138 Non-Hodgkin’s lymphomas (NHL), 3, 8, 138, 191, 195, 200, 218–219, 222, 226, 408–410, 423–425, 473–474 Non-myeloablative stem cell transplants (NST), 411 with fully myeloablative HSCT, comparison, 411–412 incidence of GVHD, 412 infections, 411–412 transfusion requirement, 412 Non-opioid analgesics, 439 acetaminophen, 439 aspirin, 439 COX-2 inhibitors, 440 morphine, 442 NSAIDs, 439–440 tramadol, 442 Non-small-cell lung cancer (NSCLC), 27, 107 and acetaminophen, 439 alkaloid natural products, 7–8, 12–13, 16, 25–33 hematologic tumors, 216–221, 223, 226–228, 385 Hodgkin’s lymphomas, 27 melanoma skin cancer, 51 NSAID, 439–440 Nonsteroidal anti-inflammatory drugs (NSAID), 128, 392, 439–440, 442, 445 Norepinephrine, 304, 438, 445 Normothermia, 371 Nucleic acid, 27, 88, 148, 155, 300, 394 Nutritional status, 473 support, 477 support of cancer patients, 473 support on chemotheraphy, effects of, 474–475

Subject Index support on surgery, effects of, 475, 477, 481 support on tumor response, effects of, 474, 486 Nutrition and tryptophan availability, 504–505 Nutrition in management of cancer patient, 473–489 American cancer society recommendations, 488 dietary counseling strategies, 476 factors and recurrence/survival risk, 477–489 randomized controlled trials for (CIN), 487 treatment/recovery, 474–477 O Obesity, 410, 474, 478–479, 482–484 Olanzapine, 446, 461–462, 464, 466–467 Oncogenesis, 263, 349 Oncogenic viruses, 319 Oncolytic virotherapy antitumoral potency activity, 303–304 chemotherapy and radiotherapy, 305 immune responses, 304 therapeutic gene expression, 304 cancer stem cells, 305–306 clinical trials, 307 tumor selectivity inherent, 296–298 mRNA stability, 301–302 mRNA translational control, 302–303 transcriptional targeting, 301 transductional targeting, 303 viral gene inactivation, 298–301 ONYX-015, 295–296, 300–301, 305, 307 Opioid analgesics in U.S., 443 Opioid-induced chronic nausea and emesis, 464–465 Organ failure, sustained IDO activity, 503–504 OSI-211, 17, 103 Osteogenic sarcoma, 129 Osteoporosis, 132, 166–167, 205, 351, 477 Osteosarcoma, 125, 129, 132, 138, 193 Ovarian cancer, 13, 113, 176, 248 Ovarian function suppression (OFS), 165, 173–175, 183 Ovarian tissue cryopreservation and transplantation, 203–204 Ovary Chinese hamster, 222 germ cell tumors, 200 postnatal, 196 Overweight, 474, 479, 484, 488 Oxaliplatin, 134–135, 145–151, 154, 157, 254, 335, 426 R Oxycontin , 442–445 P Paclitaxel, 8–13, 45 analogs, 11–12 and docetaxel, 12–13 mechanism of action, 9–10 metabolism, 12 resistance, 12 -tubulin interaction, 10–11 Pain and cancer patient, 437 management, 439–449 cancer pain types, 438–439

Subject Index pharmacological, 439–447 surgical, 447–449 relief, 444–445, 447–449 suppression, 437–440, 442–446, 448–449 types, cancer assessment, 438–439 neuropathic pain, 438 nociceptive pain, 438 Palliation, 346 Palliative care blunt (non-chemotherapy) embolization, 346 fentanyl, 444 hormonal therapy, 165, 180–181, 183 mitoxantrone, 93 olanzapine, 461 peritonectomy, 372 Palmar-plantar erythrodysesthesia syndrome (PPES), 95 Palonosetron, 454, 457–458, 462–467 Pamidronate or zolendronate, 446 Pancreatic cancer capecitabine and oxaliplatin, 134 irinotecan use in, 107 K-ras mutation in, 253 TMTX, 134 Panitumumab, 252–253 Paragangliomas, 346 Patupilone (EPO906), 52–53 PBMC, 265, 355, 497, 504, 260 Pemetrexed (LY231514), 135–136 Peptide/DC system, 288–289 Peptide vaccines, 260–264, 274 Pericarditis-myocarditis syndrome, 96 Peripheral blood stem cells (PBSC), 76, 355, 407–408, 414–416, 418, 421, 423 Pharmacological management of cancer pain, 439–447 adjuvant analgesic, 439 non-opioid analgesics, 439 three-level analgesic ladder, 439, 449 Pituitary adenoma, 165, 179 Plant alkaloids neoplasms, 4–5 Plant-derived natural products as anticancer agents camptothecin analogs, 13–17 paclitaxel analogs, 8–13 podophyllotoxin derivatives, 3–8 Plasma cell leukemia, 218, 352 components, 393 concentrations, 29–30, 44, 77, 109, 112, 127, 134, 481, 486 irinotecan, 109, 111 membrane, 90, 319 MTX levels, 131, 134 multiple myeloma cells, 351–355 proteins, 16, 29, 45, 109, 127, 149–150, 246, 385, 388 Plasmacytoma, 218 Plasma transfusion/coagulopathy, 392–393 components, 393 guidelines for treatment, 392–393 hemostasis, 392 Platelet antigens, 382, 389 count, 76, 115–116, 387–390, 396, 410

519 depression, 76 function, 387, 440 specific antigens, 390 transfusion, 387–390 guidelines for, 387–388 leukocyte-reduced platelets, 388–389 management of platelet refractoriness, 390 platelet components, 388 refractoriness to platelets, 389–390 thrombocytopenia, 387 thrombopoietin and platelet substitutes, 390 Platinum complexes AMD473, 148 BBR3464, 148–149 cisplatin, 145–149 identification of new analogs, 149 induced cell death, 150–153 apoptosis/terminal phase, 153 damage recognition, 151–152 decision/commitment phase, 152–153 DNA adducts, 150–151 pharmacokinetics, 149–150 pharmacology, 149–150 PVB, 195 resistance, 153–158 DNA damage tolerance, 156–158 DNA repair, 155–156 inactivation, 155 reduced accumulation, 154–155 satraplatin (JM216), 147–148 toxicity, 150 P388 leukemia, 93–94 P-815 leukemia, 5 Plural effusions, 350 Podophyllotoxin derivatives, 3–8 clinical combination therapy, 7 clinical single agent activity, 6–7 etopohos, 5 etoposide, 4 new analogs in development, 7–8 pharmacology, 6 structure and mechanism of action, 5–6 teniposide, 4 toxicity, 7 in vitro and in vivo assay systems, 5 Polymorphic epithelial mucin (PEM), 259 Polyp Prevention Trial (PPT), 484 Post-embolization syndrome, 343–344, 346 Prednimustine, 72 Prednisolone, 72, 180, 194–195, 200 Prednisone, 27, 48–49, 148, 194–195, 199, 391, 421, 423 Premenopausal women, hormonal therapy, 175 Progenitor cells, 130, 272, 307, 349, 357, 407–408, 503–504 Progestational agents, 166, 174, 176–177 Progesterone receptor antagonists, 166, 174, 178 Propoxyphene, 442–443, 445 Prostate cancer androgen-deprivation therapy, 180–181 anti-androgens, 182 estrogen agonists, 181 LHRH agonists, 181

520 Prostate cancer (cont.) LHRH antagonists, 182 nutritional factors and survival in, 482–483 secondary hormonal manipulations, 182–183 Prostate-specific antigen (PSA), 49, 51, 181–183, 266, 271, 301, 483 Protein kinase inhibitors, 319–328 canertinib, 325 C-Kit and BCR-ABL tyrosine kinases, 320–321 dasatinib, 321–322 downstream signalling pathway and EGFR receptor inhibitors, 323 EGFR and HER2 (TKI), 322 erlotinib, 323–325 gefitinib, 322–323 lapatinib, 325 mTOR inhibitor, 327 nilotinib, 322 Raf kinase inhibitors, 327 sorafenib, 327 sunitinib, 325–326 temsirolimus, 328 tyrosine kinase inhibitors (VEGF), 320, 325 vandetanib, 326–327 VEGF pathway and its inhibitors, 326 Protein synthesis, 150, 297, 300, 327, 474 Proteinuria, 246, 248, 334, 336 Pulmonary edema fibrosis, 77, 132 metastases, 267–269 toxicity, 33, 77, 131–132, 149 tumors, 271 Pulmonary toxicity, 77 Purged bone marrow, 408, 419, 424 Purines, 62, 75, 126, 130, 134–136 analogs synthesis, 126, 130, 135–136 PVB (cisplatin, vincristine and bleomycin), 195 Q Quality of life, 106, 173, 180, 251, 383, 421, 446, 456, 473, 476, 501, 504–505 Quninolinic acid, 504 R Radiation -induced emesis, 464 induced Hodgkin’s disease, 195, 425 therapy, 6, 96, 176–178, 181, 191, 195, 251, 266, 383, 425, 453, 455, 475–477 Radiofrequency ablation (RFA), 344, 365, 447 Radiolabeled drug, 30 Radiotherapy and chemotherapy, 61, 221, 239, 274, 296, 303, 305, 307–308, 351, 366, 368, 382–383, 464 Raf kinase inhibitors, 327 RAGE (renal carcinoma antigen gene), 259 Raltitrexed (Tomudex), 134–135 Reactive oxygen species (ROS), 43–44, 497 Receptors antiemetic, 454 dopamine, 453–454 dopamine-serotonin, 455, 458

Subject Index down-regulators, 167 EGFR, 323 estrogen, 167 glucocorticoid, 178 neurotransmitters and, 453 NRTK, 319–322 progesterone, 166, 174, 178 RTK, 43, 227, 250, 319, 322, 325 SERM, 166–167, 173, 176–177, 183 serotonin (5-HT3), 455–457 substance P (NK-1), 455, 458–459 T cell, 240, 289–291, 302 Receptor for HA-mediated motility (RHAMM), 354 Recirculation, 355 Recombant DNA technology, 267 Recombinant fowlpox virus, 265 Recombinant vaccinia virus (rVV), 265–266, 298 Rectal cancer, 134, 246, 333, 368–369 suppository, 440–441 Red blood cell transfusion, 382–387, 389 allo-immunization to red blood cells, 386 artificial oxygen carriers, 386–387 frozen blood, 386 leukocyte-reduced blood, 384–385 packed red blood cells, 384 washed blood, 385–386 whole blood, 384 Refractory emesis, 464 Refractory therapy, 464 Regional radiofrequency hyperthermia, 366–369, 372 Renal angiomyolipomas, 344 Renal artery embolization cancer, 272 damage, 130–131 dysfunction, 31, 33, 91, 93, 113–114, 351 failure, 130, 150, 439–440 function, 93, 112, 114, 128, 130 insufficiency, 31, 114, 178, 183, 439–440, 445 toxicity, 77, 130, 146 tubules, 127, 130 Renal cell cancer, 286, 324, 328, 332, 335–336, 427 Renal cell carcinomas (RCC), 50, 240, 247–248, 271, 286, 325–327, 335, 342, 344–345, 427 Renal parenchyma, 344, 440 Renal toxicity, 77, 130, 146 Reovirus, 296–297, 304–307 Replicative bypass process, 157 Reproductive toxicity, 77 Rescue therapy, 456, 462, 464 Research Triangle Institute (RTI), 9, 13 Respiratory failure depression, 442 infections, 300 insufficiency, 77 Response rate, 6–7, 12–13, 45–49, 51–52, 105–108, 113, 129–130, 136, 145, 148, 168–169, 171, 174, 176–179, 240–243, 247–249, 251–252, 261, 286–287, 305, 307, 322–325, 327, 333, 337, 343, 345–346, 367–368, 370–371, 421–423, 425, 457, 460, 465 Retinoblastoma, 132

Subject Index Revised European-American Classification of Lymphoid Neoplasms (REAL) classification, 423 Rhabdomyosarcoma, 3, 27 Rhesus monkeys, 205, 455 Risk factors for ATE, 334 of cancer death, 166, 482 of GvHD, 418 of infection, 393–397, 422, 448, 475–476 of pneumonitis, 132, 395 of transfusion therapy, 391 RNA polymerase, 151 synthesis, 105, 298 viruses, 296–297 RNA-dependent protein kinase (PKR), 297, 301 S Sagopilone (ZK-EPO), 54 Sarcoma 180, 145 endometrial stromal sarcoma (ESS), 177 Ewing’s, 27 hormonal therapy in uterine, 177–178 Kaposi’s, 7–8, 13, 92–93, 240, 242–243, 332 limb, 93, 371 osteogenic, 129 soft tissue, 52, 91, 191, 369–370 Satraplatin (JM216), 147–148 Secondary or graafian follicle, 196 Sedation, 370, 442–445, 454, 458, 461 Seizures, 32–33, 131, 445 Selective estrogen receptor modulators (SERM), 166–167, 173, 176–177, 183 Selective serotonin reuptake inhibitors (SSRI), 446, 504 Selenium and Vitamin E Cancer Prevention Trial (SELECT), 482–483 Semen cryopreservation, 201–202 Semiquantitative immunostaining, 501 Semustine, 67–68 Sepsis, 108, 388, 391–394, 397, 496–497, 503 Sequential high-dose therapy (SHDT), 418 Serum albumin, 16, 44, 503 Severe combined immunodeficiency (SCID), 300, 356 Side effects of anthracyclines, 95 of antifolates, 134 associated with ketoconazole, 183 of bevacizumab, 248 of chemotherapy and radiation therapy, 475 of docetaxel, 46 gabapentin, 446 opioid, 442 of panitumumab, 252 of Sipuleucel-T, 273 of sorafenib, 327 of ZD6474 (Zactima), 336 Signalling lymphocyte-activation molecule (SLAM), 297 Single day-chemotherapy, 463

521 Sipuleucel-T (Provenge), 273 Skin cancer, 437, 486 dry, 322 eruption, 78 lesion, 237–238 metastases, 287, 307 rash, 183, 246, 321–322, 324–325, 327 squamous cell carcinoma of, 486 toxicity, 95, 132, 253 Small cell lung cancer (SCLC), 7–8, 16, 91, 106–107, 112–113, 130, 136, 154, 260, 326 SN 1/SN 2 (nucleophilic substitution, first/second order), 61 Soft tissue sarcomas, 52, 138, 191, 369–371 Solid tumors, 426–427 germ cell tumor (GCT), 426 HDT for primary therapy of high risk disease, 426–427 HDT for relapsed refractory disease, 426 Soluble proteins, 263 Somatic hypermutations, 353 Sorafenib (nexavar), 248, 327–328, 335–336 South West Oncology Group (SWOG), 49, 421–422 SPARC (secreted protein acid rich in cystine), 44 S phase, 14, 41, 105, 114, 117, 130, 136, 152, 157, 222 Spleen, 30, 220, 350, 408, 417 Splenectomy, 420 Splenic lymphocytes, 220 Spreading, 89, 203, 241, 304, 306–307, 325, 342, 344, 372, 393, 395, 472 Squamous cell carcinoma of esophagus, 153 of head and neck, 50, 245, 251, 323–324 of skin, 490 START trials, 321 State food and drug administration (SFDA), China, 296 Stem cell mobilization and collection, 408–410 definition, 408 HPC collection, 409–410 mechanism of HPC mobilization, 408–409 mobilization regimens, 409 Steroids, 45–46, 53, 72, 95, 110, 132, 176, 180, 183, 197, 253, 355, 396, 398, 400, 483 Stomach, 17, 91, 127, 138, 376, 479 Streptozotocin, 68–69 Sunitinib, 248, 325–326, 328 Surgery cardiac, 388 colorectal, 389 stereotactic radiosurgery (SRS), 178 transphenoidal, 179 Survival of cancer patients, 16, 48, 129, 147, 453, 487 disease, 486, 488 of transfused platelets, 393 Syndrome of inappropriate antidiuretic hormone secretion (SIADH), 32 T Tachycardia, 46 Target cells, 262, 286, 289–290, 501

522 Taxanes antitumor activity, 46–50 breast cancer, 47–48 dose and schedule, 45–46 lung cancer, 49 mechanism of action, 41–42 microtubules, 39–40 other cancers, 49–50 pharmacology, 44–45 prostrate cancer, 48–49 resistance, 42–44 toxicity, 46 Taxol, 3, 8–10, 12–13, 40, 326 T cell CD4+ and CD8+, 240, 260, 273 cytotoxic clones, 274 depletion, 424, 426 exhaustion, 272 growth factor, 285 malignancies, 241 receptor (TCR), 240, 289–291, 302 Temsirolimus, 328 Teniposide (VM26), 3–8 Teratogenecity, 77 Terminally ill cancer patients, 180, 507–508 TESE, 202 Testicular cancer, 3, 6–8, 25, 27, 145–146, 191, 193, 195, 201 germ cell transplantation, 202–203 non-seminomatous germ cell tumors, 155 Testosterone, 166–167, 175, 180–183, 191–193, 196, 204–205, 487 Thalamotomy, 451, 453 Therapy related complications, 452 Thermal chemosensitization, 377 Thiotepa, 63–66, 73–74, 76 Thrombocytopenia, 16, 32, 46, 115–116, 135–136, 148, 321, 324, 385, 387, 391–394, 396, 413 Thyroid cancer/carcinoma, 298, 326–327, 350 stimulating hormone (TSH), 179 TLK117, 74–75 TLK199, 74–75 T lymphocytes CD4+, 259–260, 506 CD8+, 268, 303, 506 cytotoxic, 257, 260–261, 291, 502 -depleted marrow, 42, 417 hTRT-specific, 263 tumor-specific, 268 Topoisomerase I inhibitors, camptothecins clinical use irinotecan, 105–107 resistance, 108–109 topotecan, 107–108 dose adjustments irinotecan, 114–115 topotecan, 114 doses and schedules, 113–114

Subject Index drug interactions irinotecan, 118 topotecan, 117–118 mechanisms of action, 105 pharmacokinetics irinotecan, 109–112 topotecan, 112–113 structures of, 103–105 toxicity irinotecan, 117 topotecan, 115–117 Topoisomerase II (Topo II), 6, 8, 14–15, 87, 89, 92–94, 222, 224–225 Topotecan, 15–16 clinical use, 107–108 dose adjustments, 114 drug interactions, 117–118 pharmacokinetics, 112–113 toxicity, 115–117 Total body irradiation (TBI), 196, 201, 415, 421–422, 424–427 Toxicity of bleomycin, 32 of mitomycin, 33 of procarbazine, 193 between vinblastine and vincristine, 31–33 Transarterial chemoembolization (TACE), 342–343 Trans-arterial embolization (TAE), 346–347 Transcatheter head and neck cancers, 345–346 hepatic neoplasms, 341–344 metastases, 346 urological malignancies, 344–345 Transcatheter embolization, 347–348 Transforming growth factor-α (TGF-α), 250, 298, 332 Transforming growth factor-β (TGF-β), 218, 268, 272, 360, 499–500 Transfusion of blood and blood products, 386, 388–389, 397–398 of granulocytes, 394–396 of plasma, 396–397 reactions, 386, 388, 393, 395, 397, 399–400 of viable tumor cells, 343, 345 Transfusion associated graft vs. host disease (TA-GVHD), 395–396 Transitional cell carcinoma, 155 Transplantable cancer glioma tumor, 105, 107, 110, 113, 157, 248, 272 murine tumors, 259, 270, 354 Transplantation allogeneic, 355, 396, 414, 426, 428 autologous blood stem cell, 76, 355, 411–412, 421, 426, 468 bone marrow, 76, 196, 200–201, 396–397, 399, 412–414, 419–420, 422–423, 426–429, 481 non-myeloablative allogeneic stem cell, 414 ovarian tissue cryopreservation and, 203–204 testicular germ cell, 202–203 Trastuzumab, 248–250 adjuvant therapy, 249–250 metastatic breast cancer, 249 side effect profile/cardiac toxicity, 250 Triazenes, 69–70

Subject Index Tricyclic antidepressants (TCA), 442, 445, 448–450 Trimetrexate (TMTX), 134 Tumor cell engineering, 288 Tumor immune escape, 500–502 Tumor-infiltrating lymphocytes (TIL), 285–287, 499, 503 Tumor lysate/fusion on DC system, 288–289 Tumor RNA/DC system, 289 Tumors associated antigens, 238–239, 257–260, 267, 270–271, 273, 303, 409, 496, 499–500 cell kill, 303 cell resistance, 94 cells in circulation, 291 glycolysis, 478 and host interactions, 500–502 inoculation, 264–265, 267 load, 369 melanoma antigens, 258–259 necrosis, 369 necrosis factor (TNF), 41, 153, 220–221, 296, 332, 501 other TAA, 259–260 progression, 168–169, 171, 183, 219, 239, 261, 320, 323–324, 431, 500 promoters, 488 regression, 178, 258, 261–262, 273, 299, 304, 306, 333 resistance to drugs, 216 response, 149, 261, 291, 322, 335, 387, 431, 500 xenografts, 9, 17, 44, 72, 297 Tumor selectivity, mechanisms of inherent tumor selectivity, 296–298 measles virus, 297 myxoma virus (MYXV), 296 Newcastle disease virus (NDV), 297 other viruses, 297–298 reovirus, 297 vesicular stomatitis virus (VSV), 296–297 mRNA translational control CXCR4, 303 eIF4E, 303 regulation of mRNA stability, 301–302 COX-2, 301–302 coxsackievirus A21, 302 hepatotoxicity, 302 HSV-1, 302 miRNAs, 302 transcriptional targeting, 301 CN706, 301 G92A, 301 HSV-1, 301 transductional targeting, 303 viral gene inactivation adenovirus, 300–301 GLV-1h68, 298–299, 300 HSV-1, 300 other viruses, 301 VACV, 298–301 Tumor stem cells characteristics of early vs. late MM cells, 354 clonal B cells in MM, 352–353 differentiation, 353–354 hypothesis, 350–351

523 multiple myeloma (MM), 351–352 other cancer stem cells, 356 pathological characteristics of early MM cells, 354–355 resemble non-malignant tissue stem cells, 351 Tumor-stroma interaction/pathways, 225–227 bortezomib, 227 chemotherapy targeting bcl-2, 226–227 immunomodulatory drugs, 227 soluble factors and adhesion molecules, 227 Tyrosine kinases inhibitors (TKI), 227, 242, 246, 248, 250, 319–320, 322, 325–326, 336, 424 non receptor tyrosine kinases (NRTK), 319–322 receptor tyrosine kinases (RTK), 43, 227, 250, 319, 322, 325 U Ulceration, gastric, 444 Ultraviolet (UV) radiation, 87, 90, 266, 332 Underweight, 474 3 -Untranslated regions (3 -UTR), 301 Uridine-diphosphate glucuronosyltransferase isozyme 1A1 (UGT1A1), 110–111, 113–114, 118 Urinary dysfunction excretion, 77, 91 excretion of irinotecan, 112 excretion of platinum, 150 Urological malignancies, 344–345 Urticaria, 46, 78, 394 Uterine cancer, 167 cervix, 368 Uterine sarcomas, 177–178 V Vaccines, cancer, 257–274 dendritic cell-based vaccines, 269–273 DNA-based vaccines, 267–269 melanoma antigens, 258–259 other tumor-associated antigens, 259–260 peptide vaccines, 260–264 recombinant viruses as vaccines, 264–267 Sipuleucel-T (Provenge), 273 Vaccinia virus (VV/VACV), 42, 264–267, 269, 295, 298–299, 303–305, 307 Vandetanib, 326–327 Variable (V) gene rearrangement, 353 Vascular endothelial growth factor (VEGF), 218–219 Vascular leak syndrome, 241, 286 Vasculogenesis, 246 Vatalanib, 335 VEGF signaling, agents targeting bevacizumab (avastin), 332–335 PTK787/ZK222584 (vatalanib), 335 sorafenib (nexavar), 335–336 VEGF-trap, 336 ZD6474 (zactima), 336 Vertebrates, 296 Vesicular stomatitis virus (VSV), 296–297 Veterans Affairs Total Parenteral Nutrition Cooperative Study, 477 VIGOR (Vioxx gastrointestinal outcomes research) study, 440

524 Vinblastine bleomycin, 145, 195, 427 and vincristine, toxicity between, 31–33 Vinca alkaloids alkaloids, absorption, 29 clinical use, 27 disposition in normal organ function, 29 doses and schedules, 30–31 drug interactions, 33 mechanism of action, 25–27 pharmacokinetics, 28–30 properties of, 29 resistance, 27–28 rosea, 25 structure of, 26 toxicity, 31–33 Vincristine, 30–31 metabolism of, 31 toxicity between vinblastine and, 31–33 and vinblastine, 25–29 Vindesine, 25–27, 29–31, 33 Vinorelbine, 3, 25–27, 29–32, 45–46, 129, 249 Virus autonomous parvoviruses, 298 avian poxviruses, 267 canarypox, 259, 265 coxsackievirus, 298, 302, 307 cytomegalovirus (CMV), 267, 382, 384, 386, 389, 391, 394–396, 411–412 echovirus type 1, 298 Epstein Barr, 394 herpes simplex virus-1 (HSV-1), 295 human immunodeficiency virus (HIV), 242, 393–394, 396, 502 human pailloma, 242 human rhinovirus type 2, 301 myxoma virus (MYXV), 296 Newcastle disease virus (NDV), 296 poliovirus, 301 recombinant fowlpox, 265 reovirus, 296–297, 304–307 Semliki Forest, 298

Subject Index Seneca Valley, 298 Sindbis, 268, 298 vaccinia virus (VV), 42, 264–267, 269, 295, 298–299, 303 vesicular stomatitis virus (VSV), 296 West Nile, 394, 397 Vomiting chemotherapy-induced, 455–456, 463–464, 466 gastrointestinal toxicity, 131 non-hematologic toxicities, 117 See also Nausea/vomiting in cancer patients VP-16, 223 Vulvar carcinoma, 251 W Washed blood, 385–386 Weakness, 32, 382, 447 Weight loss, 179–180, 473–475, 479, 481–482, 503 White blood cell (WBC), 70, 76, 414 count, 413, 415 Whole blood, 384, 388, 395, 409 Whole body hyperthermia (WBH), 370, 374 radiant WBH (rWBH), 365–366 Whole tumor cells, 287–288 Wilms’ tumor, 3, 27 Women’s Healthy Eating and Living (WHEL) Study, 482 Women’s Intervention Nutrition Study (WINS), 482 Working Formulation (WF) classification, 423 World cancer research fund, 488 World Health Organization (WHO), 423, 439–440, 446, 449 X Xenografts, 9, 17, 44, 50, 70, 72–73, 251, 253, 295, 297, 303, 305 Y Yttrium-90, 343–344 Z Zactima, 326, 336 ZD9331, 135, 138 Ziconotide, 448