CHEMOTHERAPEUTICS OF MALIGNANT DISEASES

A. Koht

Carcinogenesis
DNA mutation hereditary acquired
radiation viruses chemicals drugs

Categories of genetic changes resulting in malignity

a) inactivation of tumor supressor genes: mutation binding to a virus protein binding to a mutated cellular protein b) activation of protooncogenes to oncogenes: point mutation (single nucleotide polymorphisms-SNPs) gene amplification chromosome translocation virus interaction

Oncogenes autonomy of cell growth

Oncogenes interfere with: mechanisms of proliferation mechanisms of differentiation

by means of: production secretion of autocrine growth factors receptors for growth factors cytosolic nuclear signal pathways transduction systems controling cell cycle

Characteristics of tumour cells

uncontrolled proliferation

dedifferentiation loss of function

invasiveness

metastatic potential

Therapeutic effect of anticancer drugs

a. The therapeutic effect of anticancer drugs may require total tumor cell kill, which is the of all neoplastic cells. b. Achievement of a therapeutic effect often involvs drugs that have a narrow therapeutic index (TI). c. A therapeutic effect is usually achieved by killing activelly growing cells, which are most sensitive to this class of agents. d. Because normal cells and cancer cells have similar sensitivity to chemotherapeutic agents, adverse effects are mostly seen in normally dividing non-neoplastic cells, sach as: hair follicles, bone marrow, sperm. e. To minimize the adverse effects and resistance, often is used combination of several agents with different mechanism of action. f. Achievement of a therapeutic effect may involve the use of drugs, sometimes sequentially (at specific stages of cell cycle).

PRODRUGS 1. Cyclophosphamide 4-Hydroxyphosphamide (liver) 2. Procarbazne dacarbazine (liver) 3. Merkaptopurine 6-merkaptopurine ribozophosphate 4. Tioquann 6-tioquann-ribzophosphate 5. Fluorouracil 5-fluoro-deoxy- uracil monophosphate 7. Mitomycin (only at the hypoxic tissue of tumors) 8. Doxorubicin idarubicin

SENSITIVITY OF TUMOURS TO CHEMOTHERAPY

chemosensitive tumours intermediary chemosensitive tumours chemoresistant tumours

Chemosensitive tumours
generally sensitive to several drugs
combined chemotherapy is prefered chemotherapy is always indicated

Intermediary chemosensitive tumours

complete remission rate about 10%
high partial response (about 50%)

combined chemotherapy is slightly more effective chemotherapy could be used (no as first-choice therapy)

Chemoresistant tumours
low response rate (about 20%)
complete remission is rare chemotherapy has only adjuvant role neoadjuvant therapy

Factors influencing chemotherapy response

fraction of proliferating cells cell cycle rate synchronisation of cell cycle within tumour tumour mass large tumours are relatively less sensitive: 1. a lot of cells in G0 2. penetration of drugs kinetics of cell killing cytotoxic drugs kill only a part of cells of certain type resistance of tumour cells

Mechanisms of resistance I.
Defect activation
cyclophosphamide needs metabolic activation metothrexate needs conversion to MTXpolyglutamate in cells

Increased inactivation
sulfhydryl substances - glutathion, metalothionein scavenge reactive molecules aldehyde dehydrogenase inactivation of cyclophosphamide

Increased nucleotide levels

can affect the effectiveness of antimetabolites

Changes in DNA repare

repare mechanisms, elimination of cross-links bleomycine other DNA-interfering drugs

Mechanisms of resistance II.

Changes in target structure
active enzyme with lower drug affinity: DFR-metothrexate

Reduced quantity of target structure

amount of topo II: etoposide

Gene amplification
metothrexate: DFR requires more MTX to block the activity

Mechanisms of resistance III.

Decreased accumulation
Decreased uptake
MTX - protein transporter melphalan/leucine transport

Increased efflux
multidrug resistance (MDR): - most often for natural drugs doxorubicine, etoposide, actinomycine D, vinca alcaloids - Pgp is normally expressed in some cells, e.g. stem cells in bone marrow

Combination chemotherapy

tumours have tendency to be resistant to some drug (cell heterogeneity)

resistance is often required during therapy with only one drug (proliferation of mutated cells) several sites of effect are possible with drugs with different side effects cummulative biochemical damage appear in cancer cells

MODALITIES OF ANTICANCER CHEMOTHERAPY

1. Intermittent application
period for bone marrow regeneration period for immunity regeneration during maintenance therapy (chlorambucil in CLL, busulfan in CML, hormones or antagonists in prostate or breast carcinoma) instilation in malignant secretions (bleomycine, thiotepa) (can be palliative by volume reduction) intrathecal (metothrexate) (infiltration of CNS in leukemia)

2. Continual therapy

3. Special applications

INDIVIDUALISATION OF CANCER THERAPY

Type of tumour: selection of anticancer drug combination (or not)

Repeated evaluation of clinical status: continuation (or not) in agressive therapy

Continual monitoring of bone marrow: before & during therapy reduction (or not) of therapeutic regimen intensity The use of drugs modifying unwanted side effects: antiemetics, colony-stimulating factors increase in therapeutic:toxic ratio

PRACTICAL USE OF ANTICANCER DRUGS

the doses are expressed in mg per m2 of body surface (more precise dose/effect ratio)

Toxic effects of anticancer chemotherapeutics

myelotoxicity alopecia loss of appetite & weight nausea & vomitus taste change stomatitis, esophagitis, constipation, diarrhea fatigue

cardiotoxicity neurotoxicity lung damage sterility & teratogenicity hepatotoxicity & nefrotoxicity wound healing growth (children) carcinogenicity

ANTICANCER DRUGS

Mechanism of action - cell cycle

intercalation blockade of metabolic steps in DNA synthesis of enzymes regulating cell cycle RNA synthesis protein synthesis microtubular functions

Cell cycle intervals & anticancer drugs interferrence

Anticancer drugs
1. 2. 3. 4. 5. 6. 7. alkylating agents (cyclophosphamide, cisplatin) antimetabolites (methotrexate) cytotoxic ATB (antracyclines) mitosis inhibitors (vincristine, taxans) topo inhibitors (topotecan, etoposide) hormones (corticoids, tamoxifen, flutamide) enzymes & other drugs (asparaginase,
procarbazine, hydroxyurea) PTK inhibitors (imatinib) (rituximab,trastuzumab)

8. 9. monoclonal antibodies

I. Alkylating agents
cyclophosphamide platinum derivatives derivatives of nitrosourea (lomustine, carmustine) estramustin melphalan chlorambucil busulphan dacarbazine

Mechanism of action
inter- or intra-chain cross-linking interference with transcription & replication (S phase & G2 block) apoptosis

Alkylating agents
Side effects
myelosuppresion

GIT toxicity inhibition of gametogenesis (sterility-males) secondary malignities (acute leukemias)

Cyclophosphamide
(mustard gas)
frequently used also as immunosupressive agent P-450 activation p.o., i.v, i.m. derivative - ifosfamide

Cyclophosphamide
Side effects
myelosuppression

GIT toxicity hemorrhagic cystitis acroleine N-acetylcyst., mesna

Cisplatin, carboplatin
platinum complex 2 chlorid ions 2 amonium groups
cross-linking, DNA denaturation solid tumors - testes & ovarial

Cisplatin
Kinetics
slow i.v. perfusion
(water soluble)

Side effects myelosuppression GIT toxicity nephrotoxicity emetogenity ototoxicity neuropathies

II. Antimetabolites

Antagonists of folic acid

Pyrimidine derivatives
(thymine, cytosine, uracil)

DNA

RNA

Purine derivatives
(adenine, guanine)

Methothrexate
(antifolate) Mechanism of action
folates purine nucleotides thymidilate DNA reduction to FH4 DHFR - high affinitt for FH4 - key enzyme transport of monocarbon groups uracile methylation to 2-deoxyuridylate (DUMP) & thymidylate (DTMP)

DNA synthesis

Methothrexate
Kinetics low liposolubility p.o., i.v., i.m., i.t. folate transport
(in the cell)

Side effects myelosuppression, GIT, pneumonitis, nephrotoxicity (tubular

precipitation - hydratation)

polyglutamation
(intracellular)

higher affinity to DHFR as FH2 FH4 depletion

high doses followed by folic acid

Fluorouracil (5-FU)
(pyrimidine (uracile) derivative)
Mechanism of action interference with thymidylate & DNA synthesis
fluorodeoxyuridine monophosphate formation (FDUMP)

parenteral application mainly solid tumors

(GI)

Side effects GI epithelial damage myelotoxicity

Cytarabine
(pyrimidine (cytidine) derivative)
Mechanism of action
intracellular phosphorylation DNA & RNA incorporation DNA polymerase inhibition Inhibition of replication & reparation

Kinetics & indications

s.c. (myelodysplastic syndrome), i.v., i.t. AML, CML remission, lymphoma, myelodysplast. sy

Side effects
myelosuppression, GIT, nausea, vomiting

III. Cytotoxic ATB

Anthracyclines
(daunorubicine, doxorubicine, epirubicine, idarubicine)

Bleomycines

Daunorubicine
(anthracycline)
Mechanism of action Kinetics i.v. infusion metab. & excretion (mainly liver)

intercalating ATB topo II inhibition Indications induction therapy ALL, AML, CML blast. trans.

Side effects
myelotoxicity accumulative cardiotoxity (free radicals) alopecia local necrosis (extravascular appl.)

Doxorubicine
(anthracycline)
Mechanism of action
intercalating ATB inhibition of topo II much broader indication spectrum as dau Hodgkin, NHL, myeloma, at least all localizations of solid tumors

i.v. perfusion, intravesically

Side effects
myelotoxicity
cardiotoxicity
(dexrazoxan)

alopecia, mucositis, necroses in mouth & if applied paravenously

Bleomycines
(glycopeptide ATB-radiomimetic)
Fe ion chelatation, interaction with O2
superoxide & hydroxyl radicals degradation of preformed DNA chain fragmentation radiomimetic effect most effective in G2 & M phase, as well as G0 testicular tumors & malignant lymphomas orofacial tumors, ca vulvae, penis, skin i.v., i.m.

Side effects shivering, fever lung fibrosis allergies, mucocutaneous reactions low hemat. tox.

IV. Mitosis inhibitors

Vinca alcaloids
(vincristine, vinblastine, vinorelbine)

Taxans
(paclitaxel, docetaxel)

Mechanism of action
Inhibition of polymerisation:

colchicin

vinca alcaloids
Microtubulus

Tubuline

Stimulation of polymerisation taxans

Inhibition of depolymerisation

Vincristine (vinblastine, vinorelbine)

(mitosis inhibitors)
Mechanism of action inhibition of tubuline polymerisation inhibition of mitotic spindle formation effective in G2/M phase Side effects myelosuppression phagocytosis, chemotaxy of leukocytes axonal transport in neurons paresthesies, neuromuscular abnormalities

Vincristine, vinblastine
Indications Vincristine
ALL & AML Hodgkin lymphoma, NHL multiple myeloma
combination therapy in some solid tumors

Vinblastine
Hodgkin lymphoma, NHL testicular tumors choriocarcinoma Grawitz tumor

Paclitaxel, docetaxel
(mitosis inhibitors)
Mechanism of action
microtubular stabilisation final effect like vinca alcaloids

Kinetics
very low water solubility only as i.v. perfusion

Paclitaxel, docetaxel
Side effects myelosuppression neurotoxicity hypersensitivity
(premedication with steroids & antihistaminics)

Indications
metastatic tumors (breast) progressive ovarial tumors NSCLC Kaposi sarcoma (AIDS)

V. Topoisomerase inhibitors
topo I inhibitors
(topotecan, irinotecan)

topo II inhibitors
(etopozide, tenipozide)

Topotecan (irinotecan)
(topo I inhibitors)
Mechanism of action
topo I inhibition its levels are during the whole cell cycle

Indications
metastatic ovarial tumors in case of first line therapy failure
(topotecan)

Side effects
diarrhea, reversible myelosuppression relatively low toxicity

colorectal ca in progress (irinotecan)

Etopozide (tenipozide)
(topo II inhibitors)
Mechanism of action
Inhibition of mitochondrial functions & nucleoside transport topo II inhibition

Indications
solid tumors (lung-SCLC, testicular, trophoblast, ovarial, urinary blader)

Side effects
nausea, vomitus myelosuppression, alopecia

malignant lymphoma, acute non-lymphatic leukemia

VI. Hormones
Glucocorticoids
(prednisolone, dexamethasone)

Antihormones
(tamoxifen, flutamid)

Tamoxifen (toremifen)
Mechanism of action
nonsteroidal antiestrogene inhibits estradiol binding to receptors

Side effects
metrorhagies thrombophlebitis flush alopecia estrogene endometrial effect

Indications
p.o. appl. in breast cancer with positive estrogene receptors

VII. Enzymes & other chemotherapeutics

Enzyme
(asparaginase)

Other chemotherapeutics
(procarbazine, hydroxyurea)

Asparaginase
(enzyme)

Mechanism of action, kinetics, indications cleaves asparagine, useful in malignities where the cells lost possibility of its synthesis i.m., i.v. in ALL Side effects weak myelosuppression, GIT toxicity & alopecia nausea, vomiting, CNS depression, anaphylaxis, hepatotoxicity

VIII. PTK inhibitors

(imatinib mesylate)
Mechanism of action, kinetics, indications PTK inhibition phosphate group transport from ATP & phosphorylation of tyrozine residues in substrate proteins Inhibition of transduction signals transmission p.o. appl. in therapy of CML & GIST

Side effects
nausea, vomiting, diarrhea edema, headache & muscle pain neutropenia & thrombocytopenia

IX. Monoclonal antibodies

(rituximab, trastuzumab)
Rituximab
monoclonal antibody only for i.v. appl. indicated in lymphoma therapy

Trastuzumab
monoclonal antibody only for i.v. appl. indicated in HER2 Neu positive breast ca therapy

Side effects
pseudoinfluenza sy. fever headache, chest, abdominal, muscle & joint pain nausea, vomiting, diarrhea & exanthema

Angiogenesis in cancer

Vasculogenesis vs Angiogenesis
Vasculogenesis

Formation of blood vessels from differentiating angioblasts and their organization into a primordial vascular network, consisting of the major blood vessels of the embryo

Agiogenesis

Formation of vascular sprouts from preexisting vessels

Physiological versus pathological angiogenesis

Physiological angiogenesis Pathological angiogenesis Therapeutic goal Inhibition of angiogenesis Stimulation of angiogenesis Myocardial ischemia Peripheral ischemia Cerebral ischemia Wound healing Reconstructive surgery Ulcer healing

Embryogenesis Female reproductive system Development of follicles Corpus luteum formation Embryo implantation Successful wound healing

Hemangiomas Psoriasis Kaposi's sarcoma Ocular neovascularization Rheumatoid arthritis Endometriosis Atherosclerosis

Tumor growth and metastasis

Progression of Cancer

Established tumor
1 kg

1g

Dormant in situ Cancer

Dormant cancer cells regain tumorigenic potential
Suzuki M et al AJP 169: 673-681

1 mg

Initiation

Promotion

Hypoxia crosstalk
Accessory cells

1 mg

1 ng

Angiogenic switch

The balance hypothesis for the angiogenic switch

VEGF family FGF family PDGF TGF family Angiogenin Angiopoietin-1/Tie2 TNF-a HGF/scatter factor IGF family IL-8 Nitric oxide Prostaglandins Tissue factor MMPs . . .

Hanahan D & Folkman J. Cell. 86:353, 1996

Angiostatin/other plasminogen kringles Antithrombin (cleaved) Endostatin Fibronectin fragments PEX 16-kDa Prolactin Prothrombin kringle-2 Maspin Restin Vasostatin IL-1, -4, -10, -12, -18 IFNs TIMPs 1,25-(OH)2-vitamin D 2-Methoxyestradiol Angiopoietin-2 EMAP-II gro-b IP-10 . . .

Normal Blood Vessels vs Tumor Blood Vessels

McDonald & Choyke Nat Med 2003

Bevacizumab
Recombinant, humanized monoclonal antibody that binds to VEGF-A Approved for first-line treatment of Non-Small Cell Lung Cancer in combination with Carboplatin and Paclitaxel Adding bevacizumab to chemotherapy results in increased median Progression Free Survival by 33%

Concerns
Since bevacizumab is expected to inhibit new angiogenic growth, concerns have been raised regarding postoperative wound-healing and bleeding complications in patients who undergo surgery within 1 to 2 months of Bevacizumab therapy

Side efects
Gastrointestinal (GI) perforation

Wound healing complication

Hemorrhage Neutropenia

Immunosuppressant drugs

- inhibit interleukin-2 production or action cyclosporin, tacrolimus, sirolimus

- inhibit cytokine gene expression corticosteroids - inhibit purine and pyrimidine synthesis azathioprine - block the T cell surface molecules involved in signalling polyclonal and monoclonal antibodies - act by cytotoxic mechanisms cyclophosphamide, chlorambucil

Usage in therapy: - autoimmune disease (some forms of

haemolytic anaemia, glomerulonephritis)

- prevention /or therapy of transplant rejection (kidneys, bone

marrow, heart, liver, etc.)

Hazard: - decreased response to infections - facilitation of emergence of malignant cells

Cyclosporin
-a fungal polypeptide with potent immunosuppresive activity Pharmacokinetics
- i.v., oral absorption - hepatic metabolism-metabolites excreted in the bile -accumulation in most tissues at conc. 3 to 4 times that seen in the plasma

Unwanted reactions: - nephrotoxicity - hepatotoxicity - hypertension

Tacrolimus
- a macrolide antibiotic - i.v., orally - metabolized by the liver Unwanted reactions:
- neurotoxicity - GIT upsets, metabolic disturbances (hyperglycaemia) reversible by reducing the dosage

Glucocorticoids
- restrain the clonal proliferation of Th cells through

decreasing transcription of the gene for IL-2

- decrease the transcription of many other cytokine genes in both the induction and effector phases of the immune response

Azathioprine
is activated to 6-mercaptopurine (a pure analogue antimetabolite - that inhibits DNA synthesis)
by a cytotoxic action on dividing cells inhibits clonal proliferation in the induction phase of the immune response

Unwanted reactions: - depression of the bone marrow, - nausea and vomiting

Mycophenolate mofetil
A semisynthetic derivative of a fungal antibiotic bioactivated to mycophenolic acid

Action (fairly selective): - restrains proliferation of both T and B lymphocytes - reduces the production of cytotoxic T cells Kinetics: Well absorbed from the GIT Enterohepatic circulation-inactive glucuronides