Lithium carbonate in patients with small cell lung cancer receiving combination chemotherapy

Effect of lithium on chemotherapy-induced neutropenia in Egyptian breast cancer patients; a prospective clinical study

PURPOSE

Myelosuppressive chemotherapy-induced neutropenia (CIN) remains a major limitation of cancer treatment efficacy, necessitating very expensive supportive care. Lithium carbonate, an inexpensive drug, can increase the number of neutrophils, possibly providing an efficacious and cost-effective alternative for treating CIN. The aim of this study was to determine whether lithium therapy can attenuate chemotherapy-induced neutropenia and leukopenia in breast cancer patients.

METHODS

A total of 50 breast cancer patients were enrolled in this prospective, interventional, randomized, controlled, and single-blind study. The patients were divided into two groups: a control group (group 1, N = 25 patients) and a lithium-treated (treatment) group (group 2, N = 25 patients). Group 1 patients were further subclassified into a non-neutropenic control group (N = 16) and a neutropenic control (N = 9) based on the subsequent development of severe neutropenia, or not. The control group received 4 cycles of doxorubicin or epirubicin plus cyclophosphamide followed by 2 cycles of paclitaxel. The treatment group received the same regimen as the control group as well as oral lithium carbonate throughout the chemotherapy cycles.

RESULTS

The results showed that the absolute neutrophil count (ANC) was increased in the lithium-treated group, while it was markedly reduced in both the non-neutropenic and neutropenic control groups (by 55.56% and 65.42% post-4 chemotherapy cycles, and by 19.57% and 39.90% post-6 cycles, respectively). The same pattern of alterations was observed for the total white blood cell count in both the control and treatment groups. In addition, the incidence and period prevalence were greatly reduced in the lithium-treated group compared to non-neutropenic and neutropenic control groups.

CONCLUSION

Lithium therapy ameliorated chemotherapy-induced leukopenia and neutropenia in breast cancer patients. This may provide a new strategy for cost-effective treatment of CIN, particularly in Egyptian cancer patients.

Lithium in Cancer Therapy: Friend or Foe?

Lithium, a trace element important for fetal health and development, is considered a metal drug with a well-established clinical regime, economical production process, and a mature storage system. Several studies have shown that lithium affects tumor development by regulating inositol monophosphate (IMPase) and glycogen synthase kinase-3 (GSK-3). Lithium can also promote proliferation and programmed cell death (PCD) in tumor cells through a number of new targets, such as the nuclear receptor NR4A1 and Hedgehog-Gli. Lithium may increase cancer treatment efficacy while reducing side effects, suggesting that it can be used as an adjunctive therapy. In this review, we summarize the effects of lithium on tumor progression and discuss the underlying mechanisms. Additionally, we discuss lithium's limitations in antitumor clinical applications, including its narrow therapeutic window and potential pro-cancer effects on the tumor immune system.

The Psychiatric Drug Lithium Increases DNA Damage and Decreases Cell Survival in MCF-7 and MDA-MB-231 Breast Cancer Cell Lines Expos ed to Ionizing Radiation

Background:

Breast cancer is the most common cancer among women. Radiation therapy is used for treating almost every stage of breast cancer. A strategy to reduce irradiation side effects and to decrease the recurrence of cancer is concurrent use of radiation and radiosensitizers. We studied the effect of the antimanic drug lithium on radiosensitivity of estrogen-receptor (ER)-positive MCF-7 and ER-negative, invasive, and radioresistant MDA-MB-231 breast cancer cell lines.

Methods:

MCF-7 and MDA-MB-231 breast cancer cell lines were treated with 30 mM and 20 mM concentrations of lithium chloride (LiCl), respectively. These concentrations were determined by MTT viability assay. Growth curves were depicted and comet assay was performed for control and LiCl-treated cells after exposure to X-ray. Total and phosphorylated inactive levels of glycogen synthase kinase-3beta (GSK-3β) protein were determined by ELISA assay for control and treated cells.

Results:

Treatment with LiCl decreased cell proliferation after exposure to X-ray as indicated by growth curves of MCF-7 and MDA-MB-231 cell lines within six days following radiation. Such treatment increased the amount of DNA damages represented by percent DNA in Tails of comets at 0, 1, 4, and even 24 hours after radiation in both studied cell lines. The amount of active GSK-3β was increased in LiCl-treated cells in ER-positive and ER-negative breast cancer cell lines.

Conclusion:

Treatment with LiCl that increased the active GSK-3β protein, increased DNA damages and decreased survival independent of estrogen receptor status in breast cancer cells exposed to ionizing radiation.

Lithium and Granulocytopenia during Induction Treatment of Adult Acute Lymphoblastic Leukemia

Twelve adult patients with acute lymphoblastic leukemia (ALL) received lithium carbonate, 300 mg, three times a day during induction treatment. They were compared to 12 similar patients consecutively treated with the same induction regimen; patients and controls were comparable for age, degree and presence of splenomegaly, hemoglobin level, blast cell count, polymorphonuclear (PMN) cell count and platelet count at diagnosis. All patients developed a severe neutropenia. PMN count at nadir was slightly higher in the lithium group, but not at a level of statistical significance (p = 0.100). The median number of days with PMN < 1 × 109/liter was 4 in the lithium group and 14.5 in the non-lithium group (p = 0.014), while the median number of days with PMN < 0.5 × 109/liter was 0 and 2 days, respectively (p = 0.004). Duration of thrombocytopenia was similar in the 2 groups and so was the remission rate; 2 infective episodes occurred, one in the lithium group and one in the controls.

Delayed administration of a single dose of lithium promotes recovery from AKI

Evidence suggests that glycogen synthase kinase 3β (GSK3β) contributes to AKI; however, its role in post-AKI kidney repair remains uncertain. Here, delayed treatment with a single dose of lithium, a selective inhibitor of GSK3β and a US Food and Drug Administration-approved mood stabilizer, accelerated recovery of renal function, promoted repopulation of renal tubular epithelia, and improved kidney repair in murine models of cisplatin- and ischemia/reperfusion-induced AKI. These effects associated with reduced GSK3β activity and elevated expression of proproliferative molecules, including cyclin D1, c-Myc, and hypoxia-inducible factor 1α (HIF-1α), in renal tubular epithelia. In cultured renal tubular cells, cisplatin exposure led to transient repression of GSK3β activity followed by a prolonged upregulation of activity. Rescue treatment with lithium inhibited GSK3β activity, enhanced nuclear expression of cyclin D1, c-Myc, and HIF-1α, and boosted cellular proliferation. Similarly, ectopic expression of a kinase-dead mutant of GSK3β enhanced the expression of cyclin D1, c-Myc, and HIF-1α and amplified cellular proliferation after cisplatin injury, whereas forced expression of a constitutively active mutant of GSK3β abrogated the effects of lithium. Mechanistically, GSK3β colocalized and physically interacted with cyclin D1, c-Myc, and HIF-1α in tubular cells. In silico analysis revealed that cyclin D1, c-Myc, and HIF-1α harbor putative GSK3β consensus phosphorylation motifs, implying GSK3β-directed phosphorylation and subsequent degradation of these molecules. Notably, cotreatment with lithium enhanced the proapoptotic effects of cisplatin in cultured colon cancer cells. Collectively, our findings suggest that pharmacologic targeting of GSK3β by lithium may be a novel therapeutic strategy to improve renal salvage after AKI.

Prevention of paclitaxel-induced peripheral neuropathy by lithium pretreatment

Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating side effect that occurs in many patients undergoing chemotherapy. It is often irreversible and frequently leads to early termination of treatment. In this study, we have identified two compounds, lithium and ibudilast, that when administered as a single prophylactic injection prior to paclitaxel treatment, prevent the development of CIPN in mice at the sensory-motor and cellular level. The prevention of neuropathy was not observed in paclitaxel-treated mice that were only prophylactically treated with a vehicle injection. The coadministration of lithium with paclitaxel also allows for administration of higher doses of paclitaxel (survival increases by 60%), protects against paclitaxel-induced cardiac abnormalities, and, notably, does not interfere with the antitumor effects of paclitaxel. Moreover, we have determined a mechanism by which CIPN develops and have discovered that lithium and ibudilast inhibit development of peripheral neuropathy by disrupting the interaction between paclitaxel, neuronal calcium sensor 1 (NCS-1), and the inositol 1,4,5-trisphosphate receptor (InsP3R) to prevent treatment-induced decreases in intracellular calcium signaling. This study shows that lithium and ibudilast are candidate therapeutics for the prevention of paclitaxel-induced neuropathy and could enable patients to tolerate more aggressive treatment regimens.

Effects of lithium carbonate on carboplatin-induced thrombocytopenia in dogs

OBJECTIVE

To describe the effects of lithium carbonate on thrombopoiesis in clinically normal dogs and in dogs treated with carboplatin.

ANIMALS

18 young adult sexually intact female Beagles.

PROCEDURES

Dogs were assigned to each of 3 treatment groups (6 dogs/group). Group 1 received 150 mg of lithium carbonate (14 to 16 mg/kg), PO, every 12 hours on days 1 through 21. Group 2 received carboplatin (300 mg/m(2), IV) on day 0 and cephalexin (30 mg/kg, PO, q 12 h) on days 14 through 21. Group 3 received lithium, carboplatin, and cephalexin at the aforementioned doses and schedules. Plasma lithium and blood platelet concentrations were measured on days 0, 2, 4, 7, 9, 11, 14, 16, 18, and 21. Number of megakaryocytes in bone marrow specimens and the percentage of large unstained cells and CD34+ mononuclear cells in bone marrow aspirates were determined on days 0, 7, 14, and 21 by manual enumeration, automated hematologic analysis, and flow cytometric immunophenotyping, respectively.

RESULTS

Plasma lithium concentrations ranged from 0.12 to 2.41 mmol/L. All dogs given lithium achieved a concentration within the target interval of 0.5 to 1.5 mmol/L by days 4 to 7. Thrombopoiesis was increased in dogs receiving lithium alone. All dogs given carboplatin developed mild thrombocytopenia. There were no differences between group 2 and group 3 throughout the study.

CONCLUSIONS AND CLINICAL RELEVANCE

Lithium stimulated thrombopoiesis in clinically normal dogs. Lithium administration at the doses and schedules used, with concurrent administration of cephalexin, did not prevent thrombocytopenia induced by carboplatin.

Effects of lithium carbonate on hematopoietic cells in patients with persistent neutropenia following chemotherapy or radiotherapy

Neoplasm therapy is restricted by the haematological side effects of tumour-destructive therapy, requiring expensive supportive care to some extent to overcome and treat leucopenia and its consequences. An effective and very cost-effective alternative for treating neutropenia is to administer lithium carbonate. Lithium leads to a release of hematopoietic growth factors (CSF) and therefore to proliferation of neutrophil granulocytes. Normally, recombinant CSF is only administered when there are indications of severe neutropenia because of the high costs involved, all the more evident in the long-term treatment of persistent leucocytopenia. On the other hand, CSF and leucocytes play an essential role in tumour immunology and with regard to response rates to cytostatic drugs. Lithium salts have shown that they can increase the number of neutrophil granulocytes quite significantly and, to a lesser extent, the number of eosinophil granulocytes and lymphocytes as well. The average number of erythrocytes does not change significantly. Patient tolerability to lithium carbonate therapy is very good. It can be used to treat patients with chronic leucopenia following chemotherapy or radiotherapy extremely cost-effectively. Unfortunately this treatment has not won acceptance in clinical oncology in the face of highly cost-intensive treatment with recombinant CSF.

Molecular targets of lithium action

Lithium is highly effective in the treatment of bipolar disorder and also has multiple effects on embryonic development, glycogen synthesis, hematopoiesis, and other processes. However, the mechanism of lithium action is still unclear. A number of enzymes have been proposed as potential targets of lithium action, including inositol monophosphatase, a family of structurally related phosphomonoesterases, and the protein kinase glycogen synthase kinase-3. These potential targets are widely expressed, require metal ions for catalysis, and are generally inhibited by lithium in an uncompetitive manner, most likely by displacing a divalent cation. Thus, the challenge is to determine which target, if any, is responsible for a given response to lithium in cells. Comparison of lithium effects with genetic disruption of putative target molecules has helped to validate these targets, and the use of alternative inhibitors of a given target can also lend strong support for or against a proposed mechanism of lithium action. In this review, lithium sensitive enzymes are discussed, and a number of criteria are proposed to evaluate which of these enzymes are involved in the response to lithium in a given setting.

Management of lithium in patients with cancer

This article reviews the management of lithium in patients who require optimum management of cancer and simultaneous prevention of mania or depression in lithium-sensitive affective illness. Two cases are described. Discussion focuses on whether lithium should be continued during chemotherapy and radiation treatment, the complications that would lead to lithium toxicity in an otherwise stable patient, the likely settings for hypothyroidism, and the role of lithium to stabilize steroid-induced affective changes. The authors conclude that lithium may be withheld 1 or 2 days before cytotoxic chemotherapy and restarted when the patient is able to drink. It may be given as usual through routine radiation treatment, but it should be discontinued during cranial radiation. Calcium, renal, cardiac, and thyroid functions should be monitored.

Lithium enhances the proliferation of HL-60 promyelocytic leukemia cells

The effects of lithium, an agent used in the treatment of manic depression and to attenuate myelosuppression during chemotherapy, on HL-60 promyelocytic leukemia cells were investigated. By monitoring cell growth at varying concentrations (0-50 mM), as well as by following cell proliferation over 8 days, it was established that lithium stimulates HL-60 proliferation within a very narrow concentration range. Enhancement of growth was optimal at 5 mM, whereas concentrations above 10 mM were toxic. Time course studies revealed that the greatest increase in cell number occurred after 5-6 days in the presence of lithium. This was preceded by DNA synthesis reaching a maximum after 1-2 days. Viability of the cells decreased gradually after 3 days with 5 mM, but not with 2.5 mM. We suggest that HL-60 cells are a suitable model to further investigate possible mitogenic and cytotoxic effects of lithium in vitro.

Double-blind, placebo-controlled lithium treatment in chemotherapy induced aplasia for AML: reduced antibiotic requirement

A double-blind placebo-controlled study on lithium (Li) therapy after chemotherapy-induced bone marrow aplasia was undertaken in 53 patients with acute myeloblastic leukemia (AML). No difference was observed between the two groups for the duration of aplasia, the number of units of platelets or RBC transfused, the complete remission rate or the disease free survival. However, a statistically significant reduction in the number of days of antibiotic therapy required was found in the treated group (10.55 +/- 2.72 vs 12.73 +/- 3.60, P less than 0.05).

Lithium inhibits terminal differentiation of erythroleukemia cells. Evidence for a pre-commitment 'priming' event

Lithium has been found to be a novel inhibitor of the terminal differentiation of Friend murine erythroleukemia cells. A general method for the quantitative analysis of differentiation inhibitors has been developed and used to compare the site of inhibition by lithium with that by vanadate. Lithium inhibits the commitment to differentiation (K 1/2 approximately 10 mM) induced by DMSO (dimethylsulfoxide) at non-toxic concentrations that have only a small effect on the rate of proliferation. Inhibition is reversible and probably requires entry of Li+ into the cell, since it is blocked by high KCl in the medium. LiCl is most effective when present during the first 10 h of DMSO treatment, before commitment is initiated. Computer-assisted analysis of the kinetics of commitment demonstrate that inhibition by lithium is best described by including a lithium-sensitive 'priming' event, which occurs with high probability prior to commitment.

Postburn serum inhibits in vitro production of colony-stimulating factor by mononuclear peripheral blood cells

The effects of postburn serum (PBS) on the production of colony-stimulating factor (CSF) was evaluated in 13 burned patients by adding PBS to normal peripheral blood mononuclear cells (MNC) and assaying the MNC-conditioned media for CSF content. PBS inhibited CSF production by at least 50%. PBS from non-survivors significantly inhibited CSF production more than PBS from survivors. The addition of lithium chloride restored production of CSF in the presence of day 15 PBS but could not overcome the inhibitory effects of day 1 or day 8 PBS. The nature of the inhibitor(s) is uncertain, but correction of the CSF production defect by lithium chloride later in the course of thermal injury suggests that the defect may be reversible.

New concepts in management of neutropenia

Neutropenia is a life-threatening sequel of hematological disorders and a dominant factor limiting the dosage of cytotoxic chemotherapy. The role of the neutrophil is of such importance in defence against microbial invasion that measures that modify the behaviour of residual hemopoietic tissue to promote a modest increase in neutrophils, can confer considerable benefit by reducing the frequency and severity of infection. Such a change can be mediated in bone marrow depression by diversion of more progeny of immature precursors into the neutrophil series, or by enhancement of the stimulatory drive operating on neutrophil production. The former effect can be achieved by hypertransfusion of red cells to reduce the demand on the limited precursor population for cells of the erythroid series. The latter effect can be achieved by administration of lithium carbonate. Neutropenia caused by autoimmune injury to the neutrophil series can also be successfully modified by measures which suppress the underlying immune dyscrasia or the function of the reticulo-endothelial system. Corticosteroid administration and splenectomy can be helpful in certain specific types of neutropenia. Administration of cyclophosphamide and azathioprine has both mutagenic and marrow suppressive potential, but can induce remissions in severe chronic isolated neutropenia and in systemic lupus erythematosis.

The effect of lithium carbonate on chemotherapy-induced neutropenia and thrombocytopenia

Lithium carbonate ameliorates neutropenia associated with cancer chemotherapy. The effect of lithium on platelet suppression has not, however, been well established. In the present study, five patients with ovarian carcinoma received daily lithium during alternate cycles of treatment with hexamethylmelamine, cyclophosphamide, adriamycin, and cis-platinum. Analysis of myelosuppression was performed on 24 paired consecutive cycles given at identical doses, one with and one without lithium. During lithium cycles, nadir leukocyte, neutrophil, and platelet counts were significantly higher (P less than 0.01, less than 0.01, less than 0.05 respectively) and the interval between treatments was shorter (P less than 0.01). One patient who has received 11 cycles of chemotherapy continues to receive 100% doses owing to the beneficial effect of lithium on chemotherapy-induced thrombocytopenia. Lithium was poorly tolerated by some patients because of either tremor or nausea and vomiting, in spite of nontoxic serum lithium levels. The amelioration of drug-induced platelet suppression as well as neutrophil suppression noted in this study suggests that lithium's effect on hematopoiesis is not limited to stimulation of neutrophil production. The ability of lithium to decrease chemotherapy-induced myelosuppression suggests that lithium administration may facilitate escalation of chemotherapy doses in selected patients.

Sequential effects of lithium on haematopoiesis

The administration of lithium salts to haematologically normal subjects is associated with increased blood neutrophil concentrations and marrow neutrophil production and with enhanced release of colony stimulating activity (CSA) required for growth of granulocyte-macrophage progenitor cells (CFU-GM) in vitro. To examine the haematopoietic changes associated with lithium salts, mice were given LiCl daily. Blood neutrophils and serum CSA levels increased as did blood platelet concentrations. These increments were preceded by expansion of marrow neutrophil production and increased concentrations of CFU-GM as well as progenitor cells for megakaryocytes (CFU-M) and erythrocytes (BFU-E and CFU-E). An earlier and sustained increase of transplantable pluripotential stem cells (CFU-S) was detected beginning at day 2 of lithium administration. The sustained increase of CFU-S with lithium was not associated with detectable changes of endogenous stem cells (E-CFU) suggesting that a portion of the stem cell pool is resistant to the proliferative effects of lithium. These studies indicate that lithium acts initially to directly or indirectly increase marrow CFU-S with later increments of progenitor cells. The more sustained increase of blood neutrophils with lithium administration may be the result of subsequent increments of CSA resulting in enhanced marrow granulocyte production.

Lithium treatment in adults with acute myeloid leukemia receiving chemotherapy

To determine whether lithium can shorten chemotherapy-induced neutropenia, 35 adult patients with newly diagnosed acute myeloid leukemia undergoing initial chemotherapy were randomized either to receive oral lithium started at the time of biopsy-proven hypoplasia or to receive no lithium. This study failed to show statistically significant shortening of the duration of chemotherapy-induced neutropenia in the lithium treatment group.

Can hypertransfusion attenuate myelosuppression associated with combination chemotherapy in patients with inoperable bronchogenic carcinoma? A report of a randomised, controlled study

Based on the concept of "stem-cell competition," hypertransfusion has been shown to attenuate the leucopenia associated with chemotherapy in children with leukemia. We conducted a randomized, controlled study of hypertransfusion in 25 patients with inoperable lung cancer who received combination chemotherapy consisting of methotrexate, adriamycin, cyclophosphamide, and CCNU (Lomustine) (MACC scheme). Twelve patients in the hypertransfusion group were given red cell transfusion to a hemoglobin value greater than or equal to 17 gm/dl prior to each chemotherapy cycle. The two groups of patients were comparable in age, cell type, extent of disease, performance status, and initial hemoglobin level and blood counts. The mean fall in granulocyte count was greater for control group (3.76 X 10(9)/liter) than for hypertransfusion group (3.27 X 10(9)/liter), and the mean fall in platelet count was greater for control group (53.84 X 10(9)/liter) than for hypertransfusion group (35.83 X 10(9)/liter), although the differences did not reach statistical significance (p greater than 0.05) partly because our MACC scheme was probably not sufficiently myelosuppressive to bring about a difference in the two groups. Granulocytopenia-associated infections were infrequent in both groups: two episodes in 37 cycles of chemotherapy in the hypertransfusion group and three episodes in 43 cycles in the control group. Hypertransfusion was simple and safe, and the encouraging trend towards less marked myelosuppression in our hypertransfused group would warrant further studies using more intensive and myelosuppressive combination chemotherapy regimens.