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Furui Y, Komori K, Kurata T, Sakashita K. Ifosfamide-Induced Encephalopathy Successfully Prevented by Methylene Blue: A Pediatric Case Report and Review of the Literature. Cureus 2023; 15:e40213. [PMID: 37435276 PMCID: PMC10332193 DOI: 10.7759/cureus.40213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/13/2023] Open
Abstract
Ifosfamide, which is widely used as a chemotherapeutic agent in various kinds of malignancies, sometimes causes neurotoxicity known as ifosfamide-induced encephalopathy (IIE). Herein, we report the case of a three-year-old girl who developed IIE during chemotherapy for Ewing's sarcoma and was treated with methylene blue as a prophylactic agent for IIE, after which she continued with ifosfamide and completed treatment without IIE recurrence. This case suggests that methylene blue may be effective in preventing the recurrence of IIE in pediatric patients. Further studies, including clinical trials, are needed to confirm the efficacy and safety of methylene blue in pediatric patients.
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Affiliation(s)
- Yu Furui
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, JPN
| | - Kazutoshi Komori
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, JPN
| | - Takashi Kurata
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, JPN
| | - Kazuo Sakashita
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, JPN
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2
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Dangles MT, Davous D, Vialle G, Auvrignon A, Angellier E, Bourdeaut F. [Intellectual disability and cancer in children: An analysis of the decision-making process]. Bull Cancer 2021; 108:813-826. [PMID: 34176585 DOI: 10.1016/j.bulcan.2021.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/21/2021] [Accepted: 02/26/2021] [Indexed: 11/25/2022]
Abstract
AIM The aim was to describe and to analyze the ethics of decision-making in situations involving children with intellectual disability and cancer, from the referent-doctor's point-of-view, in pediatric oncology units in France. METHODS Pediatricians working in pediatric oncology units were interviewed through an online questionnaire and a semi-directive interview was systematically proposed. We analyzed the ethical issues that arose during the process of decision-making and we made suggestions in order to address them. RESULTS Sixteen doctors reported twenty-one clinical cases. Of these cases, one third of the children had a change in their oncologic treatment, with a risk of pejorative outcome on the prognosis. Despite the fact that ethical issues appeared in 80 % of the cases, there were few consultations with ethical committees. Decision-making process showed no difference compared to children without intellectual disability, thus raising ethical issues in the medical team. Our study showed discrepancy between frequently reported ethical issues, high consensus rate regarding treatment decision and lack of consultation with ethical committees. DISCUSSION We propose three steps to guide the decision-making process in situations involving children with intellectual disability and cancer: 1/deeper understanding of the child through reinforced interactions with their caregivers, 2/better cross-boundary discussions, to improve the effectiveness of the multidisciplinary staff, and 3/more systematic ethical committees consultation.
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Affiliation(s)
- Marie-Thérèse Dangles
- Hôpital Necker-Enfants-Malades, service de neurologie pédiatrique, 149, rue de Sèvres, 75015 Paris, France; Université de Paris, Paris, France.
| | - Dominique Davous
- Hôpital Saint-Louis, groupe de réflexion et de recherche au sein de l'espace éthique région Île-de-France : parents et soignants face à l'éthique en pédiatrie, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - Guénola Vialle
- Chargée de mission PALIPED-RIFHOP, réseau d'Île-de-France pour l'hématologie, l'oncologie et les soins palliatifs pédiatrique, 3-5, rue de Metz, 75010 Paris, France
| | - Anne Auvrignon
- Hôpital Armand-Trousseau, service d'hématologie pédiatrique, 26, avenue du Dr Arnold-Netter, 75012 Paris, France
| | - Elisabeth Angellier
- Institut Curie, département interdisciplinaire de soins de support pour le patient en oncologie (DISSPO), 35, rue Dailly, 92210 Saint-Cloud, France
| | - Franck Bourdeaut
- Institut Curie, service d'oncologie pédiatrique, SIREDO, 26, rue d'Ulm, 75005 Paris, France
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Ataseven E, Göktepe ŞÖ, Kantar M. Ifosfamide-related encephalopathy with severe clinical presentations in children with cancer. J Oncol Pharm Pract 2021; 27:2018-2022. [PMID: 33779369 DOI: 10.1177/10781552211005533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ifosfamide is an alkylating agent, mostly used against variety of solid tumors in pediatric oncology practice. Although hemorrhagic cystitis is known as a common adverse effect, encephalopathy is the another one that should be kept in mind. It may occur in 2-5% of the children, and manifested by different clinical spectrums such as somnolence, lethargy, irritability, excitement, disorientation, confusion, weakness, hallucinations, seizures, movement disorders, and coma. CASE REPORT Herein, we present two patients who developed generalized seizure activity and one who developed coma during ifosfamide infusion.Management and outcome: In the first two patients, ifosfamide infusion was discontinued and intravenous diazepam was given. Their seizure stopped in a few minutes and neurological examination was back to normal, and no focal deficits were observed. In the third patient, ifosfamide infusion was discontinued, methylene blue and thiamine were given. After the tenth dose of methylene blue, she became neurologically normal, without any mental and motor deficit. Nevertheless, later she developed febrile neutropenia, septic shock and she died. DISCUSSION These cases highlight that pediatric oncologists and hematologists should be aware of possibility of severe neurological toxicity after administration of ifosfamide in adolescent patients. Apart from seizure, clinicians should also be prepared to notice drowsiness during ifosfamide infusions in children. Most of the time cessation of ifosfamide and hydration is enough. However, in severe toxicities there is a risk of irreversible neurological damage, and for these patients methylene blue (MB) and thiamine treatment should be kept in mind.
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Affiliation(s)
- Eda Ataseven
- Department of Pediatrics, Division of Pediatric Oncology, Ege University School of Medicine, Izmir, Turkey
| | - Şebnem Önen Göktepe
- Department of Pediatrics, Division of Pediatric Oncology, Ege University School of Medicine, Izmir, Turkey
| | - Mehmet Kantar
- Department of Pediatrics, Division of Pediatric Oncology, Ege University School of Medicine, Izmir, Turkey
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Abahssain H, Moukafih B, Essangri H, Mrabti H, Meddah B, Guessous F, Fadhil FZ, Souadka A, Errihani H. Methylene blue and ifosfamide-induced encephalopathy: Myth or reality? J Oncol Pharm Pract 2020; 27:143-149. [PMID: 33153383 DOI: 10.1177/1078155220971843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ifosfamide-induced encephalopathy (IIE) is a rare and serious adverse reaction. Thus far, no standard medication has been documentedto be efficient in the reversal of IIE, and while ifosfamide infusion interruption and hydration are recommended, methylene blue (MB) administration remains controversial. METHODS We retrospectively reviewed medical records to assess cases with IIE after ifosfamide infusion. We included all patients having received an ifosfamide infusion during their hospitalization in the medical oncology unit of the National Institute of Oncology in Rabat, Morocco, between September 2016 and September 2017. We subsequently conducted a literature review to determine the role of MB in IIE by searching PubMed using the terms "Methylene Blue" and "Ifosfamide". RESULTS A total of 88 patients received ifosfamide, and four patients had IIE. Ifosfamide infusion was stopped immediately after the IIE occurrence, and patients underwent renal function correction with hydration. All patients received MB infusion, and three patients had an improvement of their neurological status. As regards the literature review, 34 articles were reviewed and 16 items were included in the review. Overall, 38 (65.5%) patients received MB infusion and 28 (75.6%) patients responded favorably to the treatment. CONCLUSIONS Methylene blue can be used as a treatment for IIE owing to the severity of the IIE as well as absence of standard medication. Nonetheless, side effects such as serotonergic syndrome should be investigated. More broadly, prospective studies and controlled trials are needed to explore the contribution of MB in IIE management and encourage its use.
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Affiliation(s)
- Halima Abahssain
- Medicine and Pharmacy Faculty, National Institute of Oncology, Medical Oncology Unit, Mohamed V University, Rabat, Morocco
| | - Badreddine Moukafih
- Medicine and Pharmacy Faculty, National Institute of Oncology, Medical Oncology Unit, Mohamed V University, Rabat, Morocco
| | - Hajar Essangri
- Medicine and Pharmacy Faculty, Mohamed V University, Rabat, Morocco
| | - Hind Mrabti
- Medicine and Pharmacy Faculty, National Institute of Oncology, Medical Oncology Unit, Mohamed V University, Rabat, Morocco
| | - Bouchra Meddah
- Medicine and Pharmacy Faculty, Mohamed V University, Rabat, Morocco
| | - Fadila Guessous
- Mohammed VI University of Health Sciences, Casablanca, Morocco
| | | | - Amine Souadka
- Medicine and Pharmacy Faculty, National Institute of Oncology, Surgical Oncology Unit, Mohamed V University, Rabat, Morocco
| | - Hassan Errihani
- Medicine and Pharmacy Faculty, National Institute of Oncology, Medical Oncology Unit, Mohamed V University, Rabat, Morocco
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Ide Y, Yanagisawa R, Kubota N, Sakashita K, Tozuka M, Nakamura T, Honda T. Analysis of the clinical characteristics of pediatric patients who experience ifosfamide-induced encephalopathy. Pediatr Blood Cancer 2019; 66:e27996. [PMID: 31535455 DOI: 10.1002/pbc.27996] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/10/2019] [Accepted: 08/27/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Several kinds of pediatric hematological and/or malignant diseases are treated with chemotherapy regimens including ifosfamide (IFO). IFO-induced encephalopathy (IIE) is one of the serious side effects, but there is not enough evidence regarding the clinical features of IIE in children. PROCEDURE We performed a retrospective study on pediatric patients treated with chemotherapy regimens, including IFO, at a single center. We recorded the clinical characteristics of all patients; we compared the clinical characteristics between patients who developed IIE and those who did not. RESULTS In total, 88 patients received a chemotherapy regimen including IFO. IIE developed in seven patients (8.0%). The median age of patients at the time of IIE development was 4.3 (range 1.4-6.5) years in the younger population. Six of seven patients with IIE improved with supportive therapy only; however, one patient died due to heart failure. Overall survival was not different between the two groups. Multivariable analysis revealed that the co-administration of cisplatin (CDDP) or carboplatin (CBDCA) was a significant risk factor associated with IIE. Although there was no significant difference in laboratory data between the groups before chemotherapy, patients who developed IIE showed exacerbation in several laboratory tests, including those for renal and liver functions. CONCLUSIONS Renal dysfunction caused by the combination of nephrotoxic agents (IFO and CDDP/CBDCA) seems to be important for the development of pediatric IIE. It was thought to be difficult to predict IIE onset based on laboratory data before the initiation of chemotherapy regimens; however, careful observation of laboratory data during IFO chemotherapy regimens may help predict IIE onset and facilitate early treatment.
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Affiliation(s)
- Yuichiro Ide
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan.,Life Science Research Center, Nagano Children's Hospital, Matsumoto, Japan
| | - Ryu Yanagisawa
- Life Science Research Center, Nagano Children's Hospital, Matsumoto, Japan.,Division of Blood Transfusion, Shinshu University Hospital, Matsumoto, Japan.,Center for Advanced Cell Therapy, Shinshu University Hospital, Matsumoto, Japan
| | - Noriko Kubota
- Life Science Research Center, Nagano Children's Hospital, Matsumoto, Japan.,Department of Laboratory Medicine, Nagano Children's Hospital, Azumino, Japan
| | - Kazuo Sakashita
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Minoru Tozuka
- Life Science Research Center, Nagano Children's Hospital, Matsumoto, Japan.,Department of Laboratory Medicine, Nagano Children's Hospital, Azumino, Japan
| | - Tomohiko Nakamura
- Life Science Research Center, Nagano Children's Hospital, Matsumoto, Japan
| | - Takayuki Honda
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
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Hamdaoui M, Mutschler V, Entz-Werle N. Apport de l’EEG dans le diagnostic de la neurotoxicité à l’Ifosfamide. Neurophysiol Clin 2018. [DOI: 10.1016/j.neucli.2018.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Sun LR, Cooper S. Neurological Complications of the Treatment of Pediatric Neoplastic Disorders. Pediatr Neurol 2018; 85:33-42. [PMID: 30126755 DOI: 10.1016/j.pediatrneurol.2018.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/25/2018] [Indexed: 01/19/2023]
Abstract
Neurological complications resulting from childhood cancer treatments are common. Treatment for childhood neoplastic disorders is often multimodal and may include procedures, cranial irradiation, chemotherapy, transplant, and immunotherapy, each of which carries distinct neurological risks. Procedures, such as lumbar punctures, are commonly used in this population for diagnostic purposes as well as intrathecal medication administration. Surgery is associated with an array of potential neurological complications, with posterior fossa syndrome being a common cause of morbidity in pediatric brain tumor patients after neurosurgical resection. Cranial irradiation can cause late neurological sequelae such as stroke, cerebral vasculopathy, secondary malignancy, and cognitive dysfunction. Neurotoxic effects of chemotherapeutic agents are common and include neuropathy, coagulopathy causing stroke or cerebral sinovenous thrombosis, encephalopathy, seizures, cerebellar dysfunction, myelopathy, and neuropsychologic difficulties. Hematopoietic stem cell transplant has a high risk of neurological complications including central nervous system infection, seizures, and stroke. Immunotherapies, including chimeric antigen receptor-modified T-cells (CAR T-cells) and immune checkpoint inhibitors, are emerging as potentially effective strategies to treat some types of childhood cancer, but may carry with them substantial neurotoxicity which is just beginning to be recognized and studied. With evolving treatment protocols, childhood cancer survivorship is increasing, and the role of the neurologist in managing both the acute and chronic neurological consequences of treatment is becoming more important. Prevention, early recognition, and treatment of therapy-associated neurotoxicity are imperative to ensuring children can remain on the most effective therapeutic regimens and to improve the neurological function and quality of life of childhood cancer survivors.
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Affiliation(s)
- Lisa R Sun
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Pediatric Neurology, Baltimore, Maryland; The Johns Hopkins University School of Medicine, Department of Neurology, Division of Cerebrovascular Neurology, Baltimore, Maryland.
| | - Stacy Cooper
- The Johns Hopkins University School of Medicine, Department of Oncology, Division of Pediatric Oncology, Baltimore, Maryland
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8
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Vakiti A, Pilla R, Alhaj Moustafa M, Joseph JJ, Shenoy AG. Ifosfamide-Induced Metabolic Encephalopathy in 2 Patients With Cutaneous T-Cell Lymphoma Successfully Treated With Methylene Blue. J Investig Med High Impact Case Rep 2018; 6:2324709618786769. [PMID: 30083561 PMCID: PMC6069036 DOI: 10.1177/2324709618786769] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 06/06/2018] [Accepted: 06/12/2018] [Indexed: 12/13/2022] Open
Abstract
Ifosfamide, an alkylating agent used in cancer treatments, can cause neurotoxicity. The clinical presentation can range from mild symptoms such as acute confusion to non-convulsive seizures, severe irreversible coma, and death. The benefit of methylene blue use in treating ifosfamide-induced metabolic encephalopathy is not well established. In this article, we present 2 cases of ifosfamide-induced metabolic encephalopathy responsive to methylene blue treatment.
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Affiliation(s)
- Anusha Vakiti
- MedStar Washington Hospital Center, Washington, DC, USA
| | - Ravi Pilla
- MedStar Washington Hospital Center, Washington, DC, USA
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9
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Severe post-treatment leukopenia associated with the development of encephalopathy following ifosfamide infusion. Anticancer Drugs 2016; 27:235-8. [DOI: 10.1097/cad.0000000000000321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Rojas JC, Bruchey AK, Gonzalez-Lima F. Neurometabolic mechanisms for memory enhancement and neuroprotection of methylene blue. Prog Neurobiol 2011; 96:32-45. [PMID: 22067440 DOI: 10.1016/j.pneurobio.2011.10.007] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 10/26/2011] [Accepted: 10/27/2011] [Indexed: 12/21/2022]
Abstract
This paper provides the first review of the memory-enhancing and neuroprotective metabolic mechanisms of action of methylene blue in vivo. These mechanisms have important implications as a new neurobiological approach to improve normal memory and to treat memory impairment and neurodegeneration associated with mitochondrial dysfunction. Methylene blue's action is unique because its neurobiological effects are not determined by regular drug-receptor interactions or drug-response paradigms. Methylene blue shows a hormetic dose-response, with opposite effects at low and high doses. At low doses, methylene blue is an electron cycler in the mitochondrial electron transport chain, with unparalleled antioxidant and cell respiration-enhancing properties that affect the function of the nervous system in a versatile manner. A major role of the respiratory enzyme cytochrome oxidase on the memory-enhancing effects of methylene blue is supported by available data. The memory-enhancing effects have been associated with improvement of memory consolidation in a network-specific and use-dependent fashion. In addition, low doses of methylene blue have also been used for neuroprotection against mitochondrial dysfunction in humans and experimental models of disease. The unique auto-oxidizing property of methylene blue and its pleiotropic effects on a number of tissue oxidases explain its potent neuroprotective effects at low doses. The evidence reviewed supports a mechanistic role of low-dose methylene blue as a promising and safe intervention for improving memory and for the treatment of acute and chronic conditions characterized by increased oxidative stress, neurodegeneration and memory impairment.
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Affiliation(s)
- Julio C Rojas
- Departments of Psychology, Pharmacology and Toxicology, University of Texas at Austin, 1 University Station A8000, Austin, TX 78712, USA
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11
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Giraud B, Hebert G, Deroussent A, Veal GJ, Vassal G, Paci A. Oxazaphosphorines: new therapeutic strategies for an old class of drugs. Expert Opin Drug Metab Toxicol 2010; 6:919-38. [DOI: 10.1517/17425255.2010.487861] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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12
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Bernard PA, McCabe T, Bayliff S, Hayes D. Successful treatment of ifosfamide neurotoxicity with dexmedetomidine. J Oncol Pharm Pract 2010; 16:262-5. [DOI: 10.1177/1078155209360074] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neurotoxicity related to the use of ifosfamide is a well-known complication. While the use of methylene blue is a known antidote, symptomatic treatment of the central nervous system (CNS) effects can be challenging. We present a case of class IV neurotoxicity with the successful treatment of symptomology. In this case report we present a 2-year-old female with relapsed alveolar rhabdomyosarcoma undergoing palliative chemotherapy. Patient received ifosfamide in addition to etoposide and mesna. The patient developed acute hallucinations, agitation, and delirium. The patient was transferred to the pediatric intensive care unit where she was administered dexmedetomidine overnight in addition to methylene blue. The patient awoke the next morning following discontinuation of the dexmedetomidine infustion and subsequently had no further central nervous system effects. This case demonstrates the novel use of an alpha-2 agonist in the treatment of neurotoxicity related to ifosfamide administration.
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Affiliation(s)
- Philip A Bernard
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY 40536, USA,
| | - Tara McCabe
- Pediatric Clinical Pharmacy Specialist, University of Kentucky Health Care, Lexington, KY 40538, USA
| | - Sherry Bayliff
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY 40536, USA
| | - Don Hayes
- Departments of Pediatrics and Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, USA
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13
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Central and peripheral nervous system toxicity of common chemotherapeutic agents. Cancer Chemother Pharmacol 2008; 63:761-7. [PMID: 19034447 DOI: 10.1007/s00280-008-0876-6] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 11/10/2008] [Indexed: 12/18/2022]
Abstract
Central and peripheral nervous system toxicity are frequent complications of most chemotherapy regimens, often leading to reduction of dosages or cessation of the responsible drugs. However, sometimes the afflicted toxicity may not be reversible, especially if it is not recognized early, further compromising the quality of life of the cancer patients. The most common chemotherapeutic agents that might cause CNS toxicity manifested as encephalopathy of various severities include methotrexate, vincristine, ifosfamide, cyclosporine, fludarabine, cytarabine, 5-fluorouracil, cisplatin and the interferons (alpha > beta). Involvement of the peripheral nervous system manifested as distal peripheral neuropathy results after therapy with cisplatin, vincristine, taxanes, suramin and thalidomide. Although several compounds have been proposed as neuroprotective agents, few have been shown to be active against the chemotherapy induced neurotoxicity.
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Storme T, Deroussent A, Mercier L, Prost E, Re M, Munier F, Martens T, Bourget P, Vassal G, Royer J, Paci A. New ifosfamide analogs designed for lower associated neurotoxicity and nephrotoxicity with modified alkylating kinetics leading to enhanced in vitro anticancer activity. J Pharmacol Exp Ther 2008; 328:598-609. [PMID: 19017849 DOI: 10.1124/jpet.108.144170] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Ifosfamide is a well known prodrug for cancer treatment with cytochrome P450 metabolism. It is associated with both antitumor activity and toxicities. Isophosphoramide mustard is the bisalkylating active metabolite, and acrolein is a urotoxic side product. Because acrolein toxicity is limited by coadministration of sodium mercaptoethanesulfonate, the incidence of urotoxicity has been lowered. Current evidence suggests that chloroacetaldehyde, a side-chain oxidation metabolite, is responsible for neurotoxicity and nephrotoxicity. The aim of our research is to prevent chloroacetaldehyde formation using new enantioselectively synthesized ifosfamide analogs, i.e., C7,C9-dimethyl-ifosfamide. We hypothesize that reduced toxicogenic catabolism may induce less toxicity without changing anticancer activity. Metabolite determinations of the dimethyl-ifosfamide analogs were performed using liquid chromatography and tandem mass spectrometry after in vitro biotransformation by drug-induced rat liver microsomes and human microsomes expressing the main CYP3A4 and minor CYP2B6 enzymes. Both human and rat microsomes incubations produced the same N-deschloroalkylated and 4-hydroxylated metabolites. A coculture assay of 9L rat glioblastoma cells and rat microsomes was performed to evaluate their cytotoxicity. Finally, a mechanistic study using (31)P NMR kinetics allowed estimating the alkylating activity of the modified mustards. The results showed that C7,C9-dimethyl-ifosfamide exhibited increased activities, although they were still metabolized through the same N-deschloroalkylation pathway. Analogs were 4 to 6 times more cytotoxic than ifosfamide on 9L cells, and the generated dimethylated mustards were 28 times faster alkylating agents than ifosfamide mustards. Among these new ifosfamide analogs, the 7S,9R-enantiomer will be assessed for further in vivo investigations for its anticancer activity and its toxicological profile.
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Affiliation(s)
- Thomas Storme
- Unité Mixte de Recherche 8638 Centre National de Recherche Scientifique Medicinal Chemistry Laboratory-Faculty of Pharmacy, University Paris Descartes, Paris, France
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15
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Alici-Evcimen Y, Breitbart WS. Ifosfamide neuropsychiatric toxicity in patients with cancer. Psychooncology 2008; 16:956-60. [PMID: 17278152 DOI: 10.1002/pon.1161] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Ifosfamide is a chemotherapy agent commonly used in the treatment of several solid tumors and hematologic malignancies. Common ifosfamide toxicities are bone marrow suppression, alopecia, nausea and vomiting. Less common, but striking, are the rare but dramatic neuropsychiatric toxicities with discrete neurological symptoms and delirium. We report here a case of ifosfamide neuropsychiatric toxicity which presented with an isolated psychotic disorder with delusions, and was successfully treated with methylene blue. Current literature on treatment and prophylaxis of this clinically challenging chemotherapy-induced complication is presented.
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Affiliation(s)
- Yesne Alici-Evcimen
- Memorial Sloan-Kettering Cancer Center, Department of Psychiatry and Behavioral Sciences, 1275 York Avenue, Box 421, New York, NY 10021, USA.
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16
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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