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Smita P, Narayan PA, J K, Gaurav P. Therapeutic drug monitoring for cytotoxic anticancer drugs: Principles and evidence-based practices. Front Oncol 2022; 12:1015200. [PMID: 36568145 PMCID: PMC9773989 DOI: 10.3389/fonc.2022.1015200] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/24/2022] [Indexed: 12/13/2022] Open
Abstract
Cytotoxic drugs are highly efficacious and also have low therapeutic index. A great degree of caution needs to be exercised in their usage. To optimize the efficacy these drugs need to be given at maximum tolerated dose which leads to significant amount of toxicity to the patient. The fine balance between efficacy and safety is the key to the success of cytotoxic chemotherapeutics. However, it is possibly more rewarding to obtain that balance for this class drugs as the frequency of drug related toxicities are higher compared to the other therapeutic class and are potentially life threatening and may cause prolonged morbidity. Significant efforts have been invested in last three to four decades in therapeutic drug monitoring (TDM) research to understand the relationship between the drug concentration and the response achieved for therapeutic efficacy as well as drug toxicity for cytotoxic drugs. TDM evolved over this period and the evidence gathered favored its routine use for certain drugs. Since, TDM is an expensive endeavor both from economic and logistic point of view, to justify its use it is necessary to demonstrate that the implementation leads to perceivable improvement in the patient outcomes. It is indeed challenging to prove the utility of TDM in randomized controlled trials and at times may be nearly impossible to generate such data in view of the obvious findings and concern of compromising patient safety. Therefore, good quality data from well-designed observational study do add immense value to the scientific knowledge base, when they are examined in totality, despite the heterogeneity amongst them. This article compiles the summary of the evidence and the best practices for TDM for the three cytotoxic drug, busulfan, 5-FU and methotrexate. Traditional use of TDM or drug concentration data for dose modification has been witnessing a sea change and model informed precision dosing is the future of cytotoxic drug therapeutic management.
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Affiliation(s)
- Pattanaik Smita
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India,*Correspondence: Pattanaik Smita,
| | - Patil Amol Narayan
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kumaravel J
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prakash Gaurav
- Department of Clinical Hematology and Medical Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Zhou X, Chang Y, Qian J, Shen C, Han J, Zhao H, Chang R. Clinical Benefit of Therapeutic Drug Monitoring in Colorectal Cancer Patients Who Received Fluorouracil-Based Chemotherapy. Med Sci Monit 2021; 27:e929474. [PMID: 34330885 PMCID: PMC8336255 DOI: 10.12659/msm.929474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background The impact of therapeutic drug management (TDM) on reducing toxicity and improving efficacy in colorectal cancer (CRC) patients receiving fluorouracil-based chemotherapy is still unclear. Material/Methods A total of 207 patients (Study Group n=54, Historical Group n=153) with metastatic colorectal cancer were enrolled. All of them received 6 administrations of the 5-FU based regimens. Initial 5-FU dosing of all patients was calculated using body surface area (BSA). In the Study Group, individual exposure during each cycle was measured using a nanoparticle immunoassay, and the 5-FU blood concentration was calculated using the area under the curve (AUC). We adjusted the 5-FU infusion dose of the next cycle based on the AUC data of the previous cycle to achieve the target of 20–30 mg×h/L. Results In the fourth cycle, patients in the target concentration range (AUC mean, 26.3 mg×h/L; Median, 28 mg×h/L; Range, 14–38 mg×h/L; CV, 22.4%) accounted for 46.8% of all patients, which were more than the ones in the first cycle (P<0.001). 5-FU TDM significantly reduced the toxicity of chemotherapy and improved its efficacy. The Study Group (30/289) showed a lower percentage of severe adverse events than that in the Historical Group (185/447) (P<0.001). The incidences of complete response and partial response in the Study Group were higher than those in the Historical Group (P=0.032). Conclusions TDM in colorectal cancer can reduce toxicity, improve efficacy and clinical outcome, and can be routinely used in 5-FU-based chemotherapy.
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Affiliation(s)
- Xingqin Zhou
- Department of Radiotherapy, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China (mainland)
| | - Yazhou Chang
- School of Medicine, Southeast University, Nanjing, Jiangsu, China (mainland)
| | - Jing Qian
- Department of Radiotherapy, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China (mainland)
| | - Chaoyan Shen
- Department of Radiotherapy, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China (mainland)
| | - Jie Han
- Department of Radiotherapy, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China (mainland)
| | - Hongyu Zhao
- Department of Radiotherapy, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China (mainland)
| | - Renan Chang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China (mainland)
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Dolat M, Macaire P, Goirand F, Vincent J, Hennequin A, Palmier R, Bengrine-Lefevre L, Ghiringhelli F, Royer B, Schmitt A. Association of 5-FU Therapeutic Drug Monitoring to DPD Phenotype Assessment May Reduce 5-FU Under-Exposure. Pharmaceuticals (Basel) 2020; 13:ph13110416. [PMID: 33238487 PMCID: PMC7700344 DOI: 10.3390/ph13110416] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/13/2020] [Accepted: 11/20/2020] [Indexed: 12/27/2022] Open
Abstract
In order to limit 5-fluorouracil (5-FU) toxicity, some health agencies recommend evaluating dihydropyrimidine dehydrogenase (DPD) deficiency before any 5-FU treatment introduction. In our study, we investigated relationships between 5-FU clearance and markers of DPD activity such as uracilemia (U), dihydrouracilemia (UH2)/U ratio, or genotype of the gene encoding DPD (DPYD). All patients with gastrointestinal cancers who received 5-FU-based regimens form March 2018 to June 2020 were included in our study. They routinely benefited of a pre-therapeutic DPYD genotyping and phenotyping. During 5-FU infusion, blood samples were collected to measure 5-FU steady-state concentration in order to adapt 5-FU doses at the following cycles. A total of 169 patients were included. Median age was 68 (40–88) years and main primary tumor sites were colorectal (40.8%) and pancreas (31.4%), metastatic in 76.3%. 5-FU was given as part of FOLFIRINOX (44.4%), simplified FOLFOX-6 (26.6%), or docetaxel/FOLFOX-4 (10.6%). Regarding DPD activity, median U and UH2/U were, respectively, 10.8 ng/mL and 10.1, and almost 15% harbored a heterozygous mutation. On the range of measured U and UH2/U, no correlation was observed with 5-FU clearance. Moreover, in patients with U < 16 ng/mL, 5-FU exposure was higher than in other patients, and most of them benefited of dose increase following 5-FU therapeutic drug monitoring (TDM). If recent guidelines recommend decreasing 5-FU dose in patients harboring U ≥ 16 ng/mL, our study highlights that those patients are at risk of under-exposure and that 5-FU TDM should be conducted in order to avoid loss of efficacy.
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Affiliation(s)
- Marine Dolat
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
| | - Pauline Macaire
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
- INSERM U1231, University of Burgundy Franche-Comté, 21000 Dijon, France
| | - Françoise Goirand
- Laboratoire de Pharmacologie/Toxicologie, CHU de Dijon, 21000 Dijon, France;
| | - Julie Vincent
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
| | - Audrey Hennequin
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
| | - Rémi Palmier
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
| | - Leïla Bengrine-Lefevre
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
| | - François Ghiringhelli
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
- INSERM U1231, University of Burgundy Franche-Comté, 21000 Dijon, France
| | - Bernard Royer
- Laboratoire de Pharmacologie Clinique, CHU Jean-Minjoz, 3, Boulevard Alexandre-Fleming, 25030 Besançon, France;
- INSERM, EFS BFC, UMR1098, Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Université Bourgogne Franche-Comté, 25000 Besançon, France
| | - Antonin Schmitt
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
- INSERM U1231, University of Burgundy Franche-Comté, 21000 Dijon, France
- Correspondence:
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Goirand F, Lemaitre F, Launay M, Tron C, Chatelut E, Boyer JC, Bardou M, Schmitt A. How can we best monitor 5-FU administration to maximize benefit to risk ratio? Expert Opin Drug Metab Toxicol 2018; 14:1303-1313. [PMID: 30451549 DOI: 10.1080/17425255.2018.1550484] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION 5-Fluorouracil (5-FU) is currently used as a chemotherapy in several cancers such as head-and-neck (H&N) and colorectal cancers. 5-FU dosing is traditionally based on body surface area (BSA), but this strategy is usually associated with severe toxicities. 5-FU is mainly catabolized by dihydropyrimidine dehydrogenase (DPD), and 5-FU dosage adaptation according to DPD status at the first cycle of treatment is now recommended. To further optimize 5-FU-based chemotherapy, a body of evidences justifies therapeutic drug monitoring (TDM). Areas covered: 5-FU pharmacokinetics, relationships between pharmacokinetics and efficacy or toxicity of 5-FU, proofs of interest of 5-FU TDM and its practical considerations are discussed. Expert opinion: BSA-adjusted 5-FU administration is associated with a large inter-individual variability, and according to this strategy, many patients experience under- or overexposure. Moreover, relationships between 5-FU area under the curve (AUC) and its toxicity or efficacy have been demonstrated, at least in patients with colorectal or H&N cancers. 5-FU therapeutic index has been validated and algorithms of 5-FU dosage adaptation according to its AUC are now available. Advances in pre-analytical and analytical steps of 5-FU TDM make its use feasible in clinical practice. Thus, there are consistent evidences to recommend 5-FU TDM in patients with advanced colorectal or H&N cancers.
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Affiliation(s)
- Françoise Goirand
- a Centre Hospitalo-Universitaire de Dijon-Bourgogne , Dijon , France
| | - Florian Lemaitre
- b Service de Pharmacologie Clinique , Laboratoire de Pharmacologie Expérimentale et Clinique, Centre d'Investigation Clinique INSERM 1414, CHU de Rennes, Université Rennes 1 , Rennes , France
| | - Manon Launay
- c Service de Pharmacologie, Hôpital Européen Georges Pompidou , Laboratoire de Pharmacologie et de Toxicologie , Paris , France
| | - Camille Tron
- b Service de Pharmacologie Clinique , Laboratoire de Pharmacologie Expérimentale et Clinique, Centre d'Investigation Clinique INSERM 1414, CHU de Rennes, Université Rennes 1 , Rennes , France
| | - Etienne Chatelut
- d Institut Claudius-Regaud et Centre de Recherches en Cancérologie de Toulouse , IUCT - Oncopole , Toulouse , France
| | - Jean-Christophe Boyer
- e Laboratoire de Biochimie et Biologie Moléculaire , CHU de Nîmes Carémeau , Nîmes , France
| | - Marc Bardou
- f Centre d'Investigations Cliniques 1432, Module Plurithématique , CHU Dijon-Bourgogne, Hôpital François Mitterrand , Dijon , France
| | - Antonin Schmitt
- g Service Pharmacie , Centre Georges-François Leclerc , Dijon , France
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Beumer JH, Chu E, Allegra C, Tanigawara Y, Milano G, Diasio R, Kim TW, Mathijssen RH, Zhang L, Arnold D, Muneoka K, Boku N, Joerger M. Therapeutic Drug Monitoring in Oncology: International Association of Therapeutic Drug Monitoring and Clinical Toxicology Recommendations for 5-Fluorouracil Therapy. Clin Pharmacol Ther 2018; 105:598-613. [PMID: 29923599 DOI: 10.1002/cpt.1124] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/09/2018] [Indexed: 12/14/2022]
Abstract
5-Fluorouracil (5-FU) is dosed by body surface area, a practice unable to reduce the interindividual variability in exposure. Endorsed by the International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT), we evaluated clinical evidence and strongly recommend TDM for the management of 5-FU therapy in patients with colorectal or head-and-neck cancer receiving common 5-FU regimens. Our systematic methodology provides a framework to evaluate published evidence in support of TDM recommendations in oncology.
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Affiliation(s)
- Jan H Beumer
- Cancer Therapeutics Program, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.,Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Edward Chu
- Cancer Therapeutics Program, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.,Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Yusuke Tanigawara
- Department of Clinical Pharmacokinetics and Pharmacodynamics, Keio University School of Medicine, Tokyo, Japan
| | - Gerard Milano
- Oncopharmacology Unit, Centre Antoine Lacassagne, Nice, France
| | - Robert Diasio
- Developmental Therapeutics Program, Mayo Clinic Cancer Center, Rochester, Minnesota, USA.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Tae Won Kim
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ron H Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Li Zhang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Dirk Arnold
- Department of Oncology, AK Altona, Asklepios Tumorzentrum Hamburg, Hamburg, Germany
| | - Katsuki Muneoka
- Division of Oncology Center, Niitsu Medical Center Hospital, Niigata City, Japan
| | - Narikazu Boku
- Department of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tsukiji, Chuo-ku, Tokyo, Japan
| | - Markus Joerger
- Department of Medical Oncology & Hematology, Cantonal Hospital, St. Gallen, Switzerland
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Lemaitre F, Goirand F, Launay M, Chatelut E, Boyer JC, Evrard A, Paludetto MN, Guilhaumou R, Ciccolini J, Schmitt A. [5-fluorouracil therapeutic drug monitoring: Update and recommendations of the STP-PT group of the SFPT and the GPCO-Unicancer]. Bull Cancer 2018; 105:790-803. [PMID: 30103904 DOI: 10.1016/j.bulcan.2018.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/26/2022]
Abstract
Despite being 60-years old now, 5-FU remains the backbone of numerous regimen to treat a variety of solid tumors such as breast, head-and-neck and digestive cancers either in neo-adjuvant, adjuvant or metastatic settings. Standard 5-FU usually claims 15-40% of severe toxicities and up to 1% of toxic-death. Numerous studies show a stiff relationship between 5-FU exposure and toxicity or efficacy. In addition, 5-FU pharmacokinetics is highly variable between patients. Indeed, 80% of the 5-FU dose is catabolized in the liver by dihydropyrimidine dehydrogenase (DPD) into inactive compounds. It is now well established that DPD deficiency could lead to severe toxicities and, thus, require dose reduction in deficient patients. However, despite dosage adaptation based on DPD status, some patients may still experience under- or over-exposure, leading to inefficacy or major toxicity. The "Suivi thérapeutique pharmacologique et personnalisation des traitements" (STP-PT) group of the "Société française de pharmacologie et de thérapeutique" (SFPT) and the "Groupe de pharmacologie clinique oncologique" (GPCO)-Unicancer, based on the latest and most up-to-date literature data, recommend the implementation of 5-FU Therapeutic Drug Monitoring in order to ensure an adequate 5-FU exposure.
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Affiliation(s)
- Florian Lemaitre
- Université Rennes 1, CHU de Rennes, centre d'investigation clinique Inserm 1414, service de pharmacologie clinique, laboratoire de pharmacologie expérimentale et clinique, 2, rue Henri-Le-Guilloux, 35000 Rennes, France
| | - Françoise Goirand
- Centre hospitalo-universitaire de Dijon-Bourgogne, 5, boulevard Jeanne-d'Arc, 21000 Dijon, France
| | - Manon Launay
- Hôpital européen Georges-Pompidou, laboratoire de pharmacologie et de toxicologie, service de pharmacologie, 20, rue Leblanc, 75908 Paris cedex 15, France
| | - Etienne Chatelut
- Institut Claudius-Regaud et centre de recherches en cancérologie de Toulouse, IUCT - Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse, France
| | - Jean-Christophe Boyer
- CHU de Nîmes Carémeau, laboratoire de biochimie et biologie moléculaire, place du Professeur-Robert-Debré, 30029 Nîmes cedex 9, France
| | - Alexandre Evrard
- CHU de Nîmes Carémeau, laboratoire de biochimie et biologie moléculaire, place du Professeur-Robert-Debré, 30029 Nîmes cedex 9, France
| | - Marie-Noelle Paludetto
- Institut Claudius-Regaud et centre de recherches en cancérologie de Toulouse, IUCT - Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse, France
| | - Romain Guilhaumou
- AP-HM, CHU Timone, service de pharmacologie clinique et pharmacovigilance, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Joseph Ciccolini
- AP-HM, CHU Timone, SMARTc CRCM UMR Inserm U1068, laboratoire de pharmacocinétique clinique, 265, rue St-Pierre, 13385 Marseille, France
| | - Antonin Schmitt
- Centre Georges-François-Leclerc, service pharmacie, 1, rue Pr.-Marion, 21000 Dijon, France.
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P53 represses pyrimidine catabolic gene dihydropyrimidine dehydrogenase (DPYD) expression in response to thymidylate synthase (TS) targeting. Sci Rep 2017; 7:9711. [PMID: 28851987 PMCID: PMC5575263 DOI: 10.1038/s41598-017-09859-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 07/12/2017] [Indexed: 12/29/2022] Open
Abstract
Nucleotide metabolism in cancer cells can influence malignant behavior and intrinsic resistance to therapy. Here we describe p53-dependent control of the rate-limiting enzyme in the pyrimidine catabolic pathway, dihydropyrimidine dehydrogenase (DPYD) and its effect on pharmacokinetics of and response to 5-fluorouracil (5-FU). Using in silico/chromatin-immunoprecipitation (ChIP) analysis we identify a conserved p53 DNA-binding site (p53BS) downstream of the DPYD gene with increased p53 occupancy following 5-FU treatment of cells. Consequently, decrease in Histone H3K9AC and increase in H3K27me3 marks at the DPYD promoter are observed concomitantly with reduced expression of DPYD mRNA and protein in a p53-dependent manner. Mechanistic studies reveal inhibition of DPYD expression by p53 is augmented following thymidylate synthase (TS) inhibition and DPYD repression by p53 is dependent on DNA-dependent protein kinase (DNA-PK) and Ataxia telangiectasia mutated (ATM) signaling. In-vivo, liver specific Tp53 loss increases the conversion of 5-FU to 5-FUH2 in plasma and elicits a diminished 5-FU therapeutic response in a syngeneic colorectal tumor model consistent with increased DPYD-activity. Our data suggest that p53 plays an important role in controlling pyrimidine catabolism through repression of DPYD expression, following metabolic stress imposed by nucleotide imbalance. These findings have implications for the toxicity and efficacy of the cancer therapeutic 5-FU.
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Prospective, Multicenter Study of 5-Fluorouracil Therapeutic Drug Monitoring in Metastatic Colorectal Cancer Treated in Routine Clinical Practice. Clin Colorectal Cancer 2016; 15:381-388. [DOI: 10.1016/j.clcc.2016.04.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 04/27/2016] [Indexed: 11/23/2022]
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9
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Chen S, Wang Y, Zhang Y, Wan Y. Low expression of PKCα and high expression of KRAS predict poor prognosis in patients with colorectal cancer. Oncol Lett 2016; 12:1655-1660. [PMID: 27602102 PMCID: PMC4998155 DOI: 10.3892/ol.2016.4845] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 03/08/2016] [Indexed: 01/13/2023] Open
Abstract
The current study aimed to determine the association between protein kinase Cα (PKCα) and Kirsten rat sarcoma viral oncogene homolog (KRAS) expression and the response to folinic acid, 5-fluorouracil and oxaliplatin (FOLFOX regimen) in patients with colorectal cancer (CRC). The protein levels of PKCα and KRAS were analyzed by immunohistochemistry in tissue samples from patients with CRC and in non-cancerous tissues, including 152 cases of colorectal adenocarcinoma, 30 cases of colorectal adenoma and 20 normal colonic mucosa samples. The association between PKCα and KRAS expression and clinicopathological features was analyzed. The rates of positive PKCα protein expression in patients with poorly, moderately and well-differentiated adenocarcinoma were 16.7% (6/36), 40.0% (24/60), and 57.1% (32/56), respectively (P<0.013). The rate of positive KRAS expression in CRC patients was significantly higher than in patients with colon adenoma and normal colon mucosa (P<0.001). Expression levels of KRAS were associated with the degree of differentiation of CRC (P<0.001). Expression of PKCα was negatively correlated with KRAS expression in CRC tissues. The mean progression-free survival (PFS) times in patients with high and low expression of PKCα were 43.9 and 38.8 months, respectively (P<0.001). The mean PFS times were 38.5 and 45.5 months in patients with high and low expression of KRAS, respectively (P=0.001). In conclusion, low PKCα and high KRAS expression predicted relatively poor prognosis in patients with CRC.
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Affiliation(s)
- Suxian Chen
- Department of Pathology, The Third Affiliated Hospital of Liaoning Medical College, Jinzhou, Liaoning 121002, P.R. China
| | - Yadi Wang
- Department of Oncology, The Third Affiliated Hospital of Liaoning Medical College, Jinzhou, Liaoning 121002, P.R. China
| | - Yun Zhang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Liaoning Medical College, Jinzhou, Liaoning 121002, P.R. China
| | - Yizeng Wan
- Department of Pathology, The Third Affiliated Hospital of Liaoning Medical College, Jinzhou, Liaoning 121002, P.R. China
- Correspondence to: Dr Yizeng Wan, Department of Pathology, The Third Affiliated Hospital of Liaoning Medical College, 2 Heping Road Section 5, Linghe, Jinzhou, Liaoning 121002, P.R. China, E-mail:
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Freeman K, Saunders MP, Uthman OA, Taylor-Phillips S, Connock M, Court R, Gurung T, Sutcliffe P, Clarke A. Is monitoring of plasma 5-fluorouracil levels in metastatic / advanced colorectal cancer clinically effective? A systematic review. BMC Cancer 2016; 16:523. [PMID: 27456697 PMCID: PMC4960837 DOI: 10.1186/s12885-016-2581-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 07/19/2016] [Indexed: 11/29/2022] Open
Abstract
Background Pharmacokinetic guided dosing of 5-fluorouracil chemotherapies to bring plasma 5-fluorouracil into a desired therapeutic range may lead to fewer side effects and better patient outcomes. High performance liquid chromatography and a high throughput nanoparticle immunoassay (My5-FU) have been used in conjunction with treatment algorithms to guide dosing. The objective of this study was to assess accuracy, clinical effectiveness and safety of plasma 5-fluorouracil guided dose regimen(s) versus standard regimens based on body surface area in colorectal cancer. Methods We undertook a systematic review. MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; EMBASE; Cochrane Library; Science Citation Index and Conference Proceedings (Web of Science); and NIHR Health Technology Assessment Programme were searched from inception to January 2014. We reviewed evidence on accuracy of My5-FU for estimating plasma 5-fluorouracil and on the clinical effectiveness of pharmacokinetic dosing compared to body surface area dosing. Estimates of individual patient data for overall survival and progression-free survival were reconstructed from published studies. Survival and adverse events data were synthesised and examined for consistency across studies. Results My5-FU assays were found to be consistent with reference liquid chromatography tandem mass spectrometry. Comparative studies pointed to gains in overall survival and in progression-free survival with pharmacokinetic dosing, and were consistent across multiple studies. Conclusions Although our analyses are encouraging, uncertainties remain because evidence is mainly from outmoded 5-fluorouracil regimens; a randomised controlled trial is urgently needed to investigate new dose adjustment methods in modern treatment regimens. Electronic supplementary material The online version of this article (doi:10.1186/s12885-016-2581-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karoline Freeman
- Division of Health Sciences, Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | | | - Olalekan A Uthman
- Division of Health Sciences, Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Sian Taylor-Phillips
- Division of Health Sciences, Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Martin Connock
- Division of Health Sciences, Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
| | - Rachel Court
- Division of Health Sciences, Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Tara Gurung
- Division of Health Sciences, Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Paul Sutcliffe
- Division of Health Sciences, Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Aileen Clarke
- Division of Health Sciences, Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
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Freeman K, Connock M, Cummins E, Gurung T, Taylor-Phillips S, Court R, Saunders M, Clarke A, Sutcliffe P. Fluorouracil plasma monitoring: systematic review and economic evaluation of the My5-FU assay for guiding dose adjustment in patients receiving fluorouracil chemotherapy by continuous infusion. Health Technol Assess 2016; 19:1-321, v-vi. [PMID: 26542268 DOI: 10.3310/hta19910] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND 5-Fluorouracil (5-FU) is a chemotherapy used in colorectal, head and neck (H&N) and other cancers. Dose adjustment is based on body surface area (BSA) but wide variations occur. Pharmacokinetic (PK) dosing is suggested to bring plasma levels into the therapeutic range to promote fewer side effects and better patient outcomes. We investigated the clinical effectiveness and cost-effectiveness of the My5-FU assay for PK dose adjustment to 5-FU therapy. OBJECTIVES To systematically review the evidence on the accuracy of the My5-FU assay compared with gold standard methods [high-performance liquid chromatography (HPLC) and liquid chromatography-mass spectrometry (LC-MS)]; the effectiveness of My5-FU PK dosing compared with BSA; the effectiveness of HPLC and/or LC-MS compared with BSA; the generalisability of published My5-FU and PK studies; costs of using My5-FU; to develop a cost-effectiveness model. DATA SOURCES We searched MEDLINE, EMBASE, Science Citation Index and other databases between January and April 2014. METHODS Two reviewers independently screened titles and abstracts with arbitration and consensus agreement. We undertook quality assessment. We reconstructed Kaplan-Meier plots for progression-free survival (PFS) and overall survival (OS) for comparison of BSA and PK dosing. We developed a Markov model to compare My5-FU with BSA dosing which modelled PFS, OS and adverse events, using a 2-week cycle over a 20 year time horizon with a 3.5% discount rate. Health impacts were evaluated from the patient perspective, while costs were evaluated from the NHS and Personal Social Services perspective. RESULTS A total of 8341 records were identified through electronic searches and 35 and 54 studies were included in the clinical effectiveness and cost-effectiveness reviews respectively. There was a high apparent correlation between My5-FU, HPLC and LC-MS/mass spectrometer but upper and lower limits of agreement were -18% to 30%. Median OS were estimated as 19.6 [95% confidence interval (CI) 17.0 to 21.0] months for PK versus 14.6 (95% CI 14.1 to 15.3) months for BSA for 5-FU+folinic acid (FA); and 27.4 (95% CI 23.2 to 38.8) months for PK versus 20.6 (95% CI 18.4 to 22.9) months for BSA for FOLFOX6 in metastatic colorectal cancer (mCRC). PK versus BSA studies were generalisable to the relevant populations. We developed cost-effectiveness models for mCRC and H&N cancer. The base case assumed a cost per My5-FU assay of £ 61.03. For mCRC for 12 cycles of a oxaliplatin in combination with 5-fluorouracil and FA (FOLFOX) regimen, there was a quality-adjusted life-year (QALY) gain of 0.599 with an incremental cost-effectiveness ratio of £ 4148 per QALY. Probabilistic and scenario analyses gave similar results. The cost-effectiveness acceptability curve showed My5-FU to be 100% cost-effective at a threshold of £ 20,000 per QALY. For H&N cancer, again, given caveats about the poor evidence base, we also estimated that My5-FU is likely to be cost-effective at a threshold of £ 20,000 per QALY. LIMITATIONS Quality and quantity of evidence were very weak for PK versus BSA dosing for all cancers with no randomised controlled trials (RCTs) using current regimens. For H&N cancer, two studies of regimens no longer in use were identified. CONCLUSIONS Using a linked evidence approach, My5-FU appears to be cost-effective at a willingness to pay of £ 20,000 per QALY for both mCRC and H&N cancer. Considerable uncertainties remain about evidence quality and practical implementation. RCTs are needed of PK versus BSA dosing in relevant cancers.
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Affiliation(s)
| | - Martin Connock
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Tara Gurung
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mark Saunders
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester, UK
| | - Aileen Clarke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Sutcliffe
- Warwick Medical School, University of Warwick, Coventry, UK
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12
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Therapeutic drug monitoring of 5-fluorouracil. Cancer Chemother Pharmacol 2016; 78:447-64. [PMID: 27217046 DOI: 10.1007/s00280-016-3054-2] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 05/03/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE For over 50 years, 5-FU has played a critical role in the systemic chemotherapy of cancer patients. 5-FU serves as the main backbone of combination chemotherapy for patients with colorectal cancer in both the adjuvant and metastatic disease settings. Herein, we review the current status of 5-FU therapeutic drug monitoring (TDM) and discuss its potential role in the clinical practice setting. METHOD PubMed and abstracts from the American Society of Clinical Oncology were searched up through September 2015 for clinical data relating to 5-FU TDM. RESULTS 5-FU dosing has been typically determined by using body surface area (BSA). However, it is now well established that BSA-based 5-FU dosing is correlated with a wide variation of 5-FU systemic exposure. Pharmacokinetic (PK) studies of 5-FU systemic exposure have shown a wide range of interpatient variation of 5-FU plasma drug levels. Over the past 30 years, increasing efforts have been placed on optimizing 5-FU dosing with the main goals of increasing antitumor efficacy while reducing drug-associated toxicity. There is growing evidence to show that 5-FU dosing based on plasma 5-FU drug level is feasible and that 5-FU TDM can improve clinical outcomes by improving efficacy of 5-FU-based combination regimens and reducing toxicities. CONCLUSION Dose adjustment of 5-FU is feasible, and PK-based dosing can significantly improve clinical outcomes by reducing toxicities and improving efficacy.
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Individual 5-Fluorouracil Dose Adjustment via Pharmacokinetic Monitoring Versus Conventional Body-Area-Surface Method. Ther Drug Monit 2016; 38:79-86. [DOI: 10.1097/ftd.0000000000000238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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14
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Patel K, Iacobuzio-Donahue CA, Gormley PE, Kern SE, Cunningham SC. Are we systematically under-dosing patients with fluorouracil? J Clin Oncol 2014; 33:e36-7. [PMID: 24616306 DOI: 10.1200/jco.2013.49.5044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Scott E Kern
- Johns Hopkins Medical Institutions, Baltimore, MD
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15
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Ma YS, Yang IP, Tsai HL, Huang CW, Juo SHH, Wang JY. High glucose modulates antiproliferative effect and cytotoxicity of 5-fluorouracil in human colon cancer cells. DNA Cell Biol 2013; 33:64-72. [PMID: 24283362 DOI: 10.1089/dna.2013.2161] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
5-Fluorouracil (5-FU)-based chemotherapy is widely used for the treatment of colorectal cancer (CRC). While optimal doses of 5-FU are generally established based on a patient's estimated body surface area, the plasma concentrations of 5-FU vary among patients. In addition, hyperglycemia in patients with CRC has been reported as a risk factor in poor prognosis. The aim of the present study was to investigate whether hyperglycemia affects antiproliferative effect of 5-FU on the human colon cancer cells (SW480, SW620, LoVo, and HCT116). Growth inhibition of 5-FU was accessed by WST-8 assay. The effect of high glucose (HG, 15 mM) and 5-FU on the cellular proliferation was evaluated by flow cytometry analysis using 5-ethynyl-2'-deoxy-uridine (EdU) incorporation plus 7-AAD. Cell death was determined by flow cytometry using Annexin V-FITC and PI. The results showed that HG, compared to physiological normal glucose (NG) concentration (5 mM), leads to increased cell proliferation and increased GI50 of 5-FU in the four colon cancer cell lines. When the cells were pretreated with a low-dose 5-FU in NG condition, subsequent HG treatment eliminated inhibitory effect of 5-FU in cancer cell growth. In the presence of 5-FU (0.5 μg/mL for LoVo and HCT116; 1 μg/mL for SW480 and SW620), culture with HG for 72 h does not significantly altered cell cycle profile in the four cell lines but significantly increased DNA replication in SW620 (21%) and LoVo (17%). Flow cytometric analysis showed that HG protects cells against 5-FU-induced cell death in SW480. Finally, HG did not alter intracellular level of reactive oxygen species (ROS), although 5-FU indeed induced higher intracellular level of ROS. In conclusion, HG attenuates growth inhibition of 5-FU and our results indicate that decreased cell death and increased DNA replication may account for the attenuating effect of a HG environment on 5-FU-induced tumor growth inhibition.
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Affiliation(s)
- Yi-Shing Ma
- 1 Graduate Institute of Genome Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
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16
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Kline CLB, Schiccitano A, Zhu J, Beachler C, Sheikh H, Harvey HA, Mackley HB, McKenna K, Staveley-O'Carroll K, Poritz L, Messaris E, Stewart D, Sivik J, El-Deiry WS. Personalized dosing via pharmacokinetic monitoring of 5-fluorouracil might reduce toxicity in early- or late-stage colorectal cancer patients treated with infusional 5-fluorouracil-based chemotherapy regimens. Clin Colorectal Cancer 2013; 13:119-26. [PMID: 24461492 DOI: 10.1016/j.clcc.2013.11.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 10/11/2013] [Accepted: 11/08/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Therapeutic plasma 5-fluorouracil (5-FU) levels are achieved in only 20% to 30% of patients with the current practice of administering 5-FU doses based on body surface area (BSA). Alternatively, 5-FU doses can be adjusted based on 5-FU pharmacokinetic (PK) monitoring. Although benefits of PK monitoring of 5-FU in metastatic colorectal cancer (CRC) have been reported, its utility among patients with early stage disease has not been reported. PATIENTS AND METHODS We retrospectively examined the effect of 5-FU PK monitoring in 84 CRC patients (49 stage IV and 35 stage II/III) receiving mFOLFOX6 (modifiedFOLFOX6; modified 5-fluorouracil, leucovorin, oxaliplatin protocol) or mFOLFIRI (modified 5-fluorouracil, leucovorin, irinotecan protocol). Forty-six of the 84 patients received 5-FU doses based on BSA and 38 received doses that were adjusted with PK monitoring. 5-FU plasma levels were measured using a nanoparticle immunoassay method. RESULTS 5-fluorouracil PK monitoring significantly improved disease-free survival in stage II/III patients (P = .0429). There was also a trend towards improved progression-free survival among stage IV patients who had their 5-FU levels PK-monitored (P = .16). Moreover, 5-FU PK monitoring significantly reduced (P = .0437) and delayed (P = .0144) adverse effects in stage II/III patients. Toxicity occurred after the second 5-FU dose in the BSA group and after the sixth to seventh dose in the PK monitoring group. In stage IV patients, the onset of toxicities was also delayed with PK monitoring (P = .0605). CONCLUSION We provide evidence that PK monitoring of 5-FU is potentially beneficial for late stage and early stage CRC. These results contribute to the growing body of evidence regarding patient benefit when treatment decisions are based on the individual patient characteristics, in this case, a patients' 5-FU levels.
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Affiliation(s)
- Christina Leah B Kline
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Angelique Schiccitano
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Junjia Zhu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Cheryl Beachler
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Hassan Sheikh
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Harold A Harvey
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Heath B Mackley
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA; Division of Radiation Oncology, Department of Radiology, Penn State College of Medicine, Hershey, PA
| | - Kevin McKenna
- Department of Surgery, Penn State College of Medicine, Hershey, PA
| | | | - Lisa Poritz
- Department of Surgery, Penn State College of Medicine, Hershey, PA
| | | | - David Stewart
- Department of Surgery, Penn State College of Medicine, Hershey, PA
| | - Jeffrey Sivik
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA
| | - Wafik S El-Deiry
- Hematology/Oncology Division, Department of Medicine, Penn State College of Medicine, Hershey, PA.
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Gotanda K, Hirota T, Matsumoto N, Ieiri I. MicroRNA-433 negatively regulates the expression of thymidylate synthase (TYMS) responsible for 5-fluorouracil sensitivity in HeLa cells. BMC Cancer 2013; 13:369. [PMID: 23915286 PMCID: PMC3750578 DOI: 10.1186/1471-2407-13-369] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 08/01/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Thymidylate synthase (TYMS) is an important folate-dependent enzyme in DNA synthesis and an important target for cancer chemotherapy. High TYMS expression levels in tumors are generally associated with resistance to 5-fluorouracil (5-FU). The cause of the variability in TYMS expression is still not fully understood, however, only a small proportion of the TYMS expression can be explained by TYMS genetic polymorphisms. The purpose of this study is to identify novel microRNAs (miRNAs) which regulate the expression of TYMS and to determine whether miRNAs binding to the 3'-untranslated region (UTR) of TYMS mRNA affect the proliferation of HeLa cells treated with 5-FU. METHODS An in silico search was performed to find potential binding sites of miRNAs in TYMS mRNA. The efficacy of predicted miRNAs at the 3'-UTR of TYMS mRNA was evaluated using a dual-luciferase reporter assay. TYMS mRNA and protein expression in HeLa cells was quantified with real-time RT-PCR and Western blotting, respectively. The effects of miR-433 on cell proliferative activity were determined by WST-8 assay. RESULTS The overexpression of miR-433 was associated with significantly decreased reporter activity in the plasmid containing the 3'-UTR of TYMS mRNA (P < 0.01). The levels of TYMS mRNA and protein in HeLa cells were significantly decreased by the overexpression of miR-433 (P < 0.05). Furthermore, miR-433 increased inhibition of cell proliferation in HeLa cells treated with 5-FU at over 2.0 μM. CONCLUSION The results indicate that miR-433 post-transcriptionally regulates the expression of TYMS mRNA and protein, and increases sensitivity to 5-FU in HeLa cells. This is the first report showing that a miRNA regulating TYMS expression has a significant impact on sensitivity to 5-FU treatment.
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