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He H, He M, Wang Y, Xiong H, Xiong Y, Shan M, Liu D, Guo Z, Kou Y, Zhang Y, Yang M, Lian J, Sun L, He F. Berberine increases the killing effect of pirarubicin on HCC cells by inhibiting ATG4B-autophagy pathway. Exp Cell Res 2024; 439:114094. [PMID: 38750718 DOI: 10.1016/j.yexcr.2024.114094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 04/17/2024] [Accepted: 05/12/2024] [Indexed: 05/26/2024]
Abstract
Pirarubicin (THP) is a new generation of cell cycle non-specific anthracycline-based anticancer drug. In the clinic, THP and THP combination therapies have been shown to be effective in hepatocellular carcinoma (HCC) patients with transcatheter arterial chemoembolization (TACE) without serious side effects. However, drug resistance limits its therapeutic efficacy. Berberine (BBR), an isoquinoline alkaloid, has been shown to possess antitumour properties against various malignancies. However, the synergistic effect of BBR and THP in the treatment of HCC is unknown. In the present study, we demonstrated for the first time that BBR sensitized HCC cells to THP, including enhancing THP-induced growth inhibition and apoptosis of HCC cells. Moreover, we found that BBR sensitized THP by reducing the expression of autophagy-related 4B (ATG4B). Mechanistically, the inhibition of HIF1α-mediated ATG4B transcription by BBR ultimately led to attenuation of THP-induced cytoprotective autophagy, accompanied by enhanced growth inhibition and apoptosis in THP-treated HCC cells. Tumor-bearing experiments in nude mice showed that the combination treatment with BBR and THP significantly suppressed the growth of HCC xenografts. These results reveal that BBR is able to strengthen the killing effect of THP on HCC cells by repressing the ATG4B-autophagy pathway, which may provide novel insights into the improvement of chemotherapeutic efficacy of THP, and may be conducive to the further clinical application of THP in HCC treatment.
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Affiliation(s)
- Haiyan He
- Department of Biochemistry and Molecular Biology, Army Medical University, Chongqing, 400038, China; Department of Laboratory Medicine, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Meng He
- Department of Biochemistry and Molecular Biology, Army Medical University, Chongqing, 400038, China
| | - Yunxia Wang
- Department of Laboratory Medicine, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Haojun Xiong
- Key Laboratory of Hepatobiliary and Pancreatic Surgery, Institute of Hepatobiliary Surgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Yu Xiong
- Department of Laboratory Medicine, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Meihua Shan
- Department of Clinical Biochemistry, Army Medical University, Chongqing, 400038, China
| | - Dong Liu
- Department of Clinical Biochemistry, Army Medical University, Chongqing, 400038, China
| | - Ziyuan Guo
- Department of Clinical Biochemistry, Army Medical University, Chongqing, 400038, China
| | - Yuhong Kou
- Department of Clinical Biochemistry, Army Medical University, Chongqing, 400038, China
| | - Yan Zhang
- Department of Biochemistry and Molecular Biology, Army Medical University, Chongqing, 400038, China
| | - Mingzhen Yang
- Department of Clinical Biochemistry, Army Medical University, Chongqing, 400038, China
| | - Jiqin Lian
- Department of Clinical Biochemistry, Army Medical University, Chongqing, 400038, China.
| | - Liangbo Sun
- Department of Clinical Biochemistry, Army Medical University, Chongqing, 400038, China.
| | - Fengtian He
- Department of Biochemistry and Molecular Biology, Army Medical University, Chongqing, 400038, China.
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2
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Anees M, Tiwari S, Mehrotra N, Kharbanda S, Singh H. Development and Evaluation of PLA Based Hybrid Block Copolymeric Nanoparticles for Systemic Delivery of Pirarubicin as an Anti-Cancer Agent. Int J Pharm 2022; 620:121761. [PMID: 35472512 DOI: 10.1016/j.ijpharm.2022.121761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022]
Abstract
Pirarubicin (PIRA) is a semi-synthetic anthracycline derivative that is reported to have lesser toxicity and better clinical outcomes as compared to its parental form doxorubicin (DOX). However, long term use of PIRA causes bone marrow suppression and severe cardiotoxicity to the recipients. Herein, we have developed a biodegradable polymeric nano platform consisting of amphiphilic di-block copolymer methoxy polyethylene glycol-polylactic acid and a hydrophobic penta-block copolymer polylactic acid-pluronic L-61-polylactic acid as a hybrid system to prepare PIRA (& DOX) encapsulated nanoparticles (NPs) with an aim to reduce its off targeted toxicity and enhance therapeutic efficacy for cancer therapy. Prepared PIRA/DOX NPs showed uniform particle size distribution, high encapsulation efficiency and sustained drug release profile. Cytotoxicity evaluation of PIRA NPs against TNBC cells and mammospheres showed its superior anti-cancer activity over DOX NPs. Anti-cancer efficacy of PIRA/DOX NPs was found significantly enhanced in presence of penta-block copolymer which confirmed chemo-sensitising ability of pluronic L-61. Most importantly, encapsulation of PIRA/DOX in the NPs reduced their off targeted toxicity and increased the maximum tolerated dose in BALB/c mice. Moreover, treatment of EAC tumor harbouring mice with PIRA NPs resulted in higher tumor regression as compared with the groups treated with free PIRA, free DOX or DOX NPs. Altogether, the results conclude that prepared PIRA NPs exhibits an excellent anti-cancer therapeutic efficacy and has a strong potential for cancer therapy.
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Affiliation(s)
- Mohd Anees
- Centre for Biomedical Engineering, Indian institute of Technology Delhi, New Delhi-110016, INDIA
| | - Sachchidanand Tiwari
- Centre for Biomedical Engineering, Indian institute of Technology Delhi, New Delhi-110016, INDIA
| | - Neha Mehrotra
- Centre for Biomedical Engineering, Indian institute of Technology Delhi, New Delhi-110016, INDIA
| | - Surender Kharbanda
- Dana Farber Cancer Institute, Harvard Medical School, Boston 02115, MA, USA
| | - Harpal Singh
- Centre for Biomedical Engineering, Indian institute of Technology Delhi, New Delhi-110016, INDIA; All India Institute of Medical Sciences, New Delhi-110029, INDIA.
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Comparison of CHOP with THP-COP for peripheral T-cell lymphoma-not otherwise specified and angioimmunoblastic T-cell lymphoma: a retrospective analysis using data from the population-based Osaka Cancer Registry. Int J Hematol 2021; 114:246-251. [PMID: 33864237 DOI: 10.1007/s12185-021-03150-6] [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: 01/02/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
Peripheral T-cell lymphoma-not otherwise specified (PTCL-NOS) and angioimmunoblastic T-cell lymphoma (AITL) are common subtypes of T-cell lymphoma. Although CHOP is a standard regimen for T-cell lymphoma, it has unsatisfactory outcomes. Pirarubicin is an anthracycline antibiotic with lower cardiotoxicity than doxorubicin. THP-COP (pirarubicin, cyclophosphamide, vincristine, and prednisone) is sometimes used for elderly patients with non-Hodgkin's lymphoma in Japan. We performed a retrospective analysis using data from the population-based Osaka Cancer Registry as well as administrative data from 2010 to 2015. Of 82 enrolled patients, 51 received CHOP and 31 received THP-COP. The median age was 65 years in the CHOP group and 75 years in the THP-COP group. The probability of 3-year overall survival (OS) was 49.0% in the CHOP group and 44.9% in the THP-COP group. In the propensity score-adjusted analysis, there was no significant difference between the THP-COP and CHOP groups in the OS of the total sample [hazard ratio (HR) 0.46, 95% CI 0.14-1.55, P = 0.2]. Although our study was limited by its retrospective nature, it showed that clinical outcomes with the THP-COP regimen were comparable to those with the CHOP regimen in PTCL-NOS and AITL. Our findings should be re-assessed in larger studies in the future.
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Tsukigawa K, Imoto S, Yamasaki K, Nishi K, Tsutsumi T, Yokoyama S, Ishima Y, Otagiri M. Synthesis and In Vitro Assessment of pH-Sensitive Human Serum Albumin Conjugates of Pirarubicin. Pharmaceuticals (Basel) 2020; 14:ph14010022. [PMID: 33396604 PMCID: PMC7823624 DOI: 10.3390/ph14010022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 12/24/2020] [Accepted: 12/27/2020] [Indexed: 12/15/2022] Open
Abstract
In a previous study, we reported on the development of a synthetic polymer conjugate of pirarubicin (THP) that was formed via an acid-labile hydrazone bond between the polymer and the THP. However, the synthetic polymer itself was non-biodegradable, which could lead to unexpected adverse effects. Human serum albumin (HSA), which has a high biocompatibility and good biodegradability, is also a potent carrier for delivering antitumor drugs. The objective of this study was to develop pH-sensitive HSA conjugates of THP (HSA-THP), and investigate the release of THP and the cytotoxicity under acidic conditions in vitro for further clinical development. HSA-THP was synthesized by conjugating maleimide hydrazone derivatives of THP with poly-thiolated HSA using 2-iminothiolane, via a thiol-maleimide coupling reaction. We synthesized two types of HSA-THP that contained different amounts of THP (HSA-THP2 and HSA-THP4). Free THP was released from both of the HSA conjugates more rapidly at an acidic pH, and the rates of release for HSA-THP2 and HSA-THP4 were similar. Moreover, both HSA-THPs exhibited a higher cytotoxicity at acidic pH than at neutral pH, which is consistent with the effective liberation of free THP under acidic conditions. These findings suggest that these types of HSA-THPs are promising candidates for further development.
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Affiliation(s)
- Kenji Tsukigawa
- Faculty of Pharmaceutical Sciences, Sojo University, 4-22-1 Ikeda, Nishi-ku, Kumamoto 860-0082, Japan; (K.T.); (S.I.); (K.Y.); (K.N.)
- DDS Research Institute, Sojo University, 4-22-1 Ikeda, Nishi-ku, Kumamoto 860-0082, Japan
| | - Shuhei Imoto
- Faculty of Pharmaceutical Sciences, Sojo University, 4-22-1 Ikeda, Nishi-ku, Kumamoto 860-0082, Japan; (K.T.); (S.I.); (K.Y.); (K.N.)
- DDS Research Institute, Sojo University, 4-22-1 Ikeda, Nishi-ku, Kumamoto 860-0082, Japan
| | - Keishi Yamasaki
- Faculty of Pharmaceutical Sciences, Sojo University, 4-22-1 Ikeda, Nishi-ku, Kumamoto 860-0082, Japan; (K.T.); (S.I.); (K.Y.); (K.N.)
- DDS Research Institute, Sojo University, 4-22-1 Ikeda, Nishi-ku, Kumamoto 860-0082, Japan
| | - Koji Nishi
- Faculty of Pharmaceutical Sciences, Sojo University, 4-22-1 Ikeda, Nishi-ku, Kumamoto 860-0082, Japan; (K.T.); (S.I.); (K.Y.); (K.N.)
| | - Toshihiko Tsutsumi
- School of Pharmaceutical Sciences, Kyushu University of Health and Welfare, 1714-1 Yoshino-machi, Nobeoka, Miyazaki 882-8508, Japan; (T.T.); (S.Y.)
| | - Shoko Yokoyama
- School of Pharmaceutical Sciences, Kyushu University of Health and Welfare, 1714-1 Yoshino-machi, Nobeoka, Miyazaki 882-8508, Japan; (T.T.); (S.Y.)
| | - Yu Ishima
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Biomedical Sciences, Tokushima University, 1-78-1 Sho-machi, Tokushima 770-8505, Japan;
| | - Masaki Otagiri
- Faculty of Pharmaceutical Sciences, Sojo University, 4-22-1 Ikeda, Nishi-ku, Kumamoto 860-0082, Japan; (K.T.); (S.I.); (K.Y.); (K.N.)
- DDS Research Institute, Sojo University, 4-22-1 Ikeda, Nishi-ku, Kumamoto 860-0082, Japan
- Correspondence: ; Tel.: +81-96-326-3887
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Shimizu T, Yamaguchi K, Yamamoto M, Kurioka R, Kino Y, Matsunaga W, Nakao S, Fukuhara H, Tanaka A, Gotoh A, Mabuchi M. Identification of HUHS190, a human naftopidil metabolite, as a novel anti-bladder cancer drug. Bioorg Med Chem Lett 2019; 30:126744. [PMID: 31759851 DOI: 10.1016/j.bmcl.2019.126744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/23/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
Abstract
We carried out structure-activity relationship study on anti-cancer effects of naftopidil (1) and its metabolites, resulted in identification of 1-(4-hydroxy-2-methoxyphenyl)piperazin-1-yl)-3-(naphthalen-1-yloxy) propan-2-ol (2, HUHS190), a major human metabolite of 1, which exhibited the most selective toxicities between against normal and cancer cells (Table 1). 2 was more hydrophilic compared to 1, was enough to be prepared in high concentration solution of more than 100 μM in saline for an intravesical instillation drug. Moreover, serum concentration of 2 was comparable to that of 1, an oral preparation drug, after oral administration at 32 mg/kg (Fig. 3). Both of 1 and 2 showed broad-spectrum anti-cancer activities in vitro, for example, 1 and 2 showed inhibitory activity IC50 = 21.1 μM and 17.2 μM for DU145, human prostate cancer cells, respectively, and IC50 = 18.5 μM and 10.5 μM for T24 cells, human bladder cancer cells. In this study, we estimated anticancer effects of 2 in a bladder cancer model after intravesical administration similar to clinical cases. A single intravesical administration of 2 exhibited the most potent inhibitory activities among the clinical drugs for bladder cancers, BCG and Pirarubicin, without obvious side effects and toxicity (Fig. 4). Thus, HUHS190 (2) can be effective for patients after post-TURBT therapy of bladder cancer without side effects, unlike the currently available clinical drugs.
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Affiliation(s)
- Tadashi Shimizu
- Laboratory of Chemical Biology, Advanced Medicinal Research Center, Hyogo University of Health Sciences, Kobe, Hyogo, Japan; School of Pharmacy, Hyogo University of Health Sciences, Kobe, Hyogo, Japan
| | - Keiko Yamaguchi
- School of Pharmacy, Hyogo University of Health Sciences, Kobe, Hyogo, Japan
| | - Momoka Yamamoto
- School of Pharmacy, Hyogo University of Health Sciences, Kobe, Hyogo, Japan
| | - Rina Kurioka
- School of Pharmacy, Hyogo University of Health Sciences, Kobe, Hyogo, Japan
| | - Yukari Kino
- School of Pharmacy, Hyogo University of Health Sciences, Kobe, Hyogo, Japan
| | - Wataru Matsunaga
- Laboratory of Cell and Gene Therapy, Institute for Advanced Medical Sciences, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Syuhei Nakao
- Synthetic Organic Chemistry Laboratory, RIKEN Cluster for Pioneering Research, Wako, Saitama, Japan
| | | | - Akito Tanaka
- Laboratory of Chemical Biology, Advanced Medicinal Research Center, Hyogo University of Health Sciences, Kobe, Hyogo, Japan; School of Pharmacy, Hyogo University of Health Sciences, Kobe, Hyogo, Japan
| | - Akinobu Gotoh
- Laboratory of Cell and Gene Therapy, Institute for Advanced Medical Sciences, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Miyuki Mabuchi
- Laboratory of Chemical Biology, Advanced Medicinal Research Center, Hyogo University of Health Sciences, Kobe, Hyogo, Japan.
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6
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Nakamura H, Koziolová E, Chytil P, Etrych T, Haratake M, Maeda H. Superior Penetration and Cytotoxicity of HPMA Copolymer Conjugates of Pirarubicin in Tumor Cell Spheroid. Mol Pharm 2019; 16:3452-3459. [PMID: 31294568 DOI: 10.1021/acs.molpharmaceut.9b00248] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
N-(2-Hydroxypropyl)methacrylamide copolymer conjugates of pirarubicin (THP), P-THP, accumulates selectively in solid tumor tissue by the enhanced permeability and retention (EPR) effect. Despite of high accumulation in solid tumors, some macromolecular antitumor agents show poor therapeutic outcome because of poor tissue diffusion into the tumor as well as obstructed tumor blood flow. Here, we confirmed that cellular uptake of P-THP was 25 times less than that of free THP at 1-4 h incubation time in vitro. The passage of P-THP through the confluent tight-monolayer cells junction was 12 times higher than free THP, and P-THP penetrated deeper into the tumor cell spheroid (1.3-1.7-fold) than free THP in 4 h. In addition, P-THP showed cytotoxicity comparable to that of free THP to tumor-cells in spheroid form, despite of 7 times lower cytotoxicity of P-THP to the monolayer cells to that of free THP in vitro. These results indicate that P-THP administration can exhibit deeper diffusion into the tumor cell spheroid than free THP. As a consequence, P-THP exhibits more efficient antitumor activity than free THP in vivo, which is also supported by better pharmacokinetics and tumor accumulation of P-THP than free THP.
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Affiliation(s)
- Hideaki Nakamura
- Faculty of Pharmaceutical Sciences , Sojo University , Ikeda 4-22-1, Nishi-ku , Kumamoto 860-0082 , Japan
| | - Eva Koziolová
- Institute of Macromolecular Chemistry , Czech Academy of Sciences , Heyrovsky Sq. 2 , 162 06 Prague 6 , Czech Republic
| | - Petr Chytil
- Institute of Macromolecular Chemistry , Czech Academy of Sciences , Heyrovsky Sq. 2 , 162 06 Prague 6 , Czech Republic
| | - Tomáš Etrych
- Institute of Macromolecular Chemistry , Czech Academy of Sciences , Heyrovsky Sq. 2 , 162 06 Prague 6 , Czech Republic
| | - Mamoru Haratake
- Faculty of Pharmaceutical Sciences , Sojo University , Ikeda 4-22-1, Nishi-ku , Kumamoto 860-0082 , Japan
| | - Hiroshi Maeda
- Department of Microbiology , Kumamoto University School of Medical Sciences , Kumamoto , Japan.,BioDynamics Research Foundation , Kuwamizu 1-24-6, Chuo-ku , Kumamoto 862-0954 , Japan
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Comparison of the pharmacological and biological properties of HPMA copolymer-pirarubicin conjugates: A single-chain copolymer conjugate and its biodegradable tandem-diblock copolymer conjugate. Eur J Pharm Sci 2017; 106:10-19. [DOI: 10.1016/j.ejps.2017.05.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/11/2017] [Accepted: 05/13/2017] [Indexed: 01/11/2023]
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Nakamura H, Koziolová E, Chytil P, Tsukigawa K, Fang J, Haratake M, Ulbrich K, Etrych T, Maeda H. Pronounced Cellular Uptake of Pirarubicin versus That of Other Anthracyclines: Comparison of HPMA Copolymer Conjugates of Pirarubicin and Doxorubicin. Mol Pharm 2016; 13:4106-4115. [PMID: 27934482 DOI: 10.1021/acs.molpharmaceut.6b00697] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Many conjugates of water-soluble polymers with biologically active molecules were developed during the last two decades. Although, therapeutic effects of these conjugates are affected by the properties of carriers, the properties of the attached drugs appear more important than the same carrier polymer in this case. Pirarubicin (THP), a tetrahydropyranyl derivative of doxorubicin (DOX), demonstrated more rapid cellular internalization and potent cytotoxicity than DOX. Here, we conjugated the THP or DOX to N-(2-hydroxypropyl)methacrylamide copolymer via a hydrazone bond. The polymeric prodrug conjugates, P-THP and P-DOX, respectively, had comparable hydrodynamic sizes and drug loading. Compared with P-DOX, P-THP showed approximately 10 times greater cellular uptake during a 240 min incubation and a cytotoxicity that was more than 10 times higher during a 72-h incubation. A marginal difference was seen in P-THP and P-DOX accumulation in the liver and kidney at 6 h after drug administration, but no significant difference occurred in the tumor drug concentration during 6-24 h after drug administration. Antitumor activity against xenograft human pancreatic tumor (SUIT2) in mice was greater for P-THP than for P-DOX. To sum up, the present study compared the biological behavior of two different drugs, each attached to an N-(2-hydroxypropyl)methacrylamide copolymer carrier, with regard to their uptake by tumor cells, body distribution, accumulation in tumors, cytotoxicity, and antitumor activity in vitro and in vivo. No differences in the tumor cell uptake of the polymer-drug conjugates, P-THP and P-DOX, were observed. In contrast, the intracellular uptake of free THP liberated from the P-THP was 25-30 times higher than that of DOX liberated from P-DOX. This finding indicates that proper selection of the carrier, and especially conjugated active pharmaceutical ingredient (API) are most critical for anticancer activity of the polymer-drug conjugates. THP, in this respect, was found to be a more preferable API for polymer conjugation than DOX. Hence the treatment based on enhanced permeability and retention (EPR) effect that targets more selectively to solid tumors can be best achieved with THP, although both polymer conjugates of DOX and THP exhibited the EPR effects and drug release profiles in acidic pH similarly.
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Affiliation(s)
- Hideaki Nakamura
- Research Institute for Drug Delivery Science, Sojo University , Ikeda 4-22-1, Nishi-ku, Kumamoto 860-0082, Japan.,Faculty of Pharmaceutical Sciences, Sojo University , Ikeda 4-22-1, Nishi-ku, Kumamoto 860-0082, Japan
| | - Eva Koziolová
- Institute of Macromolecular Chemistry, The Czech Academy of Sciences , Heyrovsky Sq. 2, 162 06 Prague 6, Czech Republic
| | - Petr Chytil
- Institute of Macromolecular Chemistry, The Czech Academy of Sciences , Heyrovsky Sq. 2, 162 06 Prague 6, Czech Republic
| | - Kenji Tsukigawa
- Faculty of Pharmaceutical Sciences, Sojo University , Ikeda 4-22-1, Nishi-ku, Kumamoto 860-0082, Japan
| | - Jun Fang
- Research Institute for Drug Delivery Science, Sojo University , Ikeda 4-22-1, Nishi-ku, Kumamoto 860-0082, Japan.,Faculty of Pharmaceutical Sciences, Sojo University , Ikeda 4-22-1, Nishi-ku, Kumamoto 860-0082, Japan
| | - Mamoru Haratake
- Faculty of Pharmaceutical Sciences, Sojo University , Ikeda 4-22-1, Nishi-ku, Kumamoto 860-0082, Japan
| | - Karel Ulbrich
- Institute of Macromolecular Chemistry, The Czech Academy of Sciences , Heyrovsky Sq. 2, 162 06 Prague 6, Czech Republic
| | - Tomáš Etrych
- Institute of Macromolecular Chemistry, The Czech Academy of Sciences , Heyrovsky Sq. 2, 162 06 Prague 6, Czech Republic
| | - Hiroshi Maeda
- Research Institute for Drug Delivery Science, Sojo University , Ikeda 4-22-1, Nishi-ku, Kumamoto 860-0082, Japan
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Wu Y, Ni Z, Yan X, Dai X, Hu C, Zheng Y, He F, Lian J. Targeting the MIR34C-5p-ATG4B-autophagy axis enhances the sensitivity of cervical cancer cells to pirarubicin. Autophagy 2016; 12:1105-17. [PMID: 27097054 DOI: 10.1080/15548627.2016.1173798] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Pirarubicin (THP) is a newer generation anthracycline anticancer drug. In the clinic, THP and THP-based combination therapies have been demonstrated to be effective against various tumors without severe side effects. However, previous clinical studies have shown that most patients with cervical cancer are not sensitive to THP treatment, and the associated mechanisms are not clear. Consistent with the clinical study, we confirmed that cervical cancer cells were resistant to THP in vitro and in vivo. Our data demonstrated that THP induced a protective macroautophagy/autophagy response in cervical cancer cells, and suppression of this autophagy dramatically enhanced the cytotoxicity of THP. By scanning the mRNA level change of autophagy-related genes, we found that the upregulation of ATG4B (autophagy-related 4B cysteine peptidase) plays an important role in THP-induced autophagy. Moreover, THP increased the mRNA level of ATG4B in cervical cancer cells by promoting mRNA stability without influencing its transcription. Furthermore, THP triggered a downregulation of MIR34C-5p, which was associated with the upregulation of ATG4B and autophagy induction. Overexpression of MIR34C-5p significantly decreased the level of ATG4B and attenuated autophagy, accompanied by enhanced cell death and apoptosis in THP-treated cervical cancer cells. These results for the first time reveal the presence of a MIR34C-5p-ATG4B-autophagy signaling axis in THP-treated cervical cancer cells in vitro and in vivo, and the axis, at least partially, accounts for the THP nonsensitivity in cervical cancer patients. This study may provide a new insight for improving the chemotherapeutic effect of THP, which may be beneficial to the further clinical application of THP in cervical cancer treatment.
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Affiliation(s)
- Yaran Wu
- a Department of Biochemistry and Molecular Biology , College of Basic Medical Sciences, Third Military Medical University , Chongqing , China
| | - Zhenhong Ni
- a Department of Biochemistry and Molecular Biology , College of Basic Medical Sciences, Third Military Medical University , Chongqing , China
| | - Xiaojing Yan
- a Department of Biochemistry and Molecular Biology , College of Basic Medical Sciences, Third Military Medical University , Chongqing , China
| | - Xufang Dai
- b Department of Educational College , Chongqing Normal University , Chongqing , China
| | - Changjiang Hu
- c Department of Gastroenterology , Xinqiao Hospital, Third Military Medical University , Chongqing , China
| | - Yingru Zheng
- d Department of Obstetrics and Gynecology , Daping Hospital, Research Institute of Surgery, Third Military Medical University , Chongqing , China
| | - Fengtian He
- a Department of Biochemistry and Molecular Biology , College of Basic Medical Sciences, Third Military Medical University , Chongqing , China
| | - Jiqin Lian
- a Department of Biochemistry and Molecular Biology , College of Basic Medical Sciences, Third Military Medical University , Chongqing , China
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10
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Liu L, Sun J, Yin H, Fang J, Jin X. pH-Responsive Polymer Conjugate of Pirarubicin With Styrene Maleic Acid Copolymer as a Potential Therapeutic for Ovarian Cancer. J Pharm Sci 2016; 105:1595-1602. [PMID: 27020984 DOI: 10.1016/j.xphs.2016.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/05/2016] [Accepted: 02/24/2016] [Indexed: 11/19/2022]
Abstract
Previous studies indicated the potential of styrene maleic acid copolymer (SMA)-conjugated pirarubicin (4'-O-tetrahydropyranyldoxorubicin [THP]) for targeted anticancer therapy based on the enhanced permeability and retention effect. In this study, to achieve further improved therapeutic efficacy, a pH-responsive SMA-conjugated THP-containing hydrazone bond (SMA-hyd-THP) was synthesized and evaluated in vitro and ex vivo using human ovarian cancer cells and tissues. SMA-hyd-THP showed good water solubility, forming micelles with a mean particle size of 48.0 nm, which is applicable for enhanced permeability and retention-based tumor accumulation. The THP loading in this preparation was 15% (wt/wt), and release rate of free THP from SMA-hyd-THP at physiological pH (7.4) was approximately 10% in 72 h. However, it increased rapidly at pH 6.5 (42%) and 5.5 (83%), which indicates that tumor environment of weak acidic condition (pH 6.5-6.9) is favorable for release of THP. This notion was partly proved by incubating SMA-hyd-THP with tumor tissues from ovarian cancer patients. In addition, release of THP was not affected by serum, suggesting that SMA-hyd-THP is relatively stable in circulation. Finally, SMA-hyd-THP showed much increased cytotoxicity against various ovarian cancer cells at acidic tumor pH (6.5). These findings may provide an option for targeted therapy against ovarian cancer.
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Affiliation(s)
- Lifeng Liu
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian Medical University, Dalian, 116033, People's Republic of China
| | - Jinghua Sun
- Department of Oncology, Second Affiliated Hospital, Dalian Medical University, Dalian, 116023, People's Republic of China
| | - Hongzhuan Yin
- Department of General Surgery, Sheng Jing Hospital, China Medical University, Shenyang, 110004, People's Republic of China
| | - Jun Fang
- School of Public Health, Anhui Medical University, 81th Meishan Road, Hefei City, Anhui Province, 230032, People's Republic of China; Institute of Drug Delivery Science, Sojo University, Ikeda 4-22-1, Kumamoto Nishi-ku, 860-0082, Japan
| | - Xianyu Jin
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian Medical University, Dalian, 116033, People's Republic of China
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11
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Tsukigawa K, Liao L, Nakamura H, Fang J, Greish K, Otagiri M, Maeda H. Synthesis and therapeutic effect of styrene-maleic acid copolymer-conjugated pirarubicin. Cancer Sci 2015; 106:270-8. [PMID: 25529761 PMCID: PMC4376435 DOI: 10.1111/cas.12592] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 12/09/2014] [Accepted: 12/13/2014] [Indexed: 01/13/2023] Open
Abstract
Previously, we prepared a pirarubicin (THP)-encapsulated micellar drug using styrene-maleic acid copolymer (SMA) as the drug carrier, in which active THP was non-covalently encapsulated. We have now developed covalently conjugated SMA-THP (SMA-THP conjugate) for further investigation toward clinical development, because covalently linked polymer-drug conjugates are known to be more stable in circulation than drug-encapsulated micelles. The SMA-THP conjugate also formed micelles and showed albumin binding capacity in aqueous solution, which suggested that this conjugate behaved as a macromolecule during blood circulation. Consequently, SMA-THP conjugate showed significantly prolonged circulation time compared to free THP and high tumor-targeting efficiency by the enhanced permeability and retention (EPR) effect. As a result, remarkable antitumor effect was achieved against two types of tumors in mice without apparent adverse effects. Significantly, metastatic lung tumor also showed the EPR effect, and this conjugate reduced metastatic tumor in the lung almost completely at 30 mg/kg once i.v. (less than one-fifth of the maximum tolerable dose). Although SMA-THP conjugate per se has little cytotoxicity in vitro (1/100 of free drug THP), tumor-targeted accumulation by the EPR effect ensures sufficient drug concentrations in tumor to produce an antitumor effect, whereas toxicity to normal tissues is much less. These findings suggest the potential of SMA-THP conjugate as a highly favorable candidate for anticancer nanomedicine with good stability and tumor-targeting properties in vivo.
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Affiliation(s)
- Kenji Tsukigawa
- Institute for Drug Delivery Science, Sojo University, Kumamoto, Japan; Faculty of Pharmaceutical Sciences, Sojo University, Kumamoto, Japan
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12
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Zheng SE, Xiong S, Lin F, Qiao GL, Feng T, Shen Z, Min DL, Zhang CL, Yao Y. Pirarubicin inhibits multidrug-resistant osteosarcoma cell proliferation through induction of G2/M phase cell cycle arrest. Acta Pharmacol Sin 2012; 33:832-8. [PMID: 22580740 DOI: 10.1038/aps.2012.20] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AIM Pirarubicin (THP) is recently found to be effective in treating patients with advanced, relapsed or recurrent high-grade osteosarcoma. In this study, the effects of THP on the multidrug-resistant (MDR) osteosarcoma cells were assessed, and the underlying mechanisms for the disruption of cell cycle kinetics by THP were explored. METHODS Human osteosarcoma cell line MG63 and human MDR osteosarcoma cell line MG63/DOX were tested. The cytotoxicity of drugs was examined using a cell proliferation assay with the Cell Counting Kit-8 (CCK-8). The distribution of cells across the cell cycle was determined with flow cytometry. The expression of cell cycle-regulated genes cyclin B1 and Cdc2 (CDK1), and the phosphorylated Cdc2 and Cdc25C was examined using Western blot analyses. RESULTS MG63/DOX cells were highly resistant to doxorubicin (ADM) and gemcitabine (GEM), but were sensitive or lowly resistant to THP, methotrexate (MTX) and cisplatin (DDP). Treatment of MG63/DOX cells with THP (200-1000 ng/mL) inhibited the cell proliferation in time- and concentration-dependent manners. THP (50-500 ng/mL) induced MG63/DOX cell cycle arrest at the G(2)/M phase in time- and concentration-dependent manners. Furthermore, the treatment of MG63/DOX cells with THP (200-1000 ng/mL) downregulated cyclin B1 expression, and decreased the phosphorylated Cdc2 at Thr(161). Conversely, the treatment increased the phosphorylated Cdc2 at Thr(14)/Tyr(15) and Cdc25C at Ser(216), which led to a decrease in Cdc2-cyclin B1 activity. CONCLUSION The cytotoxicity of THP to MG63/DOX cells may be in part due to its ability to arrest cell cycle progression at the G(2)/M phase, which supports the use of THP for managing patients with MDR osteosarcoma.
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Dumas M, Dubuet A, D'Athis P, Camus P, Escousse A. Comparative pharmacokinetics of tetrahydropyranyl-doxorubicin and doxorubicin in rat isolated lung. J Pharm Pharmacol 2011; 44:58-60. [PMID: 1350631 DOI: 10.1111/j.2042-7158.1992.tb14365.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Abstract
Rat isolated perfused lungs (Sprague-Dawley rats, n = 20) were studied to compare the pulmonary uptake of a new anthracycline, tetrahydropyranyl-doxorubicin (THP-DXR) with that of doxorubicin (DXR). Lung perfusions were initiated with a constituted medium containing either drug at concentrations of 1, 10 or 100 μm. Lungs were perfused by recirculation for 60 min. Thirteen perfusate samples were collected over 60 min and subjected to HPLC for assay. The perfusate concentration of THP-DXR decreased to 24 ± 5% of the initial concentration and to 8 ± 2%, 20 and 60 min after the beginning of the infusion, respectively. Corresponding values for DXR were 77 ± 16 and 52 ± 15%, respectively (P < 0·05). During the THP-DXR perfusion, the area under the perfusate concentration vs time curve (AUC) was decreased to one-third and the clearance was increased 3-fold (P < 0·05). The pulmonary concentration of THP-DXR reached 0·032 ± 0·01 μmol g−1 60 min after the beginning of a perfusion of 1 μm of the drug. This concentration increased to 0·379 ± 0·11 μmol g−1 when the initial dose concentration was 10 μm. Corresponding lung concentrations for DXR were 0·013 ± 0·001 and 0·150 ± 0·04 μmol g−1, respectively (P < 0·05). The perfusate concentration/initial concentration ratio decreased by the same amount whether a 1 or 10 μm initial concentration of either drug was used. An initial concentration of 100 μm of THP-DXR, unlike DXR, consistently induced oedema in the perfused lung. No metabolite of either drug was revealed during the course of our study. These findings suggest: (1) a higher lung affinity for THP-DXR; (2) a correlation between lung uptake and dose consistent with a passive diffusion transport mechanism for both drugs; (3) a higher acute toxicity induced by THP-DXR; (4) the absence of metabolic activity in the lung with regards to both anthracyclines.
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Affiliation(s)
- M Dumas
- Département d'Informatique Médicale, Faculté de Médecine, Dijon, France
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14
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Iguchi H, Kusuki M, Nakamura A, Nishiura H, Kanazawa A, Takayama M, Sunami K, Yamane H. Concurrent chemoradiotherapy with pirarubicin and 5-fluorouracil for resectable oral and maxillary carcinoma. Acta Otolaryngol 2004:55-61. [PMID: 15513513 DOI: 10.1080/03655230410018354] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE We present the response rate and adverse effects of our regimen of concurrent chemoradiotherapy with pirarubicin (THP) and 5-fluorouracil (5-FU) for oral and maxillary carcinoma. PATIENTS AND METHODS Fifteen patients with oral (10 cases) or maxillary (5 cases) squamous cell carcinoma who underwent our concurrent chemoradiotherapy with the combination of intraarterial pirarubicin, intravenous continuous 5-fluorouracil, and radiation between March 2001 and February 2003 in our department were entered in this study. THP (5 mg/day) was infused into the lingual or maxillary artery one hour before radiation on days 1-5 and 8-12, while intravenous 5-FU (150 mg/m2/day) was instilled continuously on days 1-5, 8-12, 15-19, and 22-26 in accordance with the radiation schedule (2 Gy/day). Consequently, total doses of THP, 5-FU, and radiation were 50 mg, 3000 mg/m2 and 40 Gy, respectively. After the treatment series, response rate and adverse effects were evaluated. RESULTS Response rate achieved 100% (12 cases exhibited a complete response and the remaining 3 a partial response). Notably, all 10 patients with oral carcinoma exhibited complete response. The main adverse effects were leucopenia (6/15) and mucositis (6/15), both of which were acceptable. CONCLUSIONS This concurrent chemoradiotherapy is very useful for oral and maxillary carcinoma as a preoperative modality with remarkably high response rate and acceptable adverse events.
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Affiliation(s)
- Hiroyoshi Iguchi
- Department of Otolaryngology and Head & Neck Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
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15
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Richardson DS, Johnson SA. Anthracyclines in haematology: preclinical studies, toxicity and delivery systems. Blood Rev 1997; 11:201-23. [PMID: 9481450 DOI: 10.1016/s0268-960x(97)90020-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The anthracyclines are widely used in the treatment of haematological and non-haematological malignancy and there is now more than 30 years' clinical experience with these agents but despite this, their mechanism of action is incompletely understood. The anthracyclines have been shown to intercalate with DNA and indirectly inhibit the activity of the enzyme topoisomerase II, resulting in DNA strand breaks. More recently, workers have focused on induction of apoptosis and have shown that daunorubicin stimulates production of the apoptotic mediator, ceramide and that the activity of doxorubicin can be blocked by inhibitors of CD95 (fas). One of the major problems with anthracycline therapy is the development of resistance which may be mediated by p-glycoprotein or by other mechanisms. Much recent research has concentrated on methods to modulate the drug-resistant phenotype and these include development of new analogues and use of specific reversal agents. The toxicity profile of the anthracyclines includes bone marrow suppression, severe local reaction following extravasation, radiation recall, alopecia, gastrointestinal and hepatic effects, development of secondary malignancies and significant cardiac toxicity. The risk factors for the development of anthracycline-related cardiac toxicity are well documented and several methods have been exploited in attempts at prevention. Finally, a number of drug delivery systems have been developed in order to improve therapeutic response and reduce toxicity to normal tissues, including the use of liposomal preparations.
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Sridhar KS, Samy TS, Agarwal RP, Duncan RC, Benedetto P, Krishan AG, Vogel CL, Feun LG, Savaraj NM, Richman SP. A phase I study of 4'-0-tetrahydropyranyladriamycin. Clinical pharmacology and pharmacokinetics. Cancer 1990; 66:2082-91. [PMID: 2224762 DOI: 10.1002/1097-0142(19901115)66:10<2082::aid-cncr2820661007>3.0.co;2-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A Phase I study of intravenous (IV) bolus 4'-0-tetrahydropyranyladriamycin (Pirarubicin) was done in 55 patients in good performance status with refractory tumors. Twenty-six had minimal prior therapy (good risk), 23 had extensive prior therapy (poor risk), and six had renal and/or hepatic dysfunction. A total of 167 courses at doses of 15 to 70 mg/m2 were evaluable. Maximum tolerated dose in good-risk patients was 70 mg/m2, and in poor-risk patients, 60 mg/m2. The dose-limiting toxic effect was transient noncumulative granulocytopenia. Granulocyte nadir was on day 14 (range, 4-22). Less frequent toxic effects included thrombocytopenia, anemia, nausea, mild alopecia, phlebitis, and mucositis. Myelosuppression was more in patients with hepatic dysfunction. Pharmacokinetic analyses in 21 patients revealed Pirarubicin plasma T 1/2 alpha (+/- SE) of 2.5 +/- 0.85 minutes, T beta 1/2 of 25.6 +/- 6.5 minutes, and T 1/2 gamma of 23.6 +/- 7.6 hours. The area under the curve was 537 +/- 149 ng/ml x hours, volume of distribution (Vd) 3504 +/- 644 l/m2, and total clearance (ClT) was 204 + 39.3 l/hour/m2. Adriamycinol, doxorubicin, adriamycinone, and tetrahydropyranyladriamycinol were the metabolites detected in plasma and the amount of doxorubicin was less than or equal to 10% of the total metabolites. Urinary excretion of Pirarubicin in the first 24 hours was less than or equal to 10%. Activity was noted in mesothelioma, leiomyosarcoma, and basal cell carcinoma. The recommended starting dose for Phase II trials is 60 mg/m2 IV bolus every 3 weeks.
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Affiliation(s)
- K S Sridhar
- Department of Oncology, Sylvester Comprehensive Cancer Center, Miami, Florida
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Suzuki H, Tomida A, Nishimura T. Cytocidal activity of a synthetic isoprenoid, N-solanesyl-N,N'-bis(3,4-dimethoxybenzyl)ethylenediamine, and its potentiation of antitumor drugs against multidrug-resistant and sensitive cells in vitro. Jpn J Cancer Res 1990; 81:298-303. [PMID: 2161816 PMCID: PMC5918030 DOI: 10.1111/j.1349-7006.1990.tb02564.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
A synthetic isoprenoid, N-solanesyl-N,N'-bis(3,4-dimethoxybenzyl)ethylenediamine (SDB-ethylenediamine), inhibited the colony formation of multidrug-resistant mutant cell lines derived from Chinese hamster V79 (V79/ADM) and human hepatoma PLC/PRF/5 (PLC/COL) cells to a greater extent than that of the parental cells. When combined with other clinically useful antitumor agents, it potentiated the cytotoxic activity of almost all kinds of drugs tested including adriamycin (ADM), actinomycin D, vincristine, cytosine arabinoside, and 5-fluorouracil (5-FU), and the potentiation ratios were higher against V79/ADM cells than against V79/S cells. Among the antitumor agents tested, the activities of bleomycin-group antibiotics were more strongly enhanced by SDB-ethylenediamine and the potentiation was higher in the parental cells than in V79/ADM cells. SDB-ethylenediamine enhanced the uptake of ADM and daunorubicin into V79/ADM and its parental cells, but it did not increase the uptake of 5-FU or peplomycin, indicating that different mechanisms operate for potentiation in the cases of the latter drugs, i.e., not simply an increase of intracellular drug uptake. Two fragments of SDB-ethylenediamine, solanesol (polyprenoid moiety) and the diamine component (verapamil-like moiety), showed neither cytotoxic activity nor potentiator activity, even if they were mixed together, indicating that the steric conformation of intact SDB-ethylenediamine molecule is important for these two activities.
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Affiliation(s)
- H Suzuki
- Institute of Applied Microbiology, University of Tokyo
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Ohno R, Kimura K, Amaki I, Hirano M, Hoshino A, Ikeda Y, Kimura I, Kobayashi M, Konno K, Majima H. Treatment of acute leukemia and malignant lymphoma with (2"R)-4'-O-tetrahydropyranyladriamycin. Cancer Chemother Pharmacol 1987; 20:230-4. [PMID: 3315282 DOI: 10.1007/bf00570491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Eighty-four previously treated adult patients with acute leukemia and malignant lymphoma were treated with (2"R)-4'-O-tetrahydropyranyladriamycin (THP). THP (10-55 mg/m2) was administered by i.v. bolus injection daily for acute leukemia, and according to three different schedules for malignant lymphoma: daily, weekly or once every 3-4 weeks. Complete and partial remission (CR and PR) were achieved by 1 (5%) and 3 of 19 patients with acute myelogenous leukemia and by 2 (13%) and 3 of 15 patients with acute lymphoblastic leukemia, respectively. All CRs were in the groups receiving 25 mg/m2 THP daily. CR and PR were achieved by 6 (14%) and 8 of 42 patients with non-Hodgkin lymphoma (NHL) and by 4 (50%) and 2 of 8 patients with Hodgkin's disease (HD), respectively. No particular sensitivity was found among the subtypes of NHL and HD. Response (CR + PR) was noted in 10 (40%) of 25 patients treated every 3-4 weeks, in 1 (17%) of 6 treated weekly, and in 9 (47%) of 19 treated daily. The major side effects were myelosuppression and gastrointestinal toxicities. Alopecia was observed in only 10 (12%) patients. ECG abnormalities were observed in 7 (10%) patients, all of whom had previously been treated with other anthracyclines. No severe cardiotoxicity was observed.
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Affiliation(s)
- R Ohno
- First Department of Internal Medicine, Nagoya University School of Medicine, Japan
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