Treatment of hypercalcemia in parathyroid cancer with WR-2721, S-2-(3-aminopropylamino)ethyl-phosphorothioic acid

Hypercalcemia in the Critically Ill Patient

Hypercalcemia is now frequently recognized in hospitalized patients, including those who are critically ill. Hypercalcemia in critically ill patients may be life threatening or an indication of an underlying but unsuspected disease process. All of the common causes of hypercalcemia can occur in the critically ill patient and are reviewed here. As in the general patient population, the two most common causes are probably malignant disease and primary hyperparathyroidism. Hypercalcemia is now readily reversible in most patients, particularly when the underlying pathophysiologic mechanisms responsible are recognized, and it should be treated actively.

Review : Amifostine and other chemoprotective agents in cancer chemotherapy: A brief review

Objective. Cytotoxic chemotherapy is a frequently, and increasingly, used treatment for malignant disease and is associated with substantial toxicity. A number of drugs have been developed in recent years for the prevention and treatment of chemotherapy-induced toxicity. Most are specific to one group of drugs, eg, mesna and the oxazophosphorines, or one type of toxicity, eg, the 5-HT3 antagonist antiemetics. The first multiorgan cytoprotective, amifostine, recently was launched, and another, glutathione, is under development. The purpose of this review is to con sider the agents currently available for the manage ment of cytotoxic drug-induced toxicity and their place in treatment. Special attention is directed to amifostine and drugs in development, including glu tathione, Ossirene (Baker Norton), ORG-2766, and dexrazoxane and less to agents in routine clinical use.

Data sources. A variety of sources were used, including manual and on-line (Medline) literature searching. Approved and other drug names were used as the primary search terms, linked with cytotoxic chemotherapy where limitation was required. Medi cal information departments of drug companies also were used where appropriate.

Study selection. Particular attention was directed to randomized clinical trials, but nonrandomised and animal studies were considered where appropriate.

Conclusions. Over the past decade significant advances have been made in the control of chemo therapy-induced toxicity and new agents promise even greater control. This is important, not only because they may improve the quality of life of conventionally treated cancer patients, but also be cause they should allow the dose-response relation ship for cytotoxic drug treatment to be fully explored. Unfortunately, the data available at present are insuf ficient to determine the extent to which this promise will be fulfilled.

Parathyroid carcinoma

BACKGROUND

Parathyroid carcinoma is a rare malignancy affecting 0.5-5 per cent of all patients with primary hyperparathyroidism. This article reviews the literature on the pathogenesis, pathology, clinical features, diagnosis and management of parathyroid carcinoma.

METHODS

A Medline search was performed and all relevant English language articles published between 1970 and 2005 were retrieved. The search words included 'parathyroid carcinoma', 'pathology', 'genetics', 'management' and 'radiotherapy'. Secondary references were obtained from key articles.

RESULTS AND CONCLUSION

The exact aetiology of parathyroid carcinoma remains obscure. Recently, the HRPT2 gene has been implicated in its pathogenesis and may prove to be a genetic target in future. Surgical resection is the accepted 'gold standard'. There is now a growing consensus on the use of adjuvant radiotherapy as it has been shown to provide a survival benefit.

Parathyroid cancer: biology and management

A review of all reports in the literature of parathyroid carcinoma (PTC) was undertaken to define an optimal management strategy for this rare condition. PTC is uncommon and its etiology of PTC is largely unknown although patients with familial hyperparathyroidism, multiple endocrine neoplasia type 1 and irradiation to the head and neck are at increased risk for developing the disease. PTC occurs with equal frequency in both sexes and is usually diagnosed in the fifth decade. En bloc resection of the carcinoma and the adjacent structures in the neck is the surgical treatment and is associated with an 8% local recurrence rate and a long term overall survival rate of 89% (mean follow up 69 months). In contrast simple parathyroidectomy results in a 51% local recurrence rate and 53% long-term survival rate (mean follow up 62 months). Adverse prognostic factors for survival were initial management with simple parathyroidectomy alone, the presence of nodal or distant metastatic disease at presentation and non-functioning PTC.

Diagnosis and treatment of patients with parathyroid carcinoma: an update and review

Parathyroid carcinoma is a rare cause of primary hyperparathyroidism. However, to our best knowledge, at least 163 cases of functioning parathyroid carcinoma appeared in the English literature from 1981 to 1989. We summarize the available information obtained from the reports of those patients and compare it with previous descriptions of the disease. The etiology of parathyroid carcinoma is usually obscure, but the possibility of a radiation-induced malignant change in the parathyroid gland became evident in a few patients. Clinical manifestations, including age, sex, symptoms, and biochemical findings in this review were comparable to those in previous reviews. Noninvasive localization studies such as ultrasonography may offer a diagnostic clue to parathyroid carcinoma. Measurement of DNA content is a useful adjunct for making the histologic diagnosis of parathyroid carcinoma and prediction of the clinical outcome. Since the initial operation offers the best chance for cure, pre-operative suspicion and intra-operative recognition of the parathyroid cancer are essential. The initial operation should be en bloc resection of the tumor, avoiding rupture of the tumor capsule and spillage of tumor cells. As parathyroid carcinoma is a slow-growing but tenacious malignancy, repeated resection of local recurrent tumors or even distant metastases is effective for palliation of recurrent hypercalcemia and occasional cure. When hypercalcemia is refractory to surgical therapy or no recurrent tumor can be identified, other modalities of therapy must be considered. New drugs to control hypercalcemia by inhibiting bone resorption may hold promise in patients with recurrent parathyroid carcinoma.

Radiation and chemotherapy sensitizers and protectors

Radiosensitizers and radioprotectors are part of the chemical modifier approach to cancer therapy whereby the state of the tumor cells and/or normal tissues are modified such that a therapeutic gain is achieved using conventional radiation or chemotherapy. Radiosensitization can be achieved by the use of oxygen-mimetic compounds, agents that alter DNA sensitivity to irradiation, maneuvers that alter DNA repair processes, and manipulation of tissue oxygenation. Standard chemotherapeutic agents such as cisplatin can be utilized in a manner that optimizes the radiosensitization properties. Protection and sensitization can occur by altering the thiol status of the cell. The chemical modifiers field is both developing novel approaches to cancer treatment and increasing the understanding of basic cancer biology.

WR-2721 reduces bone loss after hindlimb tenotomy in rats

WR-2721 is a thiophosphate analog of cysteamine that produces hypocalcemia in vivo. Previous studies suggest that WR-2721 produces hypocalcemia by independent inhibitory effects on parathyroid hormone (PTH) secretion, osteoclastic bone resorption, and tubular reabsorption of calcium. We sought to determine if WR-2721 would decrease bone loss in an animal model of disuse osteoporosis produced by unilateral knee tenotomy in the rat. Tenotomy significantly increased osteoclast number in tibias on the side of the procedure compared with tibias on the opposite side which had not undergone the procedure at 3 and 14 days. Femoral weight of tenotomized limbs were also reduced significantly compared with the contralateral limb at 3 and 14 days. WR-2721 treatment (240 mg/kg daily) prevented 26% of the loss of femoral dry weight and 29% of the loss of femoral ashed weight produced 14 days after tenotomy. In addition, WR-2721 treated (240 mg/kg daily) animals had fewer osteoclasts in tenotomized tibias than control animals at 3 days (6.6 +/- 0.7/mm versus 10.3 +/- 0.9/mm, p less than 0.02) and at 14 days (5.8 +/- 0.3/mm versus 8.7 +/- 0.4/mm, p less than 0.02). These data suggest that WR-2721 decreases bone loss in this model by decreasing osteoclastic bone resorption.

Effect of the radioprotector WR-2721 on operant behavior in the rat

The effect of WR-2721 on performance maintained by a fixed-ratio 20 (FR-20) schedule for water reinforcement was studied in male Sprague-Dawley rats. Graded doses of WR-2721 (range 25-100 mg/kg) were administered IP immediately prior to a 60 min test session. WR-2721 had a dose dependent monotonic disruptive effect on FR responding, with significant effects at doses of 50, 75 and 100 mg/kg. WR-2721 also decreased postsession water consumption, but only one significant effect at the highest dose (100 mg/kg). Both slopes of the dose-response regression line are parallel in effect. These data indicate that WR-2721 may affect drinking motivation, which could disrupt operant performance, and WR-2721 affects motor behavior at lower doses than those that depress "motivation" to drink. The log dose-probit analysis on the all-or-none disruptive pattern of pause of responding observed from cumulative records disclosed that the slope of this regression line (s = 1.11) was also almost identical to that of reinforcer decrement analyzed from graded dose-response relationship (s = 1.14) and shared the same estimated ED50's (58.5 and 55.6 mg/kg, respectively). A preliminary study using a variety of pharmacological interventions was also carried out to ascertain if the general functional gastrointestinal disorders produced by WR-2721 may subserve the behavioral deficits. Subcutaneous pretreatments with various selective, peripherally active, gastroprotective drugs [cimetidine (30 and 60 mg/kg), pirenzepine (5 and 10 mg/kg) and domperidone (1, 5 and 10 mg/kg)] 30 min prior to challenge with WR-2721 at dose of 100 mg/kg, demonstrated that these drugs did not yield any apparent significant attenuative effects.(ABSTRACT TRUNCATED AT 250 WORDS)

Protection from progressive renal failure and hyperparathyroid bone remodeling by WR-2721

In chronic renal failure (CRF), secondary hyperparathyroidism (sHPT) plays a major role in skeletal lesions and also probably in the deterioration of renal functions consecutive to nephrocalcinosis. In this study we tested whether WR-2721 [S-,2-(3-aminopropylamino)-ethylphosphorothioic acid], an inhibitor of parathyroid hormone (PTH) secretion, could prevent the deleterious effects of sHPT at both the bone and kidney level in an animal model of CRF. Rats were either subtotally nephrectomized (NX) or sham-operated (SHAM). They were then pairfed a high phosphorus (1.4%), middle Ca (0.6%) diet. This regimen accelerated the deterioration of renal function in NX rats which displayed signs of severe sHPT in bone (three- to fourfold increase in osteoclast number and resorption surfaces) and kidney (sixfold increase in Ca content) after four weeks. Chronic administration of WR-2721 (20 mg = 0.093 mmol/kg s.c. twice daily) during four weeks completely prevented the progressive elevation of both plasma urea and inorganic phosphate, and the fall of plasma Ca. It also prevented kidney Ca accumulation to the same extent as parathyroidectomy. However, WR-2721 given at this dose only partially prevented the histomorphometric indices of increased bone resorption and formation. This discrepant response suggests that WR-2721 could exert an additional protective effect at the kidney level that might be related to its property of acting as a free radical scavenger. In conclusion, this study suggests that WR-2721 might be a useful compound in CRF, not only because it inhibits PTH secretion, but also because it could protect against the deleterious effect of secondary hyperparathyroidism on kidney functions.

WR-2721 inhibits parathyroid adenylate cyclase

WR-2721 [S-2-(3-aminopropylamino)ethylphosphorothioic acid] is a chemoprotective and radioprotective agent that has been shown to lower serum calcium in dogs and in humans. This is secondary both to impaired release of Ca2+ from bone and diminished secretion of parathyroid hormone (PTH) from parathyroid glands. Because cAMP plays a role in the regulation of PTH secretion and WR-2721 has been shown to lower cAMP levels in radiated mouse spleen, we investigated the effects of WR-2721 on cAMP production in dispersed bovine parathyroid cells. Additionally, we studied the adenylate cyclase in plasma membranes from normal bovine parathyroid glands after exposure to WR-2721. With parathyroid cells incubated at 0.5 mM Ca2+, addition of WR-2721 in concentrations ranging from 0.02 to 2.0 mM resulted in a progressive decrease in intracellular cAMP (42-50%, respectively). In plasma membranes of bovine parathyroid cells a dose-dependent decrease in adenylate cyclase activity was noted. Inhibition of the cyclase was seen over a wide range of Mg2+ concentrations (2.5-40 mM). WR-2721 inhibited both basal and NaF, Gpp(NH)p, forskolin, and pertussin toxin-stimulated adenylate cyclase. These data suggest that WR-2721 inhibits the activity of parathyroid adenylate cyclase.

Prevention of parathyroid hormone-dependent nephrocalcinosis by chronic administration of the organic phosphorothioate WR-2721

Pharmacological inhibition of parathyroid hormone (PTH) secretion has been the object of several experimental and clinical trials in the past. It is only recently that a drug, WR-2721 [S-,2-(3-aminopropylamino)-,ethylphosphorothioic acid], has been shown to effectively inhibit PTH secretion in euparathyroid subjects and in parathyroid cancer patients within a few hours after its administration. In the present study we tested its long term efficacy as a PTH inhibitor in a model of nephrocalcinosis resulting from secondary hyperparathyroidism. Intact and thyroparathyroidectomized (TPTX) rats were pair-fed on a low Ca (0.2%)-high phosphorus (1.6%) diet (nephrocalcinotic diet) or on a normal Ca (1.1%)-normal phosphorus (0.8%) diet for 7 days. Simultaneously, either 0.2 mmol/kg of WR-2721 or its solvent was injected subcutaneously twice daily. The intact animals on the nephrocalcinotic diet had an increased urinary cyclic AMP excretion and important renal Ca accumulation. This nephrocalcinosis was markedly reduced by WR-2721 treatment. The kidney Ca content of the WR-2721-treated rats was 58 +/- 6% lower than that of the nontreated animals. The low Ca-high phosphorus diet did not cause nephrocalcinosis in the TPTX rats. WR-2721 failed to reduce the nephrocalcinosis induced by 1,25 dihydroxyvitamin D3 intoxication in TPTX rats fed the normal Ca-normal phosphorus diet. In conclusion, the present study suggests that chronic treatment with WR-2721, a potent inhibitor of PTH secretion, may be effective for preventing the deleterious consequences of hyperparathyroidism, such as nephrocalcinosis.

Human pharmacokinetics of WR-2721

The pharmacokinetic properties of WR-2721 were investigated in 13 cancer patients given a 150 mg/M2 intravenous bolus dose of the drug. An average plasma clearance value of 2.17 L/min was obtained. Very little of the drug or the two metabolites, WR-1065 and WR-33278, were excreted in urine obtained after the blood collection schedule. Plasma concentrations of WR-2721 decreased by 94% within 6 minutes of drug administration. The mean value of 6.44 L obtained for the steady-state volume of distribution indicates that the extravascular space occupied by the drug is small. These observations suggest that in human cancer patients, WR-2721 is rapidly taken up by tissues and converted to metabolites.

Normalization of hypercalcemia associated with a decrease in renal calcium reabsorption in Leydig cell tumor-bearing rats treated with WR-2721

The Rice-500 Leydig cell tumor (LCT) in Fischer rats is a model of humoral hypercalcemia of malignancy (HHM). In this model, the elevation of plasma calcium (Ca) does not result merely from an increased bone resorption, but also from an enhanced tubular Ca reabsorption (TRCa). We investigated the hypocalcemic response to WR-2721 [S-2,2-(3-aminopropylamino)-, ethylphosphorothioic acid] in LCT-bearing Fischer rats. WR-2721 is a potent inhibitor of normal and aberrant parathyroid hormone (PTH) secretion. Moreover, it exerts a PTH-independent inhibitory effect on TRCa. In hypercalcemic LCT-bearing rats WR-2721 induced a fall in plasma Ca from 3.24 +/- 0.12 to 2.66 +/- 0.23 mmol/liter within 2 h after one single injection of 0.7 mmol/kg body wt. The decrement in plasma Ca was associated with a marked increase in urinary Ca excretion, indicating an inhibition of TRCa. The elevated urine cyclic AMP of LCT-bearing rats, however, was not altered by WR-2721 treatment. These results suggest that in this HHM model, WR-2721 can normalize calcemia through its PTH-independent inhibitory effect on TRCa. WR-2721 could therefore be an effective drug to treat human hypercalcemia of malignancy, particularly in those tumors wherein a markedly enhanced renal Ca reabsorption contributes to the elevation of the plasma Ca level.