Pharmacology of Antineoplastic Agents

Outline of Lecture Topics:

1. Background 2. Antineoplastic Agents: classification a. Cell Cycle Specific (CCS) agents b. Cell Cycle Non-Specific (CCNS) agents c. Miscellaneous (e.g., antibodies) agents 4. Mechanisms of action 5. Side Effects 6. Drug Resistance

Rajarshi Patel, Ph.D. Dept Oncology +91-9033231942

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PART I
1. Background 2. Antineoplastic Agents a. Cell Cycle Specific (CCS) agents b. Cell Cycle Non-Specific (CCNS) agents c. Miscellaneous (e.g., antibodies) agents

Cancer
Definition: Cancer* is a term used for diseases in which abnormal cells divide without control and are able to invade other tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems, this process is called metastasis. Categorized based on the functions/locations of the cells from which they originate: 1. Carcinoma - skin or in tissues that line or cover internal organs. E.g., Epithelial cells. 80-90% reported cancer cases are carcinomas. 2. Sarcoma - bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. 3. Leukemia - White blood cells and their precursor cells such as the bone marrow cells, causes large numbers of abnormal blood cells to be produced and enter the blood. 4. Lymphoma - cells of the immune system that affects lymphatic system. 5. Myeloma - B-cells that produce antibodies- spreads through lymphatic system. 6. Central nervous system cancers - cancers that begin in the tissues of the brain and spinal cord.
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Cancer Therapeutic Modalities (classical)

1. Surgery

1/3 of patients without metastasis Respond to surgery and radiation.

2. Radiation

If diagnosed at early stage, close to 50% cancer could be cured.

3. Chemotherapy

50% patients will undergo chemotherapy, to remove micrometastasis. However, chemotherapy is able to cure only about 10-15% of all cancer patients.

New types of cancer treatment

Hormonal Treatments: These drugs are designed to prevent cancer cell growth by preventing the cells from receiving signals necessary for their continued growth and division. E.g., Breast cancer tamoxifen after surgery and radiation Specific Inhibitors: Drugs targeting specific proteins and processes that are limited primarily to cancer cells or that are much more prevalent in cancer cells. Antibodies: The antibodies used in the treatment of cancer have been manufactured for use as drugs. E.g., Herceptin, avastin Biological Response Modifiers: The use of naturally occuring, normal proteins to stimulate the body's own defenses against cancer. E.g., Abciximab, rituxmab Vaccines: Stimulate the body's defenses against cancer. Vaccines usually contain proteins found on or produced by cancer cells. By administering these proteins, the treatment aims to increase the response of the body against the cancer cells.
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Cancer Chemotherapy (Background)

A. Most of the recent progress using antineoplastic therapy is based on:
1. Development of new combination therapy of using existing drugs. 2. Better understanding of the mechanisms of antitumor activity. 3. Development of chemotherpeutic approaches to destroying micrometastases 4. Understanding the molecular mechanisms concerning the initiation of tumor growth and metastasis. 5. Recognition of the heterogeneity of tumors B. Recently developed principles which have helped guide the treatment of neoplastic disease 1. A single clonogenic cell can produce enough progeny to kill the host. 2. Unless few malignant cells are present, host immune mechanisms do not play a significant role in therapy of neoplastic disease. 3. A given therapy results in destruction of a constant percentage as opposed to a constant number of cells, therefore, cell kill follows first order kinetics.
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Cancer Chemotherapy
C. Malignancies which respond favorably to chemotherapy: 1. choriocarcinoma, 2. Acute leukemia, 3. Hodgkin's disease, 4. Burkitt's lymphoma, 5. Wilms' tumor, 6. Testicular carcinoma, 7. Ewing's sarcoma, 8. Retinoblastoma in children, 9. Diffuse histiocytic lymphoma and 10. Rhabdomyosarcoma.

D. Antineoplastic drugs are most effective against rapidly dividing tumor cells.

E. The Main Goal of Antineoplastic Agents

IS to eliminate the cancer cells without affecting normal tissues (the concept of differential sensitivity). In reality, all cytotoxic drugs affect normal tissues as well as malignancies - aim for a favorable therapeutic index (aka therapeutic ratio).

LD50 Therapeutic Index = ----ED50

A therapeutic index is the lethal dose of a drug for 50% of the population (LD50) divided by the minimum effective dose for 50% of the population (ED50).

F. The effects of tumor burden, scheduling, dosing, and initiation/duration of treatment on patient survival.
Untreated patients
Infrequent scheduling of treatment courses. Prolongs survival but does not cure.

More intensive and frequent treatment. Kill rate > growth rate.

Early surgical removal of the primary tumor decreases the tumor burden. Chemotherapy will remove persistant secondary tumors.
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General rules of chemotherapy

Aggressive high-dose chemotherapy

Dose- limiting is toxicity towards normal cells Cyclic regimens - repeated administrations with appropriate intervals for regeneration of normal cells (e.g., bone marrow cells) Supportive therapy - to reduce toxicity hematotoxicity bone marrow transplantation, hematopoietic growth factors Specific antagonists: antifolate (methotrexate) folate (leucovorin) MESNA - donor of SH groups, decreased urotoxicity of cyclophosphamide. Detoxifying agent. dexrazoxane: chelates iron, reduced anthracycline cardiotoxicity amifostine: reduces hematotoxicity, ototoxicity and neurotoxicity of alkylating agents

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General rules of chemotherapy

Combination of several drugs with different mechanisms of action, different resistance mechanisms, different dose-limiting toxicities.

Adjuvant therapy: Additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back. Adjuvant therapy may include chemotherapy, radiation therapy, hormone therapy, targeted therapy, or biological therapy. Neoadjuvant therapy: Treatment given as a first step to shrink a tumor before the main treatment, which is usually surgery, is given. Examples of neoadjuvant therapy include chemotherapy, radiation therapy, and hormone therapy. It is a type of induction therapy.

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General rules of chemotherapy

Supportive therapy:
-Antiemetics (5-HT3 -antagonists) -Antibiotic prophylaxis and therapy (febrile neutropenia) -Prophylaxis of urate nephropathy (allopurinol) -Enteral and parenteral nutrition -Pain analgesic drugs -Psychological support

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Antineoplastic Agents
Alkylating agents busulfan carboplatin carmustine cisplatin cyclophosphamide dacarbazine ifosfamide lomustine mechlorethamine melphalan oxaliplatin procarbazine temozolomide thiotepa

Topoisomerase inhibitors dactinomycin daunomycin doxorubicin etoposide etoposide phosphate

idarubicin irinotecan
liposomal daunomycin liposomal doxorubicin

Antimetabolites cytarabine clofarabine fludarabine gemcitabine mercaptopurine methotrexate nelarabine thioguanine Tubulin binders docetaxel ixabepilone vinblastine vincristine vinorelbine paclitaxel

Molecularly targeted erlotinib imatinib sorafenib sunitinib tretinoin

Herceptin Miscellaneous arsenic trioxide asparaginase bleomycin dexamethasone hydroxyurea mitotane
PEG-asparaginase

mitoxantrone teniposide topotecan

prednisone
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Chemotherapy: classification based on the mechanism of action

Antimetabolites: Drugs that interfere with the formation of key biomolecules including nucleotides, the building blocks of DNA.

Genotoxic Drugs: Drugs that alkylate or intercalate the DNA causing the loss of its function.
Plant-derived inhibitors of mitosis: These agents prevent proper cell division by interfering with the cytoskeletal components that enable the cell to divide. Plant-derived topoisomerase inhibitors: Topoisomerases unwind or religate DNA during replication. Other Chemotherapy Agents: These agents inhibit cell division by mechanisms that are not covered in the categories listed above.

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Cell cycle specificity of Anti-Neoplastic Agents

Vincristine, Vinblastine
Paclitaxel, Docetaxel

Cyclophosphamide Bleomycin Actinomycin D

M

G0

resting

G2

G1

Hydrocortisone
G0 = resting phase G1 = pre-replicative phase G2 = post-replicative phase S = DNA synthesis M = mitosis or cell division

Purine antagonists Methotrexate Cyclophosphamide 5-Fluorouracil Cytosine arabinoside Daunomycin

Actinomycin D 5-Fluorouracil Cytosine arabinoside Methotrexate 6-Mercaptopurine 6-Thioguanine

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Pharmacology of Antineoplastic Agents

PART II
4. Mechanisms of action 5. Side Effects 6. Drug Resistance

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Chemotherapy: Mechanisms of Action

1
Topoisomerase Inh.

DNA

Alkylating agents

Purines and Pyrimidines

RNA
Antimetabolites Asparaginase

Protein tubulin

Tubulin binders

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Major Clinically Useful Alkylating Agents

Bis(mechloroethyl)amines Nitrosoureas

Cancer Chemotherapy Chapter 55. B.G. Katzung

Aziridines

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An Example of DNA Crosslinking

O HN H2 N HO O N N N

R
N N N

O NH N NH2 OH

O P

O O P O

Crosslinking: Joining two or more molecules by a covalent bond. This can either occur in the same strand (intrastrand crosslink) or in the opposite strands of the DNA (interstrand crosslink). Crosslinks also occur between DNA and protein. DNA replication is blocked by crosslinks, which causes replication arrest and 20 cell death if the crosslink is not repaired.

Alkylating Agents (Covalent DNA binding drugs)

1. The first class of chemotherapy agents used. 2. They stop tumour growth by cross-linking guanine nucleobases in DNA double-helix strands - directly attacking DNA. 3. This makes the strands unable to uncoil and separate. 4. As this is necessary in DNA replication, the cells can no longer divide. 5. Cell-cycle nonspecific effect 6. Alkylating agents are also mutagenic and carcinogenic

G C G T A

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E.g., Mechlorethamine (Nitrogen Mustards)

Cancer Chemotherapy Dr.Rajarshi N. Patel

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Cyclophosphamide
Cyclophosphamide is an alkylating agent. It is a widely used as a DNA crosslinking and cytotoxic chemotherapeutic agent. It is given orally as well as intravenously with efficacy. It is inactive in parent form, and must be activated to cytotoxic form by liver CYT450 liver microsomaal system to 4Hydroxycyclophamide and Aldophosphamide. 4-Hydroxycyclophamide and Aldophosphamide are delivered to the dividing normal and tumor cells. Aldophosphamide is converted into acrolein and phosphoramide mustard. They crosslink DNAs resulting in inhibition of DNA synthesis23

Cyclophosphamide Metabolism
Inactive

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Cyclophosphamide Clinical Applications:

1. 2. 3. 4. 5. 6. 7. 8.

Breast Cancer Ovarian Cancer Non-Hodgkins Lymphoma Chronic Lymphocytic Leukemia (CLL) Soft tissue sarcoma Neuroblastoma Wilms tumor Rhabdomyosarcoma
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Cyclophosphamide Major Side effects

1. 2. 3. 4. 5. 6. 7.

Nausea and vomiting Decrease in PBL count Depression of blood cell counts Bleeding Alopecia (hair loss) Skin pigmentation Pulmonary fibrosis

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Ifosphamide
Mechanisms of Action Similar to cyclophosphamide Application 1. Germ cell cancer, 2. Cervical carcinoma, 3. Lung cancer 4. Hodgkins and non-Hodgkins lymphoma 5. Sarcomas Major Side Effects Similar to cyclophosphamide
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A. Alkylating agents
1. Mechanism of Action a. Nitrogen Mustards A. Mechlorethamine DNA cross-links, resulting in inhibition of DNA synthesis and function Same as above Hodgkins and nonHodgkins lymphoma Must be given Orally Nausea and vomiting, decrease in PBL count, BM depression, bleeding, alopecia, skin pigmentation, pulmonary fibrosis Same as above 2. Clinical application 3. Route 4. Side effects

B. Cyclophosphamide

Breast, ovarian, CLL, soft tissue sarcoma, WT, neuroblastoma Chronic lymphocytic leukemia Multiple myeloma, breast, ovarian Germ cell cancer, cervical carcinoma, lung, Hodgkins and non-Hodgkins lymphoma, sarcomas

Orally and I.V.

C. Chlorambucil D. Melphalan E. Ifosfamide

Same as above Same as above Same as above

Orally effective Orally effective Orally effective

Same as above Same as above Same as above

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A. Alkylating agents
1. Mechanism of Action b. Alkyl Sulfonates A. Busulfan Atypical alkylating agent. Chronic granulocytic leukemia Orally effective Bone marrow depression, pulmonary fibrosis, and hyperuricemia 4. Side effects Bone marrow depression, CNS depression, renal toxicity Nausea and vomiting, Nephrotoxicity, nerve dysfunction 2. Clinical application 3. Route 4. Side effects

c. Nitrosoureas A. Carmustine

1. Mechanism of Action DNA damage, it can cross blood-brain barrier Lomustine alkylates and crosslinks DNA, thereby inhibiting DNA and RNA synthesis. Also carbamoylates DNA and proteins, resulting in inhibition of DNA and RNA synthesis and disruption of RNA processing. Lomustine is lipophilic and crosses the blood-brain barrier DNA damage

2. Clinical application Hodgkins and nonHodgkins lymphoma, brain tumors, G.I. carcinoma Hodgkins and nonHodgkins lymphoma, malignant melanoma and epidermoid carcinoma of lung

3. Route Given I.V. must be given slowly. Orally effective

B. Lomustine

C. Streptozotocin

pancreatic cancer

Given I.V.

Nausea and vomiting, nephrotoxicity, liver toxicity 29

A. Alkylating agents
d. Ethylenimines A. Triethylene thiophosphoramide (Thio-TEPA) B. Hexamethylmelamine (HMM) 1. Mechanism of Action DNA damage, Cytochrome P450 DNA damage 2. Clinical application Bladder cancer 3. Route Given I.V. 4. Side effects Nausea and vomiting, fatigue Nausea and vomiting, low blood counts, diarrhea

Advanced ovarian tumor

Given orally after food

d. Triazenes A. Dacarbazine (DTIC)

1. Mechanism of Action Blocks, DNA, RNA and protein synthesis

2. Clinical application Malignant Melanoma, Hodgkins and nonHodgkins lymphoma

3. Route Given I.V.

4. Side effects Bone marrow depression, hepatotoxicity, neurotoxicity, bleeding, bruising, blood clots, sore mouths.

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Summary

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Tubulin Binding Agents

e.g., Vincristine, Vinblastine, Vindesine Vinorelbine: Inhibition of mitotic spindle formation by binding to tubulin. M-phase of the cell cycle.

Polymerization
Vincristine

tubulin

Depolymerization
Paclitexal (taxol)

e.g., Paclitexal: binds to tubulin, promotes microtubule formation and retards disassembly; results in 32 mitotic arrest.

B. Natural Products
1. Antimitotic Drugs
1. Mechanism of Action A. Vincristine Cytotoxic: Inhibition of mitotic spindle formation by binding to tubulin. M-phase of the cell cycle. Methylates DNA and inhibits DNA synthesis and function 2. Clinical application Metastatic testicular cancer, Hodgkins and non-Hodgkins lymphoma, Kaposis sarcoma, breast carcinoma, chriocarcinoma, neuroblastoma Hodgkins and non-Hodgkins lymphoma, brain tumors, breast carcinoma, chriocarcinoma, neuroblastoma 3. Route I.V. 4. Side effects Bone marrow depression, epithelial ulceration, GI disturbances, neurotoxicity

B. Vinblastine

I.V.

Nausea and vomiting, neurotoxicity, thrombocytosis, hyperuricemia.

2. Antimitotic Drugs
1. Mechanism of Action Paclitaxel (Taxol) Cytotoxic: binds to tubulin, promotes microtubule formation and retards disassembly; mitotic arrest results 2. Clinical application Melanoma and carcinoma of ovary and breast 3. Route I.V. 4. Side effects Myelodepression and neuropathy

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3. Epipodophyllotoxins (These are CCS)

1. Mechanism of Action A. Etoposide Binds to and inhibits Topoisomerase II and its function. Fragmentation of DNA leading to cell death, apoptosis. Same as above

Act on Topoisomerase II
3. Route I.V. 4. Side effects Myelosuppression, alopecia

2. Clinical application Testicular cancer, small-cell lung carcinoma, Hodgkin lymphoma, carcinoma of breast, Kaposis sarcoma associated with AIDS Refractory acute lymphocytic leukemia

B. Teniposide

I.V.

Myelosuppression,

Accumulation of single- or doublestrand DNA breaks, the inhibition of DNA replication and transcription, and apoptotic cell death.

Etoposide acts primarily in the G2 and S phases of the 34 cell cycle

4. Antibiotics (CCS)
1. Mechanism of Action a. Dactinomycin (ACTINOMYCIN D) It binds to DNA and inhibits RNA synthesis, impaired mRNA production, and protein synthesis inhibit DNA and RNA synthesis 2. Clinical application Rhabdomyosarcoma and Wilm's tumor in children; choriocarcinoma (used with methotrexate Acute lymphocytic/granulocytic leukemias; treatment of choice in nonlymphoblastic leukemia in adults when given with cytarabine Acute leukemia, Hodgkin's disease, non Hodgkin's lymphomas (BACOP regimen), CA of breast & ovary, small cell CA of lung, sarcomas, best available agent for metastatic thyroid CA Germ cell tumors of testes and ovary, e.g., testicular carcinoma (can be curative when used with vinblastine & cisplatin), squamous cell carcinoma 3. Route I.V. 4. Side effects Bone marrow depression, nausea and vomiting, alopecia, GI disturbances, and ulcerations of oral mucosa Side effects: bone marrow depression, GI disturbances and cardiac toxicity (can be prevented by dexrazoxane) Cardiac toxicity, Doxorubicin mainly affects the heart muscles, leading to tiredness or breathing trouble when climbing stairs or walking, swelling of the feet .

b. Daunorubicin (CERUBIDIN)

I.V.

Doxorubicin (ADRIAMYCIN)

inhibit DNA and RNA synthesis

I.V.

c. Bleomycin (BLENOXANE)

fragment DNA chains and inhibit repair

Given I.V. or I.M.

Mucosocutaneous reactions and pulmonary fibrosis; bone marrow depression much less than other antineoplastics

Inhibit DNA and RNA syntheses

Cancer Chemotherapy Dr.Rajarshi Patel 35

5. Enzymes: L-asparaginase
1. Mechanism of Action L-asparaginase Hydrolyzes L-asparagine (to L-aspartic acid) an essential amino acid to many leukemic cells 2. Clinical application Acute lymphocytic leukemia, induction of remission in acute lymphoblastic leukemia when combined with vincristine, prednisone, and anthracyclines 3. Route I.V. or I.M. 4. Side effects Nausea and vomiting, Poor appetite, Stomach cramping, Mouth sores, Pancreatitis. Less common: blood clotting

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C. Antimetabolites
Folic acid is a growth factor that provides single carbons to the precursors used to form the nucleotides used in the synthesis of DNA and RNA. To function as a cofactor folate must be reduced by DHFR to THF.

(Folic acid analog)

MTX polyglutamates Are selectively retained In tumor cells.

* *

Reduced Folate Carrier protein

MTX Kills cells during S-phase

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C. Antimetabolites
1. Mechanism of Action 2. Clinical application 3. Route 4. Side effects

1.

inhibits formation Methot of FH4 rexate (tetrahydrofolate) from folic acid by inhibiting the enzyme dihydrofolate reductase (DHFR); since FH4 transfers methyl groups essential to DNA synthesis and hence DNA synthesis blocked.

Choriocarcinoma, acute lymphoblastic leukemia (children), osteogenic sarcoma, Burkitt's and other nonHodgkins lymphomas, cancer of breast, ovary, bladder, head & neck

Orally effecti ve as well as given I.V.

bone marrow depression, intestinal lesions and interference with embryogenesis. Drug interaction: aspirin and sulfonamides displace methotrexate from plasma proteins.

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1. Mechanism of Action 2 Pyrimidine Analogs: Cytosine Arabinoside inhibits DNA synthesis

2. Clinical application most effective agent for induction of remission in acute myelocytic leukemia; also used for induction of remission acute lymphoblastic leukemia, non-Hodgkin's lymphomas; usually used in combination chemotherapy 2. Clinical application most effective agent for induction of remission in acute myelocytic leukemia; also used for induction of remission acute lymphoblastic leukemia, non-Hodgkin's lymphomas; usually used in combination chemotherapy

3. Route Orally effective

4. Side effects bone marrow depression

1. Mechanism of Action 2 Purine analogs: 6-Mercaptopurine (6MP) and Thioguanine Blocks DNA synthesis by inhibiting conversion of IMP to AMPS and to XMP as well as blocking conversion of AMP to ADP; also blocks first step in purine synthesis. Feedback inhibition blocks DNA synthesis by inhibiting conversion of IMP to XMP as well as GMP to GDP; also blocks first step in purine synthesis by feedback inhibition

3. Route Orally effective

4. Side effects bone marrow depression,

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6. Drug Resistance
One of the fundamental issue in cancer chemotherapy is the development of cellular drug resistance. It means, tumor cells are no longer respond to chemotherapeutic agents. For example, melanoma, renal cell cancer, brain cancer often become resistant to chemo. A few known reasons: 1. Mutation in p53 tumor suppressor gene occurs in 50% of all tumors. This leads to resistance to radiation therapy and wide range of chemotherapy. 2. Defects or loss in mismatch repair (MMR) enzyme family. E.g., colon cancer no longer respond to fluoropyrimidines, the thiopurines, and cisplatins.

3. Increased expression of multidrug resistance MDR1 gene which encodes P-glycoprotein resulting in enhanced drug efflux and reduced intracellular accumulation. Drugs such as athracyclines, vinca alkaloids, taxanes, campothecins, even antibody such as imatinib.
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Summary
1. The main goal of anti-neoplastic drug is to eliminate the cancer cells without affecting normal tissues.
2. Log-Kill Hypothesis states that a given therapy kills a percentage of cells, rather then a constant number, therefore, it follows first order kinetics. Aim for a favorable therapeutic index. 3. Early diagnosis is the key. 4. Combination therapy and adjuvant chemotherapy are effective for small tumor burden. 5. Two major classes of antineoplastic agents are: a. Cell Cycle Specific and b. Cell Cycle Non-Specific agents

5. Because chemotherapeutic agents target not only tumor cells, but also affect normal dividing cells including bone marrow, hematopoietic, and GI epithelium. Know what the side effects are.
6. Drug resistance is often associated with loss of p53 function, DNA mismatch repair system, and increased MDR1 gene expression.

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