Dr.

Janet Fitzakerley
MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 1 of 19

ANTINEOPLASTICS I
REFERENCES:
Katzung Basic and Clinical Pharmacology (9th ed.) Chapter 55, pg. 898-920

CRITICAL FACTS
(if med school is a Minnesota forest with millions of trees,
these are the red pines)

1.

The GOAL is to eradicate the cancer cells without affecting

normal tissues. The REALITY is that all cytotoxic drugs
affect
normal
tissues
as
well
as
malignancies
aim for a favourable therapeutic index.

2.

Cancer drugs can be divided into two general classes: CELL CYCLE SPECIFIC
DRUGS (CCS; esp. plant alkaloids and antimetabolites), and CELL CYCLE
NON-SPECIFIC DRUGS (CCNS; esp. alkylating agents and some natural
products). Antineoplastic agents can also be organized according to their
chemical class, mechanism of action, therapeutic use or their toxicities.

3.

The CELL KILL HYPOTHESIS proposes that actions of CCS drugs follow
first order kinetics: a given dose kills a constant PROPORTION of a tumor
cell population (rather than a constant NUMBER of cells).

4.

Resistance to cancer chemotherapeutic drugs is a major limitation to

treatment.
PRIMARY RESISTANCE occurs when some inherent
characteristic of the cancer cells prevents the drugs from working;
ACQUIRED RESISTANCE occurs when cancer cells become resistant during
treatment. MULTIDRUG RESISTANCE is particularly problematic; this
occurs when tumour cells become cross-resistant to a wide range of
chemically dissimilar agents after exposure to a SINGLE (typically natural
product) drug.

5.

Although crosslinking agents are dependent upon proliferation, these agents

ARE NOT cell cycle specific because the alkylation reactions that initiate cell
death can occur during any phase of the cell cycle. However, primary toxicity
occurs in late G1 and S phase (not G2, M or early G1).

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 2 of 19

6.

One major distinguishing feature among alkylating agents is the rate at which
the parent drug is converted to become strong electrophiles. For some drugs
(e.g., MECHLORETHAMINE), the reaction is virtually instantaneous --- these
agents are given IV to minimize blistering and GI effects. Others agents
(such as CYCLOPHOASPHAMIDE) must be activated in the liver and other
tissues, and they can be given orally.

7.

The anthracycline antibiotics DAUNORUBIN and DOXORUBICIN work by

intercalating into DNA.
Their major toxicity is an UNUSUAL
CARDIOMYOPATHY that is often IRREVERSIBLE and related to the TOTAL
DOSE of the drug.

8.

The vinca alkaloids (VINCRISTINE and VINBLASTINE) and the taxanes

(PACLITAXEL) are mitotic spindle poisons.
Despite their structural
similarity, VINCRISTINE and VINBLASTINE have significantly different
toxicities (VINCRISTINE=CNS; VINBLASTINE=Bone marrow suppression).

ESSENTIAL MATERIAL FROM OTHER LECTURES:

1.

Cell division & cell cycle and apoptosis, especially cell cycle and p53
- Dr. Holy, Principles.

2.

DNA & Replication - Dr. Perkins, Principles.

3.

Regulation of Gene Expression and Cancer, a multifactorial genetic disease

Dr. Cormier, Principles

4.

Principles of Pharmacology Dr. Knych, Principles

5.

Cell injury and cell death, Neoplasia, Nomenclature - Malignancy and Metastasis
- Dr. Ward, Histopathology

PRIMARY LEARNING OBJECTIVES:

1. List the potential targets and actual mechanisms of action of antineoplastic drugs.
What are the strengths and weaknesses of each approach?
2. What is the cell kill hypothesis and its implications for treatment?
3. What factors can influence the success of chemotherapy in curing cancer?
4. Understand why particular classes of drugs act at specific points in the cell cycle.
5. What are the generic mechanisms for drug resistance to antineoplastics? What
factors contribute to the development of resistance?

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 3 of 19

6. Why are most cancer drugs administered in combination?

7. Identify the steps in the activation process of cyclophosphamide and how this relates
to its specific toxicity. What is the use of MESNA?
8. Describe the specific mechanisms of action, causes of drug resistance and toxicities
associated with the drugs presented. Be able to classify these particular agents
according to 1) chemical class, 2) mechanism of action, 3) cell cycle specificity, 4)
therapeutic uses, and 5) major toxicities.

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 4 of 19

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 5 of 19

REVIEW OF THE PROBLEM

Distinguishing characteristics of cancer

genetic or epigenetic disease

characterized by rapid cell growth

Causes of Rapid Cell Growth

derived from normal tissue

loss of differentiation

loss of cell cycle checkpoints

(mutation or deletion of p53 or p16 tumor
suppressor genes)

metastasis to other tissues

increase in expression of genes that

protect cells from apoptosis (bcl2)

Non-evidence-based Medicine

New treatments can make historical survival rates obsolete

Do we know what type a cancer is? targeted therapy and genomics

Its all or nothing

GENERAL CONCEPTS
Goals for Pharmacologic Therapy

Cure

Cure in adjuvant setting

Palliation

Create a chronic disease?

Targets for Antineoplastic Drugs

1. Rapid cell growth
2. Cell surface markers (antibodies)
3. Lack of immune system responses
4. Defective genes
5. Angiogenesis

The GOAL is to eradicate the

cancer cells without affecting
normal tissues.
The REALITY is that all
cytotoxic drugs affect normal
tissues as well as malignancies.
aim for a favourable
therapeutic index.

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 6 of 19

Tissues Affected by Drugs that

Target Rapid Cell Growth
Bone marrow

Skin

Fetus

GI mucosa

Hair follicles

Cancer cells

Cell Cycle

M
G2

G1

Cancer drugs can be divided into two general

classes: CELL CYCLE SPECIFIC DRUGS (CCS;
esp. plant alkaloids and antimetabolites), and CELL
CYCLE NON-SPECIFIC DRUGS (CCNS; esp.
alkylating agents and some natural products).

CYCLE SPECIFIC DRUGS

CELL CYCLE
NON-SPECIFIC DRUGS

Only proliferating cells killed

Both proliferating and non-proliferating

cells killed

Schedule dependent
(duration rather than dose)

Dose dependent
(total dose rather than schedule)

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 7 of 19

Growth rate = growth fraction X doubling

time - apoptosis rate

The CELL KILL HYPOTHESIS

proposes that actions of CCS
drugs follow first order kinetics:
a given dose kills a constant
PROPORTION of a tumor cell
population (rather than a constant
NUMBER of cells).

Factors affecting outcome

CANCER
Cancer type
Stage
Growth fraction
(% of cells in cycle)
Rate of replication
(doubling time)
Resistance

HOST
Performance status
Marrow capacity
Renal function
Liver function
Age
Compliance

Drug Resistance
Mechanisms:

Contributing causes:

1. Increased DNA repair

1. Poor drug distribution

2. Formation of trapping agents

2. Tumor cells not in cycle

3. Changes in target enzymes

3. Sanctuary sites

4. Decreased activation of prodrugs

4. Heterogeneity of tumor cells

5. Increased inactivation
6. Decreased drug accumulation

clonal selection

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 8 of 19

Resistance
Resistance to cancer chemotherapeutic drugs is a major limitation to
treatment. PRIMARY RESISTANCE occurs when some inherent
characteristic of the cancer cells prevents the drugs from working;
ACQUIRED RESISTANCE occurs when cancer cells become
resistant as a result of treatment. MULTIDRUG RESISTANCE is
particularly problematic; this occurs when tumor cells become crossresistant to a wide range of chemically dissimilar agents after
exposure to a SINGLE (typically natural product) drug.

increased expression of:

1) mdr-1 gene levels of P-glycoprotein
2) multidrug resistance proteins 1 (MRP1-9)
3) lung resistance protein (LRP)

Ca2+ blockers (e.g. verapamil) can reverse this resistance

Combination Chemotherapy
STRATEGIES

RESULTING IN:

different mechanisms of action

decreased development of resistance

active in different stages of cell

synergistic effects

cycle

decreased toxic effects

different toxicities

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 9 of 19

DRUGS YOU NEED TO KNOW (todays drugs are capitalized; prototypes are underlined)
ALKYLATING AGENTS

IMMUNOTHERAPY

(blue cards)
BUSULFAN
CARMUSTINE (BCNU)
CYCLOPHOSPHAMIDE
DACARBAZINE
LOMUSTINE (CCNU)
MECHLORETHAMINE
MELPHALAN
THIOTEPA

Alemtuzumab
Aminoglutethimide
Bevacizumab
Cetuximab
Cyclosporine
Dexamethasone
Edrecolomab
Gemtuzumab
Ibritumomab
Interferon
Interleukin 2
Interleukin-12
Prednisone
Rituximab
Tacrolimus (fk506)
Tositumomab
Trastuzumab
Tumour necrosis factor

NATURAL PRODUCTS
(green cards)
BLEOMYCIN
DACTINOMYCIN
DAUNORUBICIN
DOXORUBICIN
ETOPOSIDE (VP-16)
IRINOTECAN
MITOMYCIN C
PACLITAXEL
VINBLASTINE
VINCRISTINE

MISCELLANEOUS
(white cards)
Angiostatin
AMSACRINE
L-asparaginase
Bortezomib
CARBOPLATIN
CISPLATIN
Erlotinib
Gefitinib
Hydroxyurea
Imatinib
Pentostatin
PROCARBAZINE
Thalidomide

ANTIMETABOLITES
Azathioprine
5-fluorouracil
6-thioguanine
6-mecaptopurine
Cytarabine (ara-c)
Gemcitabine
Methotrexate

HORMONES and RELATED

AGENTS
Aminoglutethimide
Anastrozole
Exemestane
Flutamide
Letrozole
Goserelin
Leuprolide
Letrozole
Tamoxifen

SUPPORTING AGENTS
Allopurinol
Erythropoietin
Filgrastim
Interleukin 11
Leucovorin
MESNA
Sargramostim (GM-CSF)

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

Mechanisms of Action of
Antineoplastic Drugs
1. Prevent DNA synthesis
2. Disrupt DNA, prevent DNA repair,
and/or prevent RNA synthesis
3. Interrupt mitosis
4. Interfere with protein or hormone synthesis
5. Immunotherapy
6. Prevent angiogenesis and/or formation of metastases

DRUGS THAT DISRUPT DNA

General Categories
I.

Drugs that crosslink DNA (alkylating agents)

II.

Drugs that intercalate or form adducts with DNA

III.

Drugs that cause strand breaks

January 27 and 30, 2006

Antineoplastics I
Page 10 of 19

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

I.

January 27 and 30, 2006

Antineoplastics I
Page 11 of 19

CROSSLINKING AGENTS
(ALKYLATING AGENTS, MITOMYCIN C and PLATINs)

Types

Nitrogen mustards: CYCLOPHOSPHAMIDE, MECHLORETHAMINE,

MELPHALAN

Ethylenimines: THIOTEPA

Alkyl sulfonates: BUSULFAN

Nitrosoureas: CARMUSTINE (BCNU), LOMUSTINE (CCNU)

Triazenes: DACARBAZINE

?Others: CARBOPLATIN, CISPLATIN, MITOMYCIN C

Mechanism of Action
(alkylating agents)

Activation

Nucleophilic Attack

DNA Damage

Crosslinking of DNA
Miscoding of DNA (G-T pairing)
DNA strand breakage (depurination)

Although crosslinking agents are dependent upon

proliferation, these agents ARE NOT cell cycle specific
because the alkylation reactions that initiate cell death can
occur during any phase of the cell cycle. However, primary
toxicity occurs in late G1 and S phase (not G2, M or early G1).

1) DNA damage normally activates a cell cycle checkpoint that is dependent

on the p53 gene and 2) 50% of human cancers have a mutated or absent
p53 gene

cancer cells cannot repair the DNA alkylation or undergo

apoptosis, making these drugs more effective in those types of cancers

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

Structure/Activity Relationships

One major distinguishing feature among alkylating agents is

the rate at which the parent drug is converted to become
strong
electrophiles.
For
some
drugs
(e.g.,
MECHLORETHAMINE),
the
reaction
is
virtually
instantaneous --- these agents are given IV to minimize
blistering and GI effects.
Others agents (such as
CYCLOPHOASPHAMIDE) must be activated in the liver and
other tissues, and they can be given orally.

Activation of CYCLOPHOSPHAMIDE

January 27 and 30, 2006

Antineoplastics I
Page 12 of 19

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 13 of 19

Toxicity
Acute:
1. nausea and vomiting
2. strong vesicant properties
Delayed:
1. moderate to severe myelosuppression
(peaks at 6-10 days; recovery in 14-21 days)
2. immunosuppression
3. gonadal failure
4. carcingogenesis (leukemia)
5. teratogenesis
6. mutagenesis

Resistance
1. decreased permeation
2. increased production of nucleophilic substances (e.g. glutathione)
3. increased activity of DNA repair enzymes (e.g. guanine O6-alkyl transferase)
4. increased rates of metabolism

II. DRUGS THAT INTERCALATE OR FORM ADDUCTS WITH DNA

(ANTIBIOTICS: DACTINOMYCIN, DAUNORUBICIN, DOXORUBICIN)
The
anthracycline
antibiotics
DAUNORUBIN
and
DOXORUBICIN work by intercalating into DNA. Their major
toxicity is an UNUSUAL CARDIOMYOPATHY that is often
IRREVERSIBLE and related to the TOTAL DOSE of the drug.

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 14 of 19

Mechanism of Action

Cell cycle non-specific, but maximal toxicity in S phase (at low concentrations
will pass through S and die in G2)

intercalate with DNA (primary mechanism)

Several potential cytotoxic actions:

single- and double-strand breaks (mutagenic), either via topoisomerase II

or by free radical generation

sister chromatid exchange (carcinogenic)

inhibition of topoisomerase II

in the presence of NADPH, they react with cytochrome P450 reductase to

form superoxide anion radicals including both H2O2 and hydroxyl radicals

interact with cell membranes to alter fluidity and ion transport

Pharmacokinetics

usually administered IV (vesicant)

rapid clearance from plasma

eliminated by metabolic conversion (dependent on adequate liver function)

Toxicity

UNUSUAL CARDIOMYOPATHY that is often IRREVERSIBLE and related to

the TOTAL DOSE of the drug due to increased production of free radicals
within the myocardium can be partially reduced by using exogenous
antioxidants to boost host defenses (such as superoxide dismutase and
catalase)
Acute:

1) ST-T-wave alterations and arrhythmias

2) nausea, red urine, extravasation necrosis

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 15 of 19

Delayed: 1) congestive heart failure that is unresponsive to digitalis

(may occur years after treatment)
2) myelosuppression is a major dose-limiting complication
3) stomatitis, GI disturbances and alopecia are common
4) radiation recall reaction erythema and desquamation of the
skin at sites of prior radiation therapy

Resistance
1. acceleration of the efflux of anthracyclines (P-glycoprotein)
2. increased glutathione peroxidase activity
3. decreased topoisomerase II activity

III. DRUGS THAT CAUSE STRAND BREAKS and/or PREVENT

DNA REPLICATION (some are TOPOISOMERASE INHIBITORS)
Types
1. Antibiotic: BLEOMYCIN
2. Plant alkaloids: ETOPOSIDE (epipodophyllotoxin), IRINOTECAN
(camptothecin)
3. Miscellaneous: AMSACRINE, PROCARBAZINE

Mechanisms of Action
1. BLEOMYCIN

mixture of 2 glycopeptides (BLEOMYCIN A2 and B2)

unique mechanism bleomycin binds to DNA through its amino-terminal

peptide, and generates free radicals that cut the DNA

attacks DNA but not RNA

accumulation of cells in G2 phase that have chromosomal aberrations

(chromatid breaks, gaps, fragments and translocations)

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 16 of 19

2. ETOPOSIDE and IRINOTECAN

ETOPOSIDE forms a complex with topoisomerase II and DNA that results in

double-strand breaks remains bound to enzyme so repair cannot occur

IRINOTECAN is a prodrug that is converted to a potent inhibitor of

topoisomerase I

cell cycle specific (S and G2 phases)

3. Miscellaneous
AMSACRINE

causes the formation of forms topoisomerase II-DNA complexes that are

trapped at the breaking-sealing stage

PROCARBAZINE

unknown mechanism - inhibits DNA, RNA and protein synthesis- also

causes DNA strand scission

must undergo metabolic activation (either spontaneously or via

cytochrome P450 system)

Resistance
BLEOMYCIN
1. increased hydrolase activity
2. enhanced capacity to repair DNA
ETOPOSIDE
1. amplification of transporter (P-glycoprotein)
2. mutation or decreased expression of topoisomerase II
3. mutation of p53 tumor suppressor gene (required for apoptosis)

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 17 of 19

DRUGS THAT INTERRUPT MITOSIS

General Categories
I.

Vinca alkaloids:

VINCRISTINE, VINBLASTINE

II.

Taxanes: PACLITAXEL

METAPHASE

ANAPHASE

SPINDLE = STACKED TUBULIN

I.

VINCA ALKALOIDS

Mechanism of Action

cell-cycle-specific cell division is arrested in metaphase

bind to tubulin at the forming end and TERMINATE assembly

(induce formation of structures other than microtubules)

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

January 27 and 30, 2006

Antineoplastics I
Page 18 of 19

The vinca alkaloids (VINCRISTINE and VINBLASTINE) and

the taxanes (PACLITAXEL) are mitotic spindle poisons.
Despite their structural similarity, VINCRISTINE and
VINBLASTINE have significantly different toxicities.

Structure/Activity Relationships

minor alterations in structure can result in significant changes in toxicity and

anti-tumour activity (some related alkaloids are without activity)

Resistance
cross reactivity is not absolute
1. due to increased expression of P-glycoprotein
2. mutations to tubulin that prevent drug binding

Toxicity
Mnemonic:

VINCRISTINE - CNS toxicity

VINBLASTINE - bone marrow suppression.

Acute:

Nausea and vomiting (VINBLASTINE ONLY)

Delayed:

Alopecia, bone marrow suppression (greater for VINBLASTINE),

loss of reflexes, constipation
VINCRISTINE also produces muscle weakness, peripheral neuritis,
paralytic ileus

Neurotoxicity is prominent because tubulin is essential for the structure and

function of axons. Depression of deep tendon reflexes occurs within 2-3 weeks
in 100% of patients, followed by severe paresthesias and mild to moderate
sensory loss (indication to decrease dose). VINCRISTINE has more CNS effects
because it is more lipid soluble.

Dr. Janet Fitzakerley

MED 6510 Histopathology
jfitzake@d.umn.edu www.d.umn.edu/~jfitzake

II.

January 27 and 30, 2006

Antineoplastics I
Page 19 of 19

PACLITAXEL

Mechanism of Action

cell-cycle-specific (arrest in mitosis)

ENHANCES microtubule assembly without the involvement of microtubuleassociated proteins or guanosine triphosphate, and prevents disassembly

significant activity in ovarian and advanced breast cancer

Example questions: A 56-year-old man with non-Hodgkins lymphoma

underwent a successful course of therapy with the CHOP regimen.
1.

Which of the following classes of anticancer drugs is cell cycle-specific

(CCS) and used in the CHOP regimen?

2.

A)

Alkylating agents

B)

Vinca alkaloids

C)

Antimetabolites

D)

Glucocorticoids

E)

Plant alkaloids

During the second course of treatment, this patient developed

hemorrhagic cystitis. The most likely causative agent is:
A)

Bleomycin

B)

Cyclophosphamide

C)

Doxorubicin

D)

Prednisone

E)

Vincristine