Dr. (Mrs).

Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

ANTICANCER AGENTS Dr. Nutan Rao

Introduction:
Healthy cells are under strict biochemical control for growth and differentiation. Cells divide
and proliferate under the influence of various growth stimulators and are subject to arrested
growth and programmed cell death (apoptosis). In cancer, these regulatory processes have
gone awry, and cells grow and divide uncontrollably, consuming energy and losing both
structure and function due to an inability to adequately differentiate. To add insult to injury,
rampant cell division is accompanied by disabled cell-death processes, leading first to cellular
immortality and, eventually, to genetic instability. The causes of cancer are many and varied
(e.g., chemical, environmental, viral, and mutagenic), but all ultimately lead to an aberration
in the expression of proto-oncogenes, the products of which control normal cell life. When
these genes mutate to become oncogenes in a sequential, multistep process, cancer results.
Oncogenes (e.g., myc and ras) can either overexpress or underexpress regulatory
biochemicals, resulting in preferential and accelerated cellular growth. Initially, tumors grow
exponentially, taking a consistent amount of time for every doubling of the tumor cell
population. In fact, the majority of a cancer cell’s lifetime is spent before the tumor presents
clinically. Initially, growth is very rapid (doubling time measured in days), but doubling time
can slow to weeks or months as the tumor ages due to increasingly poor vascularization and
the resulting decrease in access to blood and essential nutrients.
Tumors may be either malignant or benign. Malignant tumors have the capability of
invading surrounding tissues and moving to distant locations in the body in a process known
as metastasis; characteristics that benign tumors do not possess.
Metastasis refers to the process by which malignant cells leave the parent tumor, migrate to
distant sites, and invade new tissue. The primary metastatic highways used by meandering
cancer cells are the blood and lymph fluids.
Cancers can usually be classified as lymphatic, epithelial, nerve, or connective tissue related,
and tumor nomenclature is based on tissue of origin as follows: carcinoma (epithelial origin),
sarcoma (muscle or connective tissue origin), leukemia and lymphoma (lymphatic or
hematologic origin), and glioma (neural origin).
Cell Cycle: When cells reproduce, they do so via a very specific game plan known as the cell
cycle. Cell division (mitosis) kicks off the cycle, and after a period of 30 to 60 minutes, the
cells go into either a resting phase (called G0) or a presynthetic (gap) phase (called G1), in
which enzyme production occurs in preparation for de novo nucleic acid synthesis.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Production of DNA then occurs in an S phase that can last up to 20 hours. The S phase is
followed by a gap phase (G2), in which RNA, critical proteins, and the mitotic spindle
apparatus are generated for the next mitotic (M) phase.

Cell cycle

Antimetabolite antineoplastics damage cells in the S phase, whereas mitosis inhibitors pack
their greatest cell-killing punch in the M phase. The administration of cell cycle phase-
specific antineoplastics is carefully planned so that the drug encounters cancer cells at their
most vulnerable moments. This often involves continuous infusion therapy or treatments
spread over several days. Other antineoplastic agents are toxic to cells regardless of cycle
phase (e.g., DNA alkylating agents and most antineoplastic antibiotics). These cell cycle
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

phase-nonspecific agents can often be administered as a single bolus injection and/or at any
time that is feasible for the provider and convenient for the patient.
Cancer treatment can be comprised of surgery, radiation, antineoplastic chemotherapy, and/or
therapy with biologic response modifiers, which stimulate the patient’s own immunologic
defense mechanisms. Surgery and radiation (ionizing, thermal, or photodynamic) are favored
for isolated or localized cancers; chemotherapy and biologic response modifiers (with or
without surgery 0 and/or radiation) are reserved for disseminated or systemic cancers.
Chemotherapy can also be used after surgery and/or radiation as an “insurance policy”
against microscopic metastatic disease (adjuvant therapy) or before surgery to decrease the
size of the mass to be removed (neoadjuvant therapy).
Cancer Chemotherapy:
The word antineoplastic means “against new growth.” In general, the mechanism of
cytotoxic action for all antineoplastic agents is interference with cellular synthesis or the
function of RNA, DNA, and the proteins that sustain life. All antineoplastic agents are
poisons because they are designed to kill cells. Currently available anticancer drugs are often
highly and generally toxic, especially for cells with short half-lives. For example, nonspecific
destruction of the rapidly dividing cells of the gastrointestinal (GI) tract leads to the severe
nausea and vomiting associated with cancer chemotherapy, whereas alopecia and fatigue (as
well as susceptibility to infection) are the result of the destruction of rapidly dividing cells in
hair follicles and bone marrow, respectively.
Classification:
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Tyrosine Kinase Inhibitors: Gefitinib, Imatinib, Lapatinib, Nilotinib, Sorafenib,

Sunitinib, Temsirolimus

Alkylating Agents:
The primary target of DNA cross-linking agents is the actively dividing DNA molecule. The
DNA cross-linkers are all extremely reactive electrophilic (δ+) structures. There are
several potential nucleophilic sites on DNA, which are susceptible to electrophilic attack by
an alkylating agent (N-2, N-3, and N-7 of guanine, N-1, N-3, and N-7 of adenine, 0–6 of
thymine, N-3 of cytosine). When encountered, the nucleophilic groups on various DNA bases
(particularly, but not exclusively, the N 7 of guanine) readily attack the electrophilic drug,
resulting in irreversible alkylation or complexation of the DNA base. Some DNA alkylating
agents, such as the nitrogen mustards and nitrosoureas, are bifunctional, meaning that one
molecule of the drug can bind two distinct DNA bases. Most commonly, the alkylated bases
are on different DNA molecules, and interstrand DNA cross-linking through two guanine N7
atoms results. The DNA alkylating antineoplastics are not cell cycle specific, but they are
more toxic to cells in the late G1 or S phases of the cycle. This is the time when DNA is
unwinding and exposing its nucleotides, increasing the chance that vulnerable DNA
functional groups will encounter the electrophilic antineoplastic drug and launch the
nucleophilic attack that leads to its own destruction. Alkylation makes the uncoiling of
strands impossible and separate. Since this is necessary for replication, cells can no longer
divide. The DNA alkylators have a great capacity for inducing both mutagenesis and
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

carcinogenesis; in other words, they can promote cancer in addition to treating it. Alkylating
agents kill rapidly proliferating cells and non proliferating cells also.

Example of cross-linking:

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 cell death if the crosslink is not repaired.

General Reaction for Alkylation and inactivation of alkylating agents

Alkylating agents include: Nitrogen Mustards and Aziridine-Mediated Alkylators,

DNA methylators and organoplatinum complexes

Nitrogen Mustards and Aziridine-Mediated alkylators:

The nitrogen mustards are compounds that are chemically similar to sulfur mustard or
mustard gas developed and used in World War I. The term “mustard” comes from the
similarity in the blisters produced by the compound and those seen upon exposure to the oil
of black mustard seeds.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Alkylation of nucleophilic species by nitrogen mustards

Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Mechanism of Action of alkylating agents:

The mechanism of action of the nitrogen mustards is depicted in Figure. In step 1, the lone
pair of electrons on the unionized amino group conducts an intramolecular nucleophilic
attack at the β-carbon of the mustard, displacing chloride anion and forming the highly
electrophilic aziridinium ion intermediate, a quaternary amine. The carbon atoms of this
strained cyclic structure are highly electrophilic due to the strong negative inductive effect of
the positively charged nitrogen atom.
In step 2, a DNA nucleophile conducts an intermolecular nucleophilic attack, which breaks
the aziridine ring and alkylates DNA. Although guanine is the preferred nucleic acid base
involved in the alkylation reaction, adenine is also known to react. Of critical importance is
the fact that the lone pair of electrons on the mustard nitrogen is regenerated when the
aziridine ring cleaves.
Steps 3 and 4 are simply repetitions of steps 1 and 2, respectively, involving the second arm
of the mustard and a second molecule of DNA. Ultimately, two molecules of DNA will be
cross-linked through the carbon atoms of what was once the nitrogen mustard. Finally,
hydrolytic depurination (step 5) cleaves the bound guanine residues from the DNA strand.
This is an attempt to liberate the DNA from the mustard’s covalent “stranglehold,” but the
DNA released from this mustard trap is damaged and unable to replicate. Cell death is the
inevitable result.
CHEMISTRY The structure of nitrogen mustards differs only in the nature of the third
group (R) attached to the amino nitrogen. This group, which can be either aliphatic or
aromatic, is the prime determinant of chemical reactivity, oral bioavailability, and the nature
and extent of side effects.
An aliphatic nitrogen substituent (e.g., CH3) will release electrons to the amine through σ
bonds. This electronic enrichment enhances the nucleophilic character of the lone pair of
electrons and increases the speed at which the δ+ β-carbon of the mustard will be attacked.
Whether in a tumor cell or a healthy cell, as soon as the aziridinium ion forms, it will react
with unpaired DNA and/or other cell nucleophiles, such as electron-rich SH (mercapto or
sulfhydryl), OH (hydroxyl), and NH (amino) groups of amino acids on enzymes or
membrane-bound receptors.The body’s water can also react with (and inactivate) the
aziridinium ion. The intra- and intermolecular reactions designated as steps 1 through 4 in
Figure happen so rapidly that almost no chance exists for tissue or cell specificity, which
means a greatly increased risk of serious side effects and use-limiting toxicity.
Conversely, an aromatic nitrogen substituent (e.g.,phenyl) conjugated with the mustard
nitrogen will stabilize the lone pair of electrons through resonance. Resonance delocalization
signifi cantly slows the rate of intramolecular nucleophilic attack, aziridinium ion formation,
and DNA alkylation. Aromatic mustards have a reactivity sufficiently controlled to permit
oral administration and attenuate the severity of side effects. The higher stability also
provides the chance for enhanced tissue selectivity by giving the intact mustard time to reach
malignant cells before generating the electrophilic aziridinium ion. Nitrogen mustards can
decompose in aqueous media through formation of the inactive dehalogenated diol shown in
Figure. Both the mustard nitrogen (pathway a) and the oxygen of water (pathway b) can act
as nucleophiles to advance this degradative process. The decomposition reactions can be
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

inhibited if the nucleophilic character of these atoms is eliminated through protonation, so

buffering solutions to a slightly acidic pH helps to enhance stability in aqueous solution.

Aqueous decomposition of alkylating agent

Mechlorethamine:

2-Chloro-N-(2-chloroethyl)-N-methylethan-1-amine

Mechlorethamine is the only aliphatic nitrogen mustard currently on the U.S. market. Its use
is limited by extremely high reactivity, which leads to rapid and nonspecific alkylation of
cellular nucleophiles and excessive toxicity. It is a dialkylating agent. It is a severe vesicant,
and if accidental skin contact occurs, the drug must be inactivated with 2% sodium
thiosulfate (Na2S2O3) solution. This reagent reacts with the mustard to create an inactive,
highly ionized, and water-soluble thiosulfate ester that can be washed away.

Thiosulfate inactivation of Mechlorethamine

The strong electron-withdrawing effect of the two chlorine atoms reduces the pKa of
mechlorethamine to 6.1, which gives a ratio of un-ionized to ionized drug forms of
approximately 20:1 at pH 7.4. This agent is too reactive for oral administration and too toxic
to use alone. In addition to severe nausea and vomiting, myelosuppression (lymphocytopenia
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

and granulocytopenia), and alopecia, it can cause myelogenous leukemia with extended use
due to its mutagenic/carcinogenic effects on bone marrow stem cells.
Uses: Mechlorethamine is still used in regimens for cancers of the blood (e.g.Hodgkin’s
disease, chronic myelocytic leukemia, chronic lymphocytic leukemia); fortunately, safer and
still highly potent antineoplastic agents are now available.
Chlorambucil:

4-[bis(2-chlorethyl)amino]benzenebutanoic acid
Like melphalan, chlorambucil has good oral bioavailability (which is decreased in the
presence of food) and the potential to induce nonlymphocytic leukemia. This drug is active
intact and also undergoes β-oxidation to provide an active phenylacetic acid mustard
metabolite, which is responsible for some of the observed antineoplastic activity.
Uses: It is used in the palliative treatment of chronic lymphocytic leukemia, malignant
lymphoma, and Hodgkin disease.
Synthesis of Chlorambucil:

Melphalan:

(2S)-2-amino-3-{4-[bis(2-chloroethyl)amino]phenyl}propanoic acid
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

This aromatic mustard, used primarily in the treatment of multiple myeloma, is able to
stabilize the lone pair of electrons on the mustard nitrogen through resonance with the
conjugated phenyl ring, slowing the formation of the reactive aziridinium ion. The L-isomer
of the amino acid phenylalanine (L-Phe) was purposefully incorporated into this
antineoplastic agent because naturally occurring L–amino acids are preferentially transported
into cells by the action of specific amino acid carrier proteins. It was assumed that the L-Phe
would act as a homing device and actively transport the toxic mustard inside the tumor cells,
but some studies indicate that melphalan enters cells through facilitated diffusion rather than
by active transport. Because the lone pair of electrons of melphalan (and other aromatic
mustards) is less reactive than the lone electron pair on aliphatic mustards, there is a greater
opportunity for distribution to cancer cells and a decreased incidence of severe side effects.
There is a lower incidence of nausea and vomiting compared to mechlorethamine, but
patients still experience myelosuppression, which can be severe. This drug is also mutagenic
and can induce leukemia. Dosage adjustments should be considered in patients with renal
disease.
Cyclophosphamide:

(RS)-N,N-bis(2-chloroethyl)-1,3,2-oxazaphosphinan-2-amine 2-oxide
Cyclophosphamide is a chiral prodrug antineoplastic agent requiring activation by metabolic
and nonmetabolic processes.

Metabolism of cyclophosphamide

The need for metabolic activation in the liver means lowered GI toxicity and less nonspecific
toxicity for cyclophosphamide compared with other DNA alkylating agents, but
cyclophosphamide is not without its toxic effects. Acrolein, generated during the formation of
phosphoramide mustard, is a very electrophilic and highly reactive species, and it causes
extensive damage to cells of the kidney and bladder.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Sulfhydryl alkylation by MESNA

To minimize the risk of bladder toxicity from acrolein, fluids should be forced and the
bladder irrigated. Mesna is available as adjuvant therapy in case of overt toxicity or as a
prophylactic protectant. A sulfhydryl reagent, mesna is transported in the bloodstream as the
inactive oxidized disulfide (dimesna) and selectively reduced to the reactive sulfhydryl in the
proximal tubules.
Use: Cyclophosphamide is most commonly used in combination with other antineoplastic
agents to treat a wide range of neoplasms, including leukemias and malignant lymphomas,
multiple myeloma, ovarian adenocarcinoma, and breast cancer.
Synthesis of Cyclophosphamide:

Busulfan:

1,4-butanediol dimethanesulfonate
As an alternative to utilizing aziridines as electrophilic species, it was found that simply
utilizing a carbon chain terminated at both ends by leaving groups gave compounds capable
of acting as cross-linking agents. Busulfan is a cell cycle non-specific alkylating
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

antineoplastic agent, Busulfan utilizes two sulfonate functionalities as leaving groups

separated by a four-carbon chain that reacts with DNA to primarily form intrastrand cross-
link at 5’-GA-3’sequences. The sulfonates are also subject to displacement by the sulfhydryl
functions found in cysteine and glutathione, and metabolic products are formed as a result of
nucleophilic attack by these groups to generate sulfonium species along with methane
sulfonic acid. This is followed by conversion to tetrahydrothiophene, and further oxidation
products are subsequently produced to give the sulfoxide and sulfone. The cyclic sulfone
known as sulfolane may be further oxidized to give 3-hydroxysulfolane.

Metabolic and Chemical Reactions of Busulfan

Nitrosoureas:

Development of the lead compound N-methyl-N’-nitroguanidine was based on the idea that
its chemical decomposition was leading to the formation of diazomethane (CH2N2) and
subsequent alkylation of DNA. This led to the nitrosoureas, where it was found that activity
could be enhanced by attachment of a 2-haloethyl substituent to both nitrogens.

These compounds are reasonably stable at pH=4.5 but undergo both acid and base catalyzed
decomposition at lower and higher pH, respectively. There are several pathways of
decomposition that are possible for these compounds, but the one that appears to be most
important for alkylation of DNA involves abstraction of the NH proton, which is relatively
acidic (pKa = 8–9), followed by rearrangement to give an isocyanate and a diazohydroxide.
The diazohydroxide, upon protonation followed by loss of water, yields a diazo species that
decomposes to a reactive carbocation. The isocyanate functions to carbamylate proteins and
RNA, whereas the carbocation is believed to be the agent responsible for DNA alkylation. In
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

those cases where there is a chloroethyl moiety attached to the N-nitroso urea functionality,
crosslinking of DNA occurs. Alkylation occurs preferentially at the N-7 position of guanine
with minor amounts of alkylation at guanine O-6.

Mechanism of DNA alkylation by nitrosoureas

Carmustine and Lomustine are both highly lipophilic chloroethylnitrosourea analogs
marketed for use in brain tumors and Hodgkin’s disease. Carmustine has also shown value in
the treatment of NHL and multiple myeloma.

1,3-Bis(2-chloroethyl)-1-nitrosourea

1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea
Both carmustine and lomustine can induce thrombocytopenia and leukopenia, leading to
hemorrhage and massive infection. Acute (as well as potentially fatal delayed) pulmonary
toxicity is also a risk.
Streptozocin:

2-Deoxy-2-({[methyl(nitroso)amino]carbonyl}amino)-β-D-glucopyranose
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

The glucopyranose moiety of streptozocin confers both islet cell specificity and high water
solubility to this nitrosourea-based antineoplastic. As a result, it is used exclusively in
metastatic islet cell carcinoma of the pancreas. Lacking the 2-chloroethyl substituent of
carmustine and lomustine, it is much less reactive as a DNA alkylating agent. Myelotoxicity,
while not unknown, is relatively rare. However, cumulative, dose-related renal toxicity may
be severe or fatal. Good hydration is essential to successful therapy, and kidney function
should be monitored weekly.
DNA methylating agents:
Procarbazine:

N-Isopropyl-4-[(2-methylhydrazino)methyl]benzamide
This methyl radical generator is used predominantly in the treatment of Hodgkin’s disease. It
is administered as part of a multidrug regimen that also includes a nitrogen mustard
(mechlorethamine), a mitosis inhibitor (vincristine), and prednisone. Procarbazine is
extensively metabolized in the liver, and 70% of an administered dose is excreted in the urine
as N-isopropylterephthalamic acid. In addition to methylating DNA guanine residues, it is
proposed to inhibit the de novo synthesis of proteins and nucleic acids. Procarbazine inhibits
monoamine oxidase, leading to several significant and potentially fatal drug–drug and drug–
food interactions. Facial flushing and other disulfiram-like symptoms are noted when alcohol
is concomitantly consumed because the drug also inhibits enzymes involved in ethanol
metabolism.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Dacarbazine:

5-(3,3-Dimethyl-1-triazenyl)imidazole-4-carboxamide
This DNA methylating agent is administered intravenously as a single agent in the treatment
of malignant melanoma and in combination with other agents in the treatment of metastatic
melanoma. Approximately 40% of the drug is excreted unchanged, but both the 5-
aminoimidazole-4-carboxamide (AIC, formed through the action of CYP1A enzymes) and
the carboxylic acid (AIC hydrolysis product) are major urinary metabolites. Leukopenia and
thrombocytopenia are the most common side effects and can be fatal. Patients are also at risk
for hepatotoxicity, including hepatocellular necrosis.

Metabolic and chemical activation of dacarbazine and temozolomide

Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Temozolomide:

4-methyl-5-oxo-2,3,4,6,8-pentazabicyclo[4.3.0]nona-2,7,9-triene-9-carboxamide
This imidazolotetrazine derivative is used for the treatment of glioblastoma multiforme or in
patients with anaplastic astrocytoma who have not responded to procarbazine or the
nitrosoureas. Women clear the drug less effectively than men and have a higher incidence of
severe neutropenia and thrombocytopenia in the initial therapy cycle. Myelosuppression is
the most significant adverse effect. Resistance involves drug-induced damage reversal by O
6-methylguanine-DNA methyltransferase, and the design of inhibitors of this potential target
for use in combination with temozolomide and other guanine O 6-methylating antineoplastics
is advocated.
Organoplatinum Complexes:
Mechanism Of Action: Organoplatinum antineoplastic agents contain an electron-defi cient
metal atom that acts as a magnet for electron-rich DNA nucleophiles. Like nitrogen mustards,
organoplatinum complexes are bifunctional and can accept electrons from two DNA
nucleophiles. Intrastrand cross-links most frequently occur between adjacent guanine residues
referred to as diguanosine dinucleotides (60% to 65%) or adjacent guanine and adenine
residues (25% to 30%). Interstrand cross-linking, which occurs much less frequently (1% to
3%), usually involves guanine and adenine bases.
Chemistry: All the currently marketed organoplatinum anticancer agents are Pt(II)
complexes with square planar geometry, although an octahedral Pt(IV) complex currently is
undergoing clinical trials. Platinum is inherently electron deficient, but the net charge on the
organometallic complex is zero due to the contribution of electrons by two of the four ligands
bound to the parent structure. Most commonly, the electron-donating ligand is chloride.
Before reacting with DNA, the electron-donating ligands are displaced through nucleophilic
attack by cellular water. When the displaced ligands are chloride anions (e.g., cisplatin), the
chloride-poor environment of the tumor cell facilitates the process, driving the generation of
the active, cytotoxic hydrated forms. Since the original ligands leave the metal with their
electrons, the hydrated organoplatinum molecule has a net positive charge The hydrated
platinum analogs are readily attacked by DNA nucleophiles (e.g., the N 7 of adjacent guanine
residues) due to the net positive charge that has been regained on the Pt atom. The DNA
bases become coordinated with the platinum, and in the cis configuration, DNA repair
mechanisms are unable to permanently correct the damage. The net result is a major change
in DNA conformation such that base pairs that normally engage in hydrogen bond formation
are not permitted to interact. The two amine ligands of the complex are bound irreversibly to
the Pt atom through very strong coordinate covalent bonds. They cannot be displaced by
DNA nucleophiles, but they do stabilize the cross-linked DNA–platinum complex by forming
strong ion-dipole bonds with the anionic phosphate residues on DNA. The DNA distortion
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

prompts a futile cycle of damage recognition and repair before giving up the ghost and
succumbing to cell cycle arrest and apoptosis.
Cisplatin:

(SP-4-2)-diamminedichloroplatinum(II)
The simplest of the organometallic antineoplastic agents, cisplatin is used intravenously in
the treatment of metastatic testicular and ovarian cancer and advanced bladder cancer.
It is rapidly hydrated. It is eliminated predominantly via the kidney, but approximately 10%
of a given dose undergoes biliary excretion. It is highly nephrotoxic and can cause
significant damage to the renal tubules, especially in patients with preexisting kidney disease,
with one kidney, or who are concurrently receiving other nephrotoxic drugs. To proactively
protect against kidney damage, patients should be aggressively hydrated with chloride-
containing solutions. Sodium thiosulfate may be given to reduce the nephrotoxicity. Cisplatin
is a very severe emetogen, and vomiting almost always occurs unless antiemetic therapy is
coadministered. Myelosuppression and ototoxicity that can lead to irreversible hearing loss
can also occur with cisplatin use.

Cisplatin activation and DNA cross-linking

Cisplatin inactivation by sodium thiosulfate

Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Cisplatin and the other organoplatinum anticancer agents react with aluminum and cannot be
administered through aluminum-containing needles.

Oxaliplatin:

[(1R,2R)-cyclohexane-1,2-diamine](ethanedioato-O,O')platinum(II)

This Pt(II) complex loses oxalate dianion (– OOC-COO–) in vivo to form the mono- and
dihydrated diaminocyclohexane (DACH) platinum analogs shown in Figure. The trans-(R,R)-
DACH structure serves as the carrier for the cytotoxic hydrated platinum and extends into the
major groove of DNA when the DNA–Pt complex forms. Hydrophobic DNA intrusion is
believed to contribute to the cytotoxicity of this organometallic. Oxaliplatin engages
primarily in intrastrand cross-linking with diguanosine dinucleotides, adjacent A-G
nucleotides, and guanines that are separated by one nucleotide (G-X-G). Interstrand cross-
linking, although less common, also occurs. It is significantly less mutagenic, nephrotoxic,
hematotoxic, and ototoxic than cisplatin. Oxaliplatin is used in the treatment of metastatic
colon or rectal cancer, either alone or in combination with fluorouracil.

Pulmonary fibrosis and peripheral sensory neuropathies that can be life-threatening are
known to occur. It has been proposed that the latter adverse effect is caused by oxalate-based
chelation of intracellular Ca2+ ,which inhibits voltage-gated sodium channels in sensory nerve
cells.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Antimetabolites:
Mechanism of action: Antimetabolites are compounds closely related in structure to a
cellular precursor molecule, yet these imposter substances are capable of preventing the
proper use or formation of the normal cellular product. These antimetabolites are similar
enough in structure in many cases to interact with the normal cellular process but differ in a
manner sufficient to alter the outcome of that pathway. Most antimetabolites are effective
cancer chemotherapeutic agents via interaction with the biosynthesis of nucleic acids.
Therefore, several of the useful drugs used in antimetabolite therapy are purines, pyrimidines,
folates, and related compounds. The antimetabolite drugs may exert their effects by several
individual mechanisms involving enzyme inhibition at active, allosteric, or related sites. Most
of these targeted enzymes and processes are involved in the regulatory steps of cell division
and cell/tissue growth. Often the administered drug is actually a prodrug form of an
antimetabolite and requires activation in vivo to yield the active inhibitor. The administration
of many purine and pyrimidine antimetabolites requires the formation of the nucleoside and
finally the corresponding nucleotide for antimetabolite activity. An antimetabolite and its
transformation products may inhibit several different enzymes involved in tissue growth.
These substances are generally cell cycle specific with activity in the S phase. The purine
and pyrimidine antimetabolites are often compounds incorporated into nucleic acids and the
nucleic acid polymers (DNA, RNA, etc.). The antifolates are compounds designed to interact
at cofactor sites for enzymes involved in the biosynthesis of nucleic acid bases. The
biosynthesis of these nucleic acid bases depend heavily on the availability of folate cofactors,
hence antimetabolites of the folates find utility as antineoplastic agents. The antitumor effects
of all these compounds attempting to masquerade as the natural precursor compound may
occur because of a malfunction in the biosynthesis of the corresponding macromolecules.
Classic examples of pyrimidine and purine antimetabolites are 5-fluorouracil and 6-
mercaptopurine, respectively, and the classic antifolate is methotrexate.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Pyrimidine drugs:
5-Fluorouracil (5-FU):

5-Fluoro-1H,3H-pyrimidine-2,4-dione
The pyrimidine derivative 5-fluorouracil (5-FU) was designed to block the conversion of
uridine to thymidine. The normal biosynthesis of thymidine involves methylation of the 5-
position of the pyrimidine ring of uridine. The replacement of the hydrogen at the 5-position
of uracil with a fluorine results in an antimetabolite drug, leading to the formation of a stable
covalent ternary complex composed of 5-FU, thymidylate synthase (TS), and cofactor (a
tetrahydrofolate species). The active form of fluorouracil differs from the endogenous
substrate only by the presence of the 5-fluoro group, which holds the key to the cell-killing
action of this drug. The C6 position of the false substrate is significantly more electrophilic
than normal due to the strong electron-withdrawing effect of the C5 fluorine. This greatly
increases the rate of attack by Cys195, resulting in a very fast formation of a fluorinated
ternary complex. The small size of the fluorine atom assures no steric hindrance to the
formation of this false complex.The normal pathway for the formation of thymidine from
uridine catalyzed by the enzyme TS is shown in following Scheme.

Biochemical conversion of uridine to thymidine

Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Anticancer drugs targeting this enzyme should selectively inhibit the formation of DNA
because thymidine is not a normal component of RNA. TS is responsible for the reductive
methylation of deoxyuridine monophosphate (dUMP) by 5,10-methylenetetrahydrofolate to
yield dTMP and dihydrofolate. Because thymine is unique to DNA, the TS enzyme system
plays an important role in replication and cell division.

Metabolic Activation of 5-FU to Fd-UMP

Fluorouracil is administered intravenously in the palliative treatment of colorectal, breast,

stomach, and pancreatic cancers.

Cytarabine/ Ara-C:

4-amino-1-[(2R,3S,4R,5R)-3,4-dihydroxy-5- (hydroxymethyl)oxolan-2-yl] pyrimidin-2-

one
Pyrimidine analogs as antimetabolites for cancer therapy have been developed based on the
cytosine structure as well. Modification of the normal ribose or deoxyribose moiety has
produced useful drug species such as cytarabine (ara-C). Cytosine arabinoside (ara-C or
cytarabine) is simply the arabinose sugar instead of ribose, and the only difference in
structure is the epimeric hydroxyl group at the 2’-position of the pentose sugar. This epimeric
sugar is similar enough to the natural ribose to allow ara-C to be incorporated into DNA, and
its mechanism of action may include a slowing of the DNA chain elongation reaction via
DNA polymerase or cellular inefficiencies in DNA processing or repair after incorporation.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Azacytidine:

4-Amino-1-β-D-ribofuranosyl-1,3,5-triazin-2(1H)-one
Modification of the pyrimidine ring has also been explored for the development of potential
anticancer drugs based on antimetabolite theory. Several pyrimidine nucleoside analogs have
one more or one less nitrogen in the heterocyclic ring. They are known as azapyrimidine or
deazapyrimidine nucleosides. 5-Azacytidine is an example of a drug in this category. This
compound was developed via organic synthesis and later found as a natural product of fungal
metabolism. The mode of action of this compound is complex involving reversible inhibition
of DNA methyltransferase, and this lack of methylated DNA activates tumor suppressor
genes. In certain tumor systems, it is incorporated into nucleic acids, which may result in
misreading or processing errors.
Purine drugs:
The design of antimetabolites based on purine structure began with isosteric thiol/sulfhydryl
group to replace the 6-hydroxyl group of hypoxanthine and guanine.

Anticancer drugs based on purines and related compounds

Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Mercaptopurine (6-MP):

3,7-dihydropurine-6-thione
One of the early successes was 6-mercaptopurine (6-MP), the thiol analog of hypoxanthine.
This purine requires bioactivation to its ribonucleotide, 6-thioinosinate (6-MPMP), by the
enzyme HGPRT. The resulting nucleotide is a potent inhibitor of an early step in basic purine
biosynthesis, the conversion of 5-phosphoribosylpyrophosphate into 5-phosphoribosylamine.
The ribose diphosphate and triphosphates of 6-mercaptopurine are active enzyme inhibitors,
and the triphosphate can be incorporated into DNA and RNA to inhibit chain elongation.
However, the major antineoplastic action of 6-MP appears to be related to the inhibition of
purine biosynthesis.
Mercaptopurine is used in the treatment of acute lymphatic and myelogenous leukemia. Bone
marrow suppression is the major use-limiting toxicity, although the drug can be hepatotoxic
in high doses. Dosage adjustments should be considered in the face of renal or hepatic
impairment. Since the major mechanism of action of mercaptopurine is inhibition of de novo
purine nucleotide biosynthesis rather than apoptosis secondary to the incorporation of false
nucleotides into DNA, there is a lower risk for mutagenesis and secondary malignancy
compared to thioguanine.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Thioguanine (6-TG):

2-amino-1H-purine-6(7H)-thione
Thioguanine (6-TG) is the 6-mercapto analog of guanine, analogous to 6-MP. Thioguanine is
converted into its ribonucleotide by the same enzyme that acts on 6-mercaptopurine. It is
converted further into the diphosphates and triphosphates. These species inhibit most of the
same enzymes that are inhibited by 6-mercaptopurine. Thioguanine is also incorporated into
RNA, and its 2’-deoxy metabolite is incorporated into DNA. The incorporation into RNA and
DNA and the subsequent disruption of these polymers may account for a greater portion of
the antineoplastic activity of thioguanine compared with 6-MP.
Thioguanine is administered orally in the treatment of nonlymphocytic leukemias.

Azaserine:

O-(2-Diazoacetyl)-L-serine
Azaserine is a naturally occurring serine derivative diazo compound with antineoplastic and
antibiotic properties deriving from its action as a purinergic antagonist and structural
similarity to glutamine. Azazerine acts by competitively inhibiting glutamine
amidotransferase, a key enzyme responsible for glutamine metabolism.
Folates:
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Folic acid and the structure of the major antifolate anticancer drug is shown in Figure.
Methotrexate is the classic antimetabolite of folic acid structurally derived by N-methylation
of the para-aminobenzoic acid residue (PABA) and replacement of a pteridine hydroxyl by
the bioisosteric amino group. The conversion of MOH to MNH2 increases the basicity of N-3
and yields greater enzyme affinity. This drug competitively inhibits the binding of the
substrate folic acid to the enzyme DHFR, resulting in reductions in the synthesis of nucleic
acid bases, perhaps most importantly, the conversion of uridylate to thymidylate as catalyzed
by thymidylate synthetase. In addition, purine synthesis is inhibited because the N-10-formyl
tetrahydrofolic acid is a formyl donor involved in purine synthesis. THFs are cofactors in at
least two key steps in the normal biosynthesis of purines. Methotrexate is a broad-spectrum
antineoplastic agent commonly used in the treatment of acute lymphoblastic and myeloblastic
leukemia and other lymphomas and sarcomas. The major side effects seen are bone marrow
suppression, pulmonary fibrosis, and GI ulceration. Leucovorin is often given 6 to 24 hours
after methotrexate to prevent the longterm effects on normal cells by preventing the
inhibition of DNA synthesis. Related to this is Pemetrexed, but its scope is greater in that it
not only inhibits DHFR but also TS and glycinamide ribonucleotide formyltransferase
(GARFT), which is involved in purine biosynthesis. The material is taken into tumor cells by
the reduced folate carrier systems and subsequently converted to the polyglutamate, which is
retained in the cell.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Methotrexate:

(2S)-2-[(4-{[(2,4-Diaminopteridin-6-
yl)methyl](methyl)amino}benzoyl)amino]pentanedioic acid

Methotrexate is a folic acid antagonist structurally designed to compete successfully with 7,8-
DHF for the DHFR enzyme. The direct inhibition of DHFR causes cellular levels of 7,8-DHF
to build up, which in turn results in feedback (indirect) inhibition of thymidylate synthase.
The DHFR enzyme will be pseudoirreversibly bound to a molecule it cannot reduce, which
ties up the DHFR enzyme and prevents the conversion of DHF to THF. In turn, this halts the
synthesis of the 5,10-methylene-THF cofactor required for dTMP biosynthesis and causes
feedback inhibition of the thymidylate synthase enzyme. The cell will die a “thymineless
death.” Methotrexate is given orally in the treatment of breast, head and neck, and various
lung cancers as well as in NHL. Methotrexate undergoes intracellular polyglutamation, which
adds several anionic carboxylate groups to the molecule and traps the drug at the site of
action. Polyglutamation is more efficient in tumor cells than in healthy cells, which promotes
the selective toxicity of this drug. If severe methotrexate toxicity occurs, reduced folate
replacement therapy with 5-formyltetrahydrofolate (leucovorin) must be initiated as soon as
possible. Leucovorin generates the folate cofactors needed by DHFR and GAR
transformylase to ensure the continued synthesis of pyrimidine and purine nucleotides in
healthy cells. “Leucovorin rescue” therapy is often given as prophylaxis after high-dose
methotrexate therapy.

Cancer cells can become resistant to methotrexate over time. Acquired resistance
mechanisms include increased DHFR expression, impaired transport, active cellular efflux,
and/or attenuated intracellular polyglutamation.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Pralatrexate:

N-(4-{1-[(2,4-diaminopteridin-6-yl)methyl]but-3-yn-1-yl}benzoyl)-L-glutamic acid

The only structural difference between pralatrexate and methotrexate is in the area of N10 ;
pralatrexate is a 10-deaza analog where the carbon atom replacing N10 has been substituted
with a triple bond-containing propargyl group. This structural alteration results in a signifi
cantly enhanced tumor cell uptake. This translates to more active drug inside the tumor cell
for a longer period of time. Pralatrexate is excreted intact in the urine. pralatrexate’s primary
antineoplastic enzymatic target is DHFR. In addition to T-cell lymphoma, pralatrexate might
eventually find use in the treatment of non-small cell lung cancer and, in combination with
the DNA polymerase inhibitor gemcitabine, in NHL.

Antibiotics and Natural Products

A variety of the anticancer agents available today are derived from natural sources with
several of these being obtained from microbial sources (antibiotics). Many of the
antineoplastic antibiotics are produced by the soil fungus Streptomyces. Both the antibiotic
and natural product classes have multiple inhibitory effects on cell growth; however, they
primarily act to disrupt DNA function and cell division.

There are several mechanisms by which these agents target DNA, including intercalation,
alkylation, and strand breakage either directly or as a result of enzyme inhibition.
Intercalation is a process by which a planar molecule of the appropriate size inserts itself
between adjacent base pairs of DNA and in so doing, it causes a local unwinding that may
disrupt the normal template function of DNA. Intercalation requires that the drug induce a
cavity between base pairs so that insertion may occur. The interaction of the intercalator and
the adjacent base pairs occurs by the overlap of p-orbitals of the intercalator and the base
pairs. The p-orbitals of the intercalation species are provided by a combination of aromatic
and conjugated systems that impart the planarity required for intercalation. The drug–DNA
interaction is further stabilized by side chains attached to the intercalation species. The side
chains often include a cationic moiety, which may form ionic bonds with the anionic
phosphate backbone. Alternative modes of stabilization may occur through a combination of
van der Waals interaction or hydrogen bonds. The overall result of these interactions is to
cause a local bend or kink in DNA resulting in a local shape distortion. This may produce
several effects but is often associated with inhibition of normal DNA function. By virtue of
their ability to induce bends or kinks in DNA, intercalators may also result in inhibition of
topoisomerase enzymes. In order for the cell to store the nearly 2 m of DNA that it contains,
it is necessary to fold the genetic material into a more compact form and in the process, knots
and tangles are produced. Topoisomerase enzymes are responsible for the unwinding and
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

relaxation of DNA so that transcription may occur. There are two major types of
topoisomerase enzymes, which are important sites of action for antineoplastics.
Topoisomerase I makes a single-strand break in DNA and subsequently allows the other
strand to spin, relieving any tension associated with the packing process and subsequently
reseals the broken strand. Topoisomerase II makes double-strand breaks in DNA allowing an
intact chain to pass through and then subsequently reseals the double-strand break. In this
way, it can relieve the knotting that occurs upon folding of the DNA. Both enzymes are
believed to recognize sequences of DNA, bind and function by formation of a transient
phosphodiester bond between the DNA strand and a tyrosine residue present on the protein.
There are several natural products that are capable of disrupting the formation and function of
the mitotic spindle. These include the epipodophyllotoxins, the taxanes, and the vinca
alkaloids. The mitotic spindle forms during the M phase of the cell cycle and is responsible
for moving the replicated DNA to opposite ends of the cell in preparation for cell division.

Actinomycins: The actinomycins are a group of compounds that are isolated from various
species of Streptomyces, all of which contain the same phenoxazone chromophore but differ
in the attached peptide portion. From this group emerged actinomycin D, which is known as
dactinomycin and contains identical pentapeptides.

Dactinomycin binds noncovalently to double-stranded DNA by partial intercalation between

adjacent guaninecytosine bases resulting in inhibition of DNA function. Dactinomycin has
two pentapeptide lactones attached to an aromatic (and, therefore, flat) actinocin (or
phenoxazinone) structure. It is capable of intercalating DNA and binds preferably between
guanine and cytosine residues on a single DNA strand. This interaction results in DNA
elongation and distortion, commonly referred to as a point mutation.The structural feature of
dactinomycin important for its mechanism of cytotoxicity is the planar phenoxazone ring,
which facilitates intercalation between DNA base pairs. The peptide loops are located within
the minor groove and provide for additional interactions. Additional hydrophobic interactions
and hydrogen bonds are proposed to form between the peptide loops and the sugars and base
pairs within the minor groove. In all, actinomycin D spans four to five DNA base pairs. This
results in high affinity with the molecule only slowly dissociating from DNA. Additional
modes of binding are also possible for the molecule. The primary effect of this interaction is
the inhibition of DNA-directed RNA synthesis and specifically RNA polymerase. DNA
synthesis may also be inhibited, and the agent is considered cell cycle specific for the G1
and S phases. It has been suggested that binding to single-stranded DNA may occur as the
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

strands separate during transcription, and this may be responsible for the inhibition of RNA
polymerase. Resistance is caused by a decreased ability of tumor cells to take up the drug and
P-glycoprotein (Pgp)-mediated efflux.

Use: Dactinomycin is used for the treatment of various solid tumors and muscle-related
cancers. It induces severe side effects, and nausea and vomiting can be use-limiting.
Myelosuppression is also common and, most often, is the dose-limiting toxic effect.

Anthracyclines:
The anthracycline antibiotics are characterized by a planar oxidized anthracene nucleus
fused to a cyclohexane ring that is subsequently connected via a glycosidic linkage to an
amino sugar. They were isolated from Streptomyces peucetius, hundreds of compounds
belonging to this class have subsequently been discovered of which five are used clinically in
the United States (doxorubicin, daunorubicin, idarubicin, epirubicin, and valrubicin). The
conjugated systems found in these molecules impart a red color, which is reflected in the
name. The accepted mechanism involves intercalation followed by inhibition of
topoisomerase II resulting in strand breakage leading to apoptosis. The anthracyclines are
considered specific for the S phase of the cell cycle. They allow DNA to be cut and
covalently linked to the conserved topoisomerase Tyr residue but inhibit the resealing
reaction. The flat, aromatic portion of the anthracyclinone ring system and the
daunosamine sugar bind to DNA, whereas the anthracyclinone A ring is believed to bridge
the gap between DNA and enzyme. Since a small number of anthracycline-induced DNA
breaks can result in a high level of cell death, it has been hypothesized that the site of DNA
cleavage, which contains an essential thymine-adenine (T-A) dinucleotide, is particularly
lethal to the cell.
(1) Doxorubicin:

Doxorubicin

The C13 substituent of doxorubicin is hydroxymethyl, which retards the action of cytosolic
aldoketoreductase and slows the conversion to the less active and chronically cardiotoxic
doxorubicinol. This contributes to the longer duration of action compared to analogs that
have CH3 at this position (e.g., daunorubicin). Doxorubicin is highly lipophilic and
concentrates in the liver, lymph nodes, muscle, bone marrow, fat, and skin. Doxorubicin is
used either alone or in combination therapy to treat a wide range of neoplastic disorders,
including hematologic cancers and solid tumors in breast, ovary, stomach, bladder, and
thyroid gland. The toxicities associated with doxorubicin include doselimiting cardiotoxicity
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

and myelosuppression. Most patients will experience alopecia and nausea. Cardiotoxicity
(due to free radical generation) is a limiting factor in the administration of doxorubicin,
which, in its most severe form, may progress to CHF.

(2) Daunorubicin:

The absence of the OH group at C14 in daunorubicin results in a faster conversion to the less
active and chronically cardiotoxic C13-ol metabolite (daunorubicinol) compared to
hydroxymethyl-substituted anthracyclines like doxorubicin. Daunorubicin is administered
intravenously at a dose of 45 mg/m2 for the treatment of lymphocytic and nonlymphocytic
leukemia.

Bleomycin (Structure not required)

Bleomycin is a glycopeptide antibiotic complex isolated from Streptomyces verticillus. The

clinically used product is a mixture of predominantly A2 (55%–70%) and B2 (25%–32%)
fractions. Of these fractions, A2 appears to possess the greatest antineoplastic activity.
Copper is found in the naturally occurring material, and its removal is important for the
material used clinically because it significantly reduces activity. Bleomycin binds Fe+2
through multiple interactions with the amino terminal end of the peptide chain. Bleomycin
may itself initiate the release of iron necessary for this complexation. Interaction with DNA
subsequently occurs through the bithiazole portion of the molecule, which intercalates
between G-C base pairs with a preference for genes undergoing transcription. Held in
proximity to DNA by this interaction, in an aerobic environment, Fe+2 is oxidized to Fe+3 in a
one-electron process with the electron being transferred to molecular oxygen. The agent is
most active in the G2 and M phases of the cell cycle. Through DNA intercalation, the
aromatic bithiazole ring system positions bleomycin for DNA destruction via cytotoxic free
radicals. The disaccharide, polyamine, imidazole, and pyrimidine structures are very electron
rich and readily chelate intracellular Fe2+. Once chelated, Fe2+ is oxidized to Fe3+ with a
concomitant reduction of bound oxygen. The ferric hydroperoxide bleomycin complex is
considered the cytotoxic form. Bleomycin is notable for its lack of myelotoxicity, and this
allows it to be combined with other myelosuppressants without a resulting additive effect.
The acute toxicities seen with bleomycin are erythema (reddening of the skin),
hyperpigmentation (skin darkening) found predominately on the extremities, and pulmonary
toxicity. The pulmonary toxicity may first occur as pneumonitis (inflammation of lung
tissue), which normally responds to glucocorticosteroid therapy. Chronic pulmonary toxicity
is expressed as pulmonary fibrosis, which is irreversible and limits utility of the agent. The
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

toxicity profile of bleomycin is explained by its route of inactivation. Hydrolysis of the N-

terminal amide to the carboxylic acid increase the pKa of the amine at C-2 from 7.3 to 9.4,
resulting in a greater degree of ionization and decreased binding to DNA. The enzyme
responsible for this conversion is known as bleomycin hydrolase, and it is present in most
tissue but found in low concentration in skin and lung tissue. Tumor cells that are resistant to
bleomycin may contain high levels of this enzyme. Uses include treatment of Hodgkin's
lymphoma, non-Hodgkin's lymphoma, testicular cancer, ovarian cancer, and cervical cancer
among others.

Vinca Alkaloids: Vincristine and Vinblastine: (No structures required)

The vinca alkaloids are extracted from the leaves of Catharanthus roseus (periwinkle), and
were originally investigated for their hypoglycemic properties but latter found to possess
antineoplastic actions. The alkaloids are composed of a catharanthine moiety containing the
indole subunit and the vindoline moiety containing the dihydroindole subunit joined by a
carbon–carbon bond. Vincristine and vinblastine differ only in the group attached to the
dihydroindole nitrogen, which is a methyl group in vinblastine and a formyl group in
vincristine. They have a potent antimitotic activity. Once in the cell, the vincas bind to
tubulin, disrupting formation and function of the mitotic spindle. They bind at the interface of
two heterodimers within the inner tubular lumen at a single high-affinity site on β-tubulin in
the vicinity of the guanosine triphosphate binding site on the (+) end of the tubules. Once
bound, these alkaloids attenuate the uptake of the guanosine triphosphate essential to tubule
elongation. Simultaneous binding to α- and β-tubulin results in protein cross-linking, The
agents are considered specific for the M phase of the cell cycle. Microtubules also play
important roles in axons or nerve fibers, and disruption of this function is thought to be
responsible for the neuropathies seen with this group of compounds. Vincristine binds most
tightly, whereas vinblastine has the lowest affinity. Vincristine is given by the intravenous
bolus or continuous infusion routes in the treatment of acute leukemia and various Hodgkin’s
lymphomas and NHLs. In addition to the hematologic indications that it shares with
vincristine, vinblastine has found utility in the treatment of advanced testicular carcinoma
(often in combination with bleomycin), advanced mycosis fungoides, Kaposi sarcoma, and
histiocytosis X.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Taxanes:

The taxanes, specifically, taxol (or paclitaxel) was discovered in the 1960s as part of a large-
scale screening program conducted by the National Cancer Institute on plant extracts. Taxol
isolated from the bark of the pacific yew tree Taxus brevifolia, proved to be active against
various cancer models. Now it is produced semisynthetically from an inactive natural
precursor (10-deactetylbaccatin III) found in the leaves of the European yew (Taxus baccata),
a renewable resource. Chemically, diterpenoid taxanes consist of a 15-membered tricyclic
taxane ring system (tricyclo[9.3.1.0]pentadecane) fused to an oxetane (D) ring and contain an
esterifi ed β-phenylisoserine side chain at C13.Taxanes bind to polymerized (elongated) β-
tubulin at a specific hydrophobic receptor site comprised of the 31 N-terminal residues
located deep within the tubular lumen. At standard therapeutic doses, taxane-tubulin binding
promotes a stable tubulin conformation similar to that of the guanosine triphosphate-bound
protein, which renders the microtubules resistant to depoly-merization and prone to
polymerization. This promotes the elongation phase of microtubule dynamic instability at the
expense of the shortening phase and inhibits the disassembly of the tubule into the mitotic
spindle. In turn, this interrupts the normal process of cell division. At these concentrations,
extensive polymerization causes the formation of large and dense aberrant structures known
as asters, which contain stabilized microtubule bundles. CYP2C8 bioconverts paclitaxel to
6α-hydroxypaclitaxel, the major metabolite, which is 30-fold less active than the parent
structure. CYP3A4 mediates the formation of additional minor p-hydroxylated metabolites of
the benzamido and benzoyl moieties at C3′ and C2′ respectively, and the 10-desacetyl
metabolite has been documented in urine and plasma.

Paclitaxel: (structure not required)

“The bestselling anticancer drug in history”, Paclitaxel is indicated for intravenous use in
combination with cisplatin as fi rst-line therapy for advanced ovarian and non-small cell lung
cancer. It is also used alone or in combination with the fluorouracil prodrug capecitabine in
anthracycline-resistant metastatic breast cancer. The major toxicity seen with paclitaxel is a
dose-limiting myelosuppression that normally presents as neutropenia. Paclitaxel is a
Category D teratogen and carries a high risk of fetal intrauterine mortality.

Docetaxel:

Indications are similar to Paclitaxel except that docetaxel is not used in ovarian cancer. It has
also been utilized in non–FDA-approved treatment of head, neck, gastric, bladder, and
refractory ovarian cancers.

Camptothecins: The camptothecins are inhibitors of topoisomerase I and are used clinically
for the treatment of various cancers isolated from Camptotheca acuminata, an ornamental
tree found in China.

Topotecan:

This active camptothecin analog is used by the intravenous route in the treatment of ovarian
and small cell lung cancer that has not responded to fi rst-line therapy. Myelosuppression,
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

particularly neutropenia, is use-limiting and has precluded combination therapy with other
bone marrow-suppressing drugs.

Irinotecan:

It is used in combination with 5-FU and leucovorin as first-line treatment of metastatic colon
cancer. The agent may also be used as a single agent in colorectal cancer as a second-line
therapy when 5-FU therapy has failed. Additional uses include small cell lung cancer,
NSCLC, cervical cancer, esophageal cancer, and gastric cancer. Given intravenously, the
drug is slowly bioactivated in the liver through hydrolysis of the C10-carbamate ester. The
catalyzing enzyme is a saturable carboxylesterase known as irinotecan-converting enzyme.

Histone Deacetylase inhibitors:

Histones are proteins around which DNA is wound in the process of packing DNA into the
nucleus. They also have a role in regulating the transcription of genes, and this is controlled
by the covalent modifications acetylation, phosphorylation, and methylation to which they
are subject. The specific modifications present on the histones or histone code has been
proposed to determine which transcription factors associate with specific genes and result in
their replication. Acetylation occurs at the -amino group of lysine and is accomplished by
histone acetyltransferase enzymes, whereas deacetylation is accomplished by histone
deacetylase enzymes. The result of inhibition of histone deacetylase is hyperacetylation of
lysine residues of the histone proteins. The positively charged -amino groups of the lysine
residues are believed to interact with the negatively charged phosphate backbone of DNA.
Once acetylation has occurred, this interaction is prevented, and the binding of transcription
factors is favored. Therefore, the inhibition of deacetylation by vorinostat, a histone
deacetylase inhibitor (HDACis), results in the increased transcription of certain genes.
Specifically, this has been associated with upregulation of a regulatory protein known as p21,
which serves to inhibit progression past the G1 phase of the cell cycle. Other genes and their
proteins are also effected by vorionostat such as Hsp90 (heat shock protein 90) and BCL6.

Pharmacophore for Histone Deacetylase Inhibitors

Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

(1) Romidepsin:

Romidepsin, is an anticancer agent used in cutaneous T-cell lymphoma (CTCL) and other
peripheral T-cell lymphomas (PTCLs). Romidepsin is a natural product obtained from the
bacterium Chromobacterium violaceum, and works by blocking enzymes known as histone
deacetylases, thus inducing apoptosis. Romidepsin is a depsipeptide histone deacetylase
inhibitor that induces a caspase-dependent apoptosis and retains efficacy in cells
overexpressing the prosurvival protein Bcl-2.

(2) Vorinostat:

N-Hydroxy-N'-phenyloctanediamide

Vorinostat fits the basic pharmacophore for the HDACis, which consists of a hydrophobic
cap region connected to a zinc coordinating functionality by a hydrophobic linker. The
hydroxamic acid functionality is capable of bidendate binding to zinc present in the enzyme
and is a major factor in the overall binding of the compound. Vorinostat's inhibition of
histone deacetylases results in the accumulation of acetylated histones and acetylated
proteins, including transcription factors crucial for the expression of genes needed to induce
cell differentiation. It is used for the treatment of cutaneous manifestations in patients with
cutaneous T cell lymphoma (CTCL) when the disease persists, gets worse, or comes back
during or after two systemic therapies.

Tyrosine Kinase Inhibitors: Aberrations in the activity of protein tyrosine kinases (TKs) are
associated with several neoplastic disorders, and it has been estimated that more that 80% of
human oncogenes and proto-oncogenes direct the expression of these essential
phosphorylating enzymes. When functioning normally, TKs regulate cell proliferation,
differentiation, and survival. When functioning in a deregulated manner, they accelerate cell
signaling cascades and cellular growth, induce tumors, augment antiapoptotic processes, and,
in so doing, confer resistance to many chemotherapeutic drugs. TKs are of two general types,
receptor-associated and cellular (nonreceptor), both of which are ATP-dependent. TKs that
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

serve as targets for anticancer TKIs include EGFR, VEGFR, human epidermal growth factor
receptor 2 (HER2), platelet-derived growth factor receptor (PDGFR), Bcr-Abl (a product of
the translocated breakpoint cluster [BCR]-Abelson [ABL] gene known as the Philadelphia, or
Ph, chromosome), and Src. Bcr-Abl and Src are nonreceptor kinases, whereas the remaining
are receptor-associated enzymes. Type 1 inhibitors bind to the active conformation of the
kinase, whereas type 2 TKIs inhibit the enzyme in its inactive conformation. Since the
inactive conformation of TKs differs in structure to a greater degree than the active
conformer, it has been proposed that type 2 inhibitors may have a better opportunity for
selectivity. Promiscuous TKIs inhibit several kinase enzymes and are referred to as
“multikinase inhibitors.”

Bcr-Abl Inhibitors: Imatinib, Nilotinib, and Dasatinib

Imatinib:

4-[(4-methylpiperazin-1-yl)methyl]-N-(4-methyl-3-{[4-(pyridin-3-yl)pyrimidin-2-
yl]amino}phenyl)benzamide

Imatinib is a chemotherapy medication used to treat cancer. Specifically, it is used for chronic
myelogenous leukemia (CML) and acute lymphocytic leukemia (ALL) that is Philadelphia
chromosome-positive (Ph+) and certain types of gastrointestinal stromal tumors (GIST),
systemic mastocytosis, and myelodysplastic syndrome. Imatinib is a 2-phenyl amino
pyrimidine derivative that functions as a specific inhibitor of a number of tyrosine kinase
enzymes. It occupies the TK active site, leading to a decrease in activity. The active sites of
tyrosine kinases each have a binding site for ATP. The enzymatic activity catalyzed by a
tyrosine kinase is the transfer of the terminal phosphate from ATP to tyrosine residues on its
substrates, a process known as protein tyrosine phosphorylation. Imatinib works by binding
close to the ATP binding site of bcr-abl, locking it in a closed or self-inhibited conformation,
and therefore inhibiting the enzyme activity of the protein semi-competitively. The agent is
highly protein bound and metabolized to the N-desmethyl derivative by CYP3A4-mediated
removal of the piperazinyl methyl group. The resulting metabolite is similar to the parent in
activity.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Dasatinib:

N-(2-chloro-6-methylphenyl)-2-[[6-[4-(2-hydroxyethyl)- 1-piperazinyl]-2-methyl-4-
pyrimidinyl]amino]-5-thiazole carboxamide

Because it can bind to both the active and inactive conformations of Bcr-Abl kinase,
dasatinib has a potency approximately 325 times that of imatinib, and it can be used in
patients resistant to imatinib or nilotinib. Dasatinib is used in the treatment of CML and ALL
that are Ph1 positive

EGFR and EGFR/HER2 Inhibitors:

EGFR and HER2 are closely related membrane-bound TKs. EGFR expression in solid
tumors of the breast, lung, bladder, esophagus, and oral cavity hasbeen clearly correlated with
decreased life expectancy, and it is a consistent presence in almost all epithelial-derived
cancers. Likewise, HER2 overexpression is a classic feature of treatment-resistant breast,
ovarian, lung, and gastric cancers, and it endows tumors with what’s been called an
“antiapoptotic shield”. The currently marketed reversible EGFR TKIs all contain a 4-
anilinoquinazoline pharmacophore with an oxygen-containing substituent at C6.

Lapatininb:

N-[3-Chloro-4-[(3-fluorophenyl)methoxy]phenyl]-6-[5-[(2-
methylsulfonylethylamino)methyl]-2-furyl] quinazolin-4-amine

Lapatinib inhibits receptor signal processes by binding to the ATP-binding pocket of the
EGFR/HER2 protein kinase domain, preventing self-phosphorylation and subsequent
activation of the signal mechanism. Lapatinib is and is used in combination with cabecitabine
in the treatment of breast cancer for those patients that over express the type 2 EGF-R and
who have previously received taxane, anthracycline, and trastuzumab therapy. The most
commonly seen adverse effects of lapatinib therapy are skin rash and diarrhea.
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Chemotherapy:

Chemotherapy (also called chemo) is a type of cancer treatment that uses drugs to destroy
cancer cells.

Chemotherapy works by stopping or slowing the growth of cancer cells, which grow and
divide quickly. But it can also harm healthy cells that divide quickly, such as those that line
your mouth and intestines or cause your hair to grow. Damage to healthy cells may cause side
effects. Often, side effects get better or go away after chemotherapy is over.

Depending on your type of cancer and how advanced it is, chemotherapy can:

 Cure cancer - when chemotherapy destroys cancer cells to the point that your doctor
can no longer detect them in your body and they will not grow back.

 Control cancer - when chemotherapy keeps cancer from spreading, slows its growth,
or destroys cancer cells that have spread to other parts of your body.

 Ease cancer symptoms (also called palliative care) - when chemotherapy shrinks
tumors that are causing pain or pressure.

Sometimes, chemotherapy is used as the only cancer treatment. But more often, you will get
chemotherapy along with surgery, radiation therapy, or biological therapy. Chemotherapy
can:

 Make a tumor smaller before surgery or radiation therapy. This is called neo-adjuvant
chemotherapy.

 Destroy cancer cells that may remain after surgery or radiation therapy. This is called
adjuvant chemotherapy.

 Help radiation therapy and biological therapy work better.

 Destroy cancer cells that have come back (recurrent cancer) or spread to other parts of
your body (metastatic cancer).

The choice of drug depends on:

 The type of cancer you have. Some types of chemotherapy drugs are used for many
types of cancer. Other drugs are used for just one or two types of cancer.

 Whether you have had chemotherapy before

 Whether you have other health problems, such as diabetes or heart disease

Combination Therapy for Breast Cancer:

There are a number of tried-and-true chemotherapy regimens used to treat breast cancer,
including:
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

 AC: Adriamycin and Cytoxan

 AT: Adriamycin and Taxotere

 CMF: Cytoxan, methotrexate, and fluorouracil

 FAC: fluorouracil, Adriamycin, and Cytoxan

 CAF: Cytoxan, Adriamycin, and fluorouracil

(The FAC and CAF regimens use the same medicines but use different doses and
frequencies)

Only one medicine may be recommended at a time such as Adriamycin or another

anthracycline, or a taxane (Taxotere, Taxol, or Abraxane).

Several important factors to be considered foe deciding on a chemotherapy regimen:

 The characteristics of the cancer. The cancer's stage, hormone-receptor status, HER2
status, and lymph node status will influence the chemotherapy regimen.

 Menopausal status and general health. If you have heart problems, high blood
pressure, or another condition for which you're being treated, this will likely affect the
chemotherapy medicines that will work best for you. Chemotherapy is effective for
people of all ages -- your age shouldn't stop you from being offered chemotherapy.

It's important to remember that while there are many standard chemotherapy regimens, each
person's treatment plan will be unique because each cancer is unique. Doctors have
developed and tested effective treatment plans of different lengths and dosages using
different medicines.

Most short-term chemotherapy side effects can be managed with lifestyle changes and
medicines that can help reduce nausea, fatigue, and the risk of infection.

After reviewing all the options, chemotherapy regimen, dosage, and length of time to
receiveis decided. Ideal chemotherapy regimen will:

 attack all the different kinds of cells in the cancer

 use medicines that work together (if you're getting combination therapy), without
overlapping benefits or side effects

 work in a way that keeps the cancer cells from figuring out how to protect themselves

 balance the benefits you'll get from the medicine with any possible side effects
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

Chemotherapy for Leukaemia:

Chemo for acute lymphocytic leukemia (ALL) uses a combination of anti-cancer drugs. They
are given in 3 phases, usually over the course of about 2 years (see “ Typical treatment of
acute lymphocytic leukemia”).
The most commonly used drugs include:
 Vincristine (Oncovin®) or liposomal vincristine (Marqibo ®)
 Daunorubicin (daunomycin or Cerubidine®) or doxorubicin (Adriamycin®)
 Cytarabine (cytosine arabinoside, ara-C, or Cytosar®)

 L-asparaginase (Elspar®) or PEG-L-asparaginase (pegaspargase or Oncaspar®)

 Etoposide (VP-16)
 Teniposide (Vumon®)
 6-mercaptopurine (6-MP or Purinethol®)
 Methotrexate
 Cyclophosphamide (Cytoxan®)

 Prednisone
 Dexamethasone (Decadron®)
People typically get several of these drugs at different times during the course of treatment,
but they do not get all of them.

Possible side effects:

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer
cells. But other cells in the body, such as those in the bone marrow (where new blood cells
are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly.
These cells are also likely to be affected by chemo, which can lead to side effects.
The side effects of chemo depend on the type and dose of drugs given and the length of time
they are taken. Common side effects may include:
 Hair loss
 Mouth sores
 Loss of appetite
 Nausea and vomiting

 Diarrhea
 Increased risk of infections (due to low white blood cell counts)
 Easy bruising or bleeding (due to low blood platelet counts)
Dr. (Mrs). Nutan Rao Oriental College of Pharmacy Sem VII-CBSGS

 Fatigue (due to low red blood cell counts)

 Numbness, tingling, or weakness in hands or feet (from nerve damage)
These side effects are usually short-term and go away once treatment is finished. There are
often ways to lessen these side effects. For example, drugs can be given to help prevent or
reduce nausea and vomiting. Be sure to ask your doctor or nurse about medicines to help
reduce side effects, and let him or her know when you do have side effects so they can be
managed effectively.
Many of the side effects of chemo are caused by low white blood cell counts. Drugs known
as growth factors (G-CSF and GM-CSF, for example) may be given to speed the recovery of
white blood cell counts during chemo to reduce the chance for serious infections.

Antibiotics and drugs that help prevent fungal and viral infections may be given before there
are signs of infection or at the earliest sign that an infection may be developing. There are
also steps that you can take to lower your risk of infection. Because white blood cell counts
are so important during treatment, some people find it helpful to keep track of them. If you
are interested in this, ask your doctor or nurse about your blood cell counts and what these
numbers mean. If your platelet counts are low, you may be given drugs or platelet
transfusions to help protect against bleeding. Likewise, shortness of breath and extreme
fatigue caused by low red blood cell counts may be treated with drugs or with red blood cell
transfusions. Certain drugs might cause specific side effects. For example, cytarabine (ara-C)
can cause certain problems, especially when used at high doses. These can include dryness in
the eyes and effects on certain parts of the brain, which can lead to problems with
coordination and balance.
Other organs that could be directly damaged by certain chemo drugs include the kidneys,
liver, testicles, ovaries, brain, heart, and lungs. Doctors and nurses carefully monitor
treatment to reduce the risk of these side effects as much as possible. If serious side effects
occur, the chemo may have to be reduced or stopped, at least for a time.
One of the most serious side effects of ALL therapy is an increased risk of getting acute
myelogenous leukemia (AML) at a later time. This occurs in a small portion of patients after
they have received chemo drugs such as etoposide, teniposide, cyclophosphamide, or
chlorambucil. Less often, people cured of leukemia may later develop non-Hodgkin
lymphoma or other cancers. Of course, the risk of getting these second cancers must be
balanced against the obvious benefit of treating a life-threatening disease such as leukemia
with chemotherapy.
Tumor lysis syndrome is another possible side effect of chemo. It is most common in patients
who have large numbers of leukemia cells, so it is seen most often in people getting chemo
for the first time. When chemo kills these cells, they break open and release their contents
into the bloodstream. This can overwhelm the kidneys, which aren’t able to get rid of all of
these substances at once. Excess amounts of certain minerals may also affect the heart and
nervous system. This can often be prevented by giving extra fluids during treatment and by
giving certain drugs, such as allopurinol and rasburicase, which help the body get rid of these
substances.