MT5008/MT5014/BT5010 : Mechanisms of disease and principles of chemotherapy

Lecture II- Anticancer drugs

Reading: Rang and Dales Pharmacology 6th Edition Chapter 51 pp 718-735

Aims of lecture

Describe the classes of anticancer drugs

major categories

Outline the mechanism of drug action Describe the side effects and toxicity of drugs Discuss treatment regimens

Aim of chemotherapy

To produce maximum tumour cell kill with any one treatment

aggressive therapy (clinical outcome vs side-effects) Problem: tumour consists of cells in 3 different states of growth
A)

cycling cells B) cells in G0 C) cells no longer dividing (but contribute to tumour volume)

cells can re-enter cell cycle (B to A)

growth

factors (tumour micro-environment)

Importance of tumour growth kinetics

variable proportion of tumour divides at any one time

lymphoma

~90%; carcinoma (solid) ~5-20%

Anticancer drugs

Most anti-cancer drugs are anti-proliferative

only affect cell division

preferentially

affect dividing cells will affect non-dividing cells (less efficiently)

Generally, most anti-cancer drugs

no effect on invasive potential of tumour or tendency to metastasise do affect normal dividing cells (side-effects)
nausea

& vomiting bone marrow toxicity

anaemia susceptibility to infection

Chemotherapy

Use of drugs to treat disease

cancer, infection lack of biochemical differences between cancerous and normal human cells mainly very toxic compounds (side-effects) testicular cancer 60-70% of patients need some chemotherapy as part of treatment of their disease surgery or irradiation
adjuvant

Rarely main method of treatment

Commonly given as adjunct (in combination with)

(after surgery/irradiation to prevent relapse) neoadjuvant (prior to surgery/irradiation to improve outcome)

Cancers where drug therapy is important

Hodgkins disease Non Hodgkins lymphoma Chronic granulocytic leukaemia Acute lymphocytic leukaemia Hairy cell leukaemia Germ cell cancers

Testes, ovary

Prostate cancer Choriocarcinoma

Major classes of cytotoxic drugs

Alkylating agents

covalently bind to DNA and prevent replication

prevent the synthesis of DNA precursors prevent cell division

Antimetabolites

Cytotoxic antibiotics

Vinca alkyloids and related compounds

mitotic spindle poisons

steroids

Hormones

Three major groups of conventional cytotoxic drugs

Drugs that

target DNA directly

Alkylating

agents

Generate free radicals Damage DNA No cell cycle specificity

interfere with DNA synthesis

Antimetabolites

Depletes cells of intermediates required for DNA synthesis

interfere with mitotic spindles

Vinca

alkyloids and taxanes

Modify or bind to tubulin

Sites of action

from: Rang, Dale, Ritter & Flower, p723

Cell cycle specific/non specific drugs

Cell Cycle Specific (CCS)

drugs will only act on cells in a specific phase of cell cycle

eg

mitosis - vinca alkyloids

dividing cells only

Cell Cycle Non Specific (CCNS)

drugs can act on cell regardless of their position in the cell cycle dividing and non dividing cells

Mechanism of action - CCS

Block cell division

At checkpoints
G1-S;
M

S-G2 phase (antimetabolites)

analogues of cell building blocks

phase (vinca alkyloids) RNA, enzymes, structural proteins

Inhibit synthesis
DNA,

Inhibit mitosis

Effective against cancers composed of frequently dividing cells

Cancers of blood and lymphatic cells

Mechanism of action - CCNS

Inhibit function of DNA in cell

Not dependent on cell cycle Prevent synthesis of DNA, RNA and proteins necessary for cell survival Prevent synthesis of components required for cell division

Effective against cancers composed of frequently and infrequently dividing cells

solid tumours, colon, breast, lung

Alkylating agents

Nitrogen mustards

related to sulphur mustard (World War I) cyclophosphamide (pro-drug)

phosphoramide

mustard

chlorambucil, melphalan lomustine, carmustine

Nitrosoureas

Busulphan Cisplatin Dacarbazine (pro-drug)

activated in liver, cleaved in target cell

Alkylating agents site of action

From: Rang & Dale, p724

Biological effects of DNA alkylation

DNA structure changed

non functional
monofunctional alkylation
Base-pair

Replication of new DNA inhibited

mutation during replication strand scission and chromosome breaks

Interstrand alkylation

bifunctional alkylation
cross

linking

Alkylating agents

CCNS Alkylate DNA

transfer an alkyl moiety from drug to target

ethyl

group transferred from drug to DNA

Irreversible effect

new DNA must be synthesised

Nitrogen Mustards - eg Mustine

Substituted diethylamine Bifunctional alkylating agent

CH2-CH2-Cl
H3C-N CH2-CH2-Cl

2 highly reactive chloroethyl chains chlorine lost spontaneously positively charged carbonium ions electrophiles react with nucleophiles
O

Also melphalan, chlorambucil and cyclophosphamide

and N of DNA bases

Nitrosoureas

Single chloroethyl chain attached to a N of nitrosourea Loss of Cl -carbonium ion More lipophilic

EG Carmustine (BCNU) Lomustine (CCNU)

better access to CNS Can cross blood brain barrier (BBB)

Severe bone marrow depression

Other alkylating agents

Methane sulphonate busulphan Activated to give 2 electrophilic sulphonium ions

Triazene - dacarbazine (DTIC)

prodrug

Activated to electrophilic carbonium ion by Ndemethylation (P450)

Cisplatin

CCNS Inhibits DNA synthesis Cl dissociates leaving an electrophilic diamine-Pt Alkylates N7 and O6 of guanine

NH3
NH3 Pt Cl

Cl

intrastrand crosslinks DNA strand breaks between guanine and cytosine

Nephrotoxic

Related compounds Carboplatin Less toxicity

Structural differences between alkylating agent anticancer drugs

Nitrogen mustards and nitrosoureas have other non reactive groups attached to N
contributes to overall reactivity and lipophilicity mustine

highly

reactive, reacts with proteins and water in blood and cells vesicant - administered as fast flowing infusion most of dose inactivated before it reaches target

melphalan, chlorambucil, cyclophosphamide

less

reactive, oral dose, longer duration of activity

Antimetabolites

Folate antagonists

methotrexate

Pyrimidine analogues

5-fluorouracil, tomudex, cytarabine, gemcitabine

mercaptopurine, thioguanine, fludarabine, pentostatin, azathioprine

Purine analogues

Antimetabolites

CCS

Methotrexate, 6-mercaptopurine, 5-fluorouracil, cytarabine, hydroxyurea analogues of substrates or products of enzymes involved in DNA synthesis

Inhibit synthesis of DNA bases

Inhibit the enzymes involved in DNA synthesis

Methotrexate (MTX) - aminopterin

MTX

analogue of folic acid - folate antagonist inhibits dihydrofolate reductase (DHFR)

1

carbon metabolism, reducing FH2 to FH4 provides carbon atoms for methylation of uracil
2-deoxyuridylate (dUMP)

thymidylate (dTMP)

MTX binds 10,000 x more tightly to enzyme than folate

prevents folate binding reversible theoretically! but folate in body too low to compete therefore MTX inhibition long lived

Structure of methotrexate (MTX) aminopterin

From: Rang & Dale, p726

Folinic acid rescue of high dose MTX

Folinic acid (5-formyl FH4, leucovorin, citrovorin)

given with high dose MTX

high

dose MTX severe toxicity after 36 h

bone marrow depression and GI toxicity

folinic acid bypasses MTX block

feeds

in carbons downstream from enzyme block important as MTX block long lived

Antimetabolites - 6 mercaptopurine

Inhibits the de novo synthesis of purine precursors of DNA

adenosine monophosphate (AMP) guanine monophosphate (GMP) Results in mutations in DNA and RNA
lethal synthesis 6-MP 2-deoxythioGMP (fraudulent nucleotide)

Antimetabolite incorporated into DNA/RNA

Metabolically activated

Incorporation Into DNA

5-Fluorouracil (5-FU)

Analogue of uridine
one of the bases of RNA precursor of thymidine and cytidine inhibits DNA and RNA synthesis at any stage that depends on uridine nucleotides lethal synthesis

5-FU

FUMP + FdUMP

(5-fluorouridine monophosphate) incorporated into RNA

FdUMP inhibits thymidylate synthase

dUMP + -CH3 (from FH4)
Thymidylate synthase

dTMP

Other antimetabolites

Cytarabine (Ara-C)

analogue of DNA and RNA precursor

2-deoxycytidine

Hydroxyurea (hydroxycarbamide)

not antimetabolite but acts like one

urea

phosphorylated to AraCTP inhibits incorporation of CTP into DNA directly inhibits DNA polymerase

analogue

inhibits ribonucleoside reductase

prevents

the conversion of ribonucleotides to deoxyribonucleotides

Cytotoxic antibiotics

CCNS
inhibit DNA function physical interaction with DNA breakage of chromosome structure

actinomycin

D, adriamycin, daunorubicin, mitomycin C, bleomycin, mithramycin

Actinomycin D

Inhibits RNA polymerase

inhibits transcription of DNA to RNA intercalates between G-C base pairs

cyclical pentapeptide chains minor groove of DNA

also inhibits topoisomerase II

Others

Adriamycin/doxorubicin

Mitomycin C

inhibits both DNA and RNA synthesis intercalates in DNA inhibits topoisomerase II
enzyme

that cuts and rejoins strands of DNA during the replication process

inhibits DNA replication enzymatically activated within the cell alkylates DNA at guanine O6
cross

links DNA

generates free radicals

DNA

damage and strand breakage

Others

Bleomycins

Procarbazine

metal-chelating glycopeptides degrade DNA

fragment

DNA and release free bases

inhibits DNA and RNA synthesis and prevents mitosis orally active drug-drug interactions
alcohol CNS

action through ROS most effective G2 but also G0 pulmonary fibrosis

active drugs

Vinca alkaloids

Derived from the Periwinkle plant

vincristine, vinblastine, vindesine (vinorelbine semisynthetic) binding to tubulin and arrest its polymerisation to microtubules prevents spindle formation in mitotic cells arrest in metaphase

Mechanism of action

Drug rapidly sequestered by white blood cells and platelets

relatively non-toxic (vincristine neurotoxicity) mild myelosuppression (not vincristine)

Other Plant Products

Etoposide

derived from the Mandrake root

inhibits

topoisomerase II inhibits mitochondrial function

nausea and vomiting, myelosuppression and alopecia

Taxol (paclitaxel, docetaxel)

derived from Yew tree bark stabilises microtubules

freezes

them in the polymerised state

effective in ovarian and drug-resistant breast cancer

Campothecins

Irinotecan, topotecan

topoisomerase I inhibitors
high

levels of topoisomerase I throughout cell-cycle

relatively few toxic effects

Hormones

Glucocorticoids

immunosuppressive
prevent

lymphocyte proliferation side-effects with long-term treatment

prednisolone
acute

lymphoblastic leukaemia; lymphomas (Hodgkin's and non-Hodgkins) combination therapy

Sex hormones and antagonists

Response of tumour to sex hormones

dependent on receptor expression

breast cancer
ER+

Oestrogen

- growth dependent on oestrogen block effect of oestrogen on tumour cells

Tamoxifen (anti-oestrogen)
binds

to ER no gene transcription side-effects (blood clots, endometrial changes)

Oestrogen and aromatase inhibitors

Oestrogen-dependent breast cancer

pre- vs. post-menopausal breast cancer

pre:

oestrogen produced by ovaries post: oestrogen produced in fat/muscle by aromatase

converts androgens to oestrogens

aromatase inhibitors
only

of use in post-menopausal women (Arimidex), letrozole (Femara)

ER+ tumours
Anastrozole

good safety profile <1% have upset stomach, mild nausea, muscle/joint aches

Response dependent on receptor expression!

Miscellaneous agents

Crisantapase

asparaginase
converts

asparagine to aspartate and NH4

effective against cells that have lost ability to synthesise asparagine

provide

exogenously fairly selective for tumour cells acute lymphoblastic leukaemia (ALL)

Miscellaneous agents

Imatinib mesylate (Gleevec, Glivec)

protein-tyrosine kinase inhibitor

inhibits

PDGF signalling especially Bcr-Abl tyrosine kinase

Chronic Myeloid Leukaemia (CML)

constitutive

abnormal tyrosine kinase activity resulting from chromosome abnormality in CML

Miscellaneous agents

Monoclonal antibodies

Rituximab
binds

to CD20 on B-cells (lymphoma) lysis (complement) or attacked by NK cells sensitises resistant cells to chemotherapy

Trastuzumab (Herceptin)
binds

to Her2/neu protein by ~25% breast cancers

rapid growth

EGFR family member (tyrosine-kinase activity)

over-expressed

potent growth signal

Types of therapy

Combination chemotherapy
planned mixtures of drugs more effective than single drug treatments mix drugs with

different

mechanisms of toxicity different mechanisms of action (minimise resistance)

MOPP for Hodgkins lymphoma

mustine,

oncovin (vincristine), procarbazine, prednisolone adriamycin, oncovin,

CHOP for non-Hodgkins lymphoma

cyclophosphamide,

prednisolone

Drugs in CHOP
Drug
Cyclophosphamide Adriamycin

Action
Alkylating agent Intercalating

Main toxicity
Bone marrow; bladder Bone marrow: heart

Vincristine
Prednisolone

Spindle poison
Unknown/ immunosuppressant

Neurological
Fluid retention weight gain: gastric irritation; hyperglycaemia

From Neal and Hoskin: Clinical Oncology: basic principles and practice, 3 rd edition, 2003

Side effects of anticancer drugs

Bone marrow toxicity

Alopecia

decreased leukocyte production decreased resistance to infection

hair loss

Impaired wound healing Depression of growth

Sterility Teratogenicity Damage to GI

especially children
cyclophosphamide

Carcinogenicity

nausea and vomitting inbuilt deterrent to patient compliance 5-HT3 receptor antagonists
ondansetron

Why are anticancer drugs so toxic to patients?

Lack of pharmacological specificity

Antibacterial chemotherapy
drugs

directed to bacterial targets bacterial targets are biochemically distinct from mammalian cells
little effect on mammalian cells

Receptor antagonists
highly

specific target cell death not aim of therapy

Specificity problems with anticancer drugs

Not specific in general

no target, cell poisons

not cancer cell specific
cancer

Where target identified

cells like normal cells biochemically therefore potential targets same in normal and cancer cells

Aim is cell death

Only specific difference is cancer cells divide more often

Cancer chemotherapy - where are we ?

All anticancer drugs toxic to patient BUT sensible use justified

Knowledge of mechanism of action used to

minimise

toxicity maximise efficacy

Most cancer are not eradicated by currently available drugs

Other issues

Drug resistance

dealt with in separate lecture

anti-emetics (cisplatin & alkylating agents)
ondansetron,

Dealing with side-effects

granisetron (5-HT3-receptor antagonists) metoclopromide

myelosuppression
remove

patients bone marrow

purging of tumour cells haematopoietic growth factors

New treatments

dealt with in separate lecture