Multiple myeloma.

Multiple myeloma occurs in over 2000 new patients in England and Wales each year. It presents most frequently as bone pain and patients tend to become dehydrated and may develop renal failure. No available treatment is curative, but about two thirds of patients achieve a stable response with low dose combination chemotherapy. Combination chemotherapy including doxorubicin and carmustine with the alkylating agents cyclophosphamide and melphalan achieve a higher stable response rate than conventional treatment with melphalan and prednisone without additional haematological toxicity. These responses are associated with loss of bone pain and patients remain symptom free for months without further treatment. Relapse occurs on average in a little under two years and, though second responses are frequently obtained, the disease eventually becomes refractory. This paper looks at who should be treated and the benefits that may be expected from the treatments available.     

Carbinolamines and related structures--potential alkylating metabolites of clinically active anticancer drugs

The precise biochemical mechanism by which a number of clinically-active anticancer compounds function remains unclear. Among these are procarbazine (NSC-77213), cyclophosphamide (NSC-26271), streptozotocin (NSC-85998), dacarbazine (NSC-45388), and hexamethylmelamine (NSC-13875). In all cases, there is an N-methyl or N-alkyl substituent which can be or has been shown to generate carbinolamine-like intermediates as a result of oxidative metabolism. Such intermediates can react with amines, imines, sulfhydryls and similar functional groups to form covalent linkages. Thus, carbinolamine metabolites of these clinically-active compounds are proposed as the active agents capable of altering covalently nucleic acids and proteins. It is this alkylating property that may be responsible for these compounds adversely effecting the mitosis of neoplastic cells. Thus, a unifying hypothesis is proposed whereby metabolic hydroxylation of various miscellaneous anticancer agents is the basis for biological activity. In essence, therefore, three broad classes of alkylating agents may be perceived: (1) the classical alkylators such as the nitrogen and sulfur mustards and the sulfonates, (2) bioreductive alkylating agents, and (3) biooxidative alkylating agents such as the carbinolamines. Though the chemical spectrum of each category may be highly diverse, nevertheless, all function as alkylating agents.     

The effect of plasma on the reaction of cyclophosphamide with 4(-p-nitrobenzyl)-pyridine.

Cyclophosphamide is not structurally modified by blood plasma and may be recovered quantitatively from it. The apparent loss of alkylating ability of cyclophosphamide, as measured by its ability to react with 4-(p-nitrobenzyl)-pyridine (NBP), following treatement with plasma is not, as has been reported, due to metabolism of the drug but rather to an inhibition of the colorimetric reaction by a constituent of the plasma. This inhibition is strongly pH dependent, reaching 100% when the pH of the solution of cyclophosphamide in plasma is above 8, and falling to less than 20% when the pH is below 6, but extraction with chloroform at pH 7 separates cyclophosphamide from the inhibitor. Although the nature of the inhibitor has not been elucidated, its presence in plasma is of great importance in the quantitative determination of cyclophosphamide, and may also be of significance in the biological effects of cyclophosphamide and other alkylating agents in vivo.     

Variability of the sensitivity of human lymphocytes to the antiproliferative action of alkylating agents

A study was made of variability of the sensitivity of peripheral blood lymphocytes from different donors to an antiproliferative action of cyclophosphamide and thiophosphamide. A similar degree of the sensitivity was revealed to alkylating agents differing in the action mode, with this degree being independent of the "stimulation index" magnitude.     

Alkylation resistance of E. coli cells expressing different isoforms of human alkyladenine DNA glycosylase (hAAG)

The alkyladenine DNA glycosylase (AAG) has been cloned from mouse and humans. AAG knock out mouse cells are sensitized to a variety of alkylating and cross-linking agents suggesting AAG is active on a variety of substrates. In humans, two isoforms have been characterized that are generated by alternative splicing and contain either exon 1a or 1b (hAAG1 or hAAG2). In this study, we examine the ability of the both known isoforms of human AAG (hAAG) to contribute to survival of Escherichia coli from treatments with simple alkylating agents and cross-linking alkylating agents. Our results show that hAAG is effective at repairing methyl lesions when expressed in E. coli, but is unable to afford increased resistance to alkylating agents producing larger alkyl lesions such as ethyl lesions or lesions produced by the cross-linking alkylating agents N,N'-bis-chloroethyl-N-nitrosourea (BCNU), N-(2-chloroethyl)-N-nitrosourea (CNU) or mitomycin C. In the case of CNU, expression of hAAG causes increased sensitivity rather than resistance, suggesting deleterious effects of hAAG activity. We also demonstrate that there are no apparent differences between the two isoforms of hAAG when recovery from damage produced by all alkylating agents is tested.     

Genetic differences in mice in the sensitivity to the immunodepressive action of alkylating agents

The immunodepressant action of cyclophosphamide, thiophosphamide and sarcolysine was examined in experimental primary immune response in mice of different lines immunized with sheep red blood cells. DBA/2 and C3H/Sn mice were marked by the highest sensitivity to the immunodepressant action of the alkylating agents. BALB/c mice were relatively resistant to the immunodepressant action. Possible reasons for the interspecific differences found are discussed.     

Sister chromatid exchange studies for monitoring DNA damage and repair capacity after cytostatics in vitro and in lymphocytes of leukaemic patients under cytostatic therapy.

The effect of various cytostatic drugs was studied on the frequency of sister chromatid exchanges (SCEs) in vitro and in PHA-stimulated lymphocytes of leukaemic patients under cytostatic therapy. The lymphocyte system is a sensitive one for the detection of DNA damage after administration of cytostatic drugs in vitro. Mitomycin C, busulphan, vincristine, chlorambucil, cytosine arabinoside, cyclophosphamide and lycurim were tested. All except cyclophosphamide induced high frequencies of SCEs in the first mitosis after their administration. The experiments with PHA-stimulated lymphocytes in vivo from patients treated with cytostatics showed that cytosine arabinoside, in combination with thioguanine, did not induce higher frequencies of SCEs, whereas in patients who were treated with cyclophosphamide alone or in combination with other cytostatic drugs, there was a higher incidence of SCEs during treatment. About 10 days after the termination of the treatment the elevated freuqencies of SCEs returned to the initial level. After administration of some mutagens, especially alkylating agents in vivo, the lymphocyte system can be used to assess induced DNA repair by continuously monitoring for SCEs.     

Adaptive resistance of Saccharomyces cerevisiae to chronic treatment with mutagens being due to a dominant mutation

The exposure of mammalian cells or tumors for weeks or months to low non-lethal doses of cytostatic drugs may induce multi-drug resistance, which can be enhanced by a variety of DNA-damaging agents. In yeast multi-drug resistance to a variety of drugs has been observed. DNA-damaging agents have not yet been tested. As the appearance of resistance is the result of long-term exposure, we decided to extend the application of test substances to a period of up to 400 days. In such long-term experiments S. cerevisiae MP1 adapted to treatment with low doses of mutagens. Consistent results were obtained for both alkylating and non-alkylating mutagenic substances. Furthermore, the adaptive resistance to the alkylating agent also adapted cells to the non-alkylating agent, which implies that there may be a single pathway for mutagens with different modes of action. Random spore analysis of adapted yeast cells and the back-cross to the parental wild type indicates that a single dominant mutation is responsible for the adaptive resistance.     

Sensitivity of the splenic immunocompetent cells of mice with different genotypes to the action of alkylating agents

It has been established in experiments in vitro that splenocytes of DBA/2GSto mice are more sensitive to the immunosuppressant action of the alkylating agents (cyclophosphamide, sarcolysine and thiophosphamide) than splenocytes of BALB/cGLacSto mice. Splenocytes of C3H/SnRap mice exhibit and intermediate type of sensitivity. T-lymphocytes of the spleen of BALB/cGLacSto and DBA/2GSto mice are more sensitive in vitro to the action of active metabolites of cyclophosphamide as compared to B-lymphocytes, with both types of the cells of DBA/2GSto mice being affected to a greater extent than the cells of BALB/cGLacSto mice.     

Cell kinetics of mouse urinary bladder epithelium. V. Changes in the proportion of cells with various nuclear DNA content after repeated doses of cyclophosphamide.

A dose of 2 mg cyclophosphamide (Sendoxan, "Pharamcia", Sweden) dissolved in 0.2 ml distilled water was injected intraperitoneally once a week to 12 hairless mice for three months. Four animals were killed at 1, 2 and 3 months and micro-flow fluormetric histograms of the bladder epithelial cells were made. The proportion of cells in diploid S phase remained normal at 1 and 2 months, but increased at 3 months. The proportion of tetraploid S-phase cells fell rapidly and markedly and there were almost no cells in this phase at 1, 2 and 3 months. The proportion of diploid cells increased, the proportion of tetraploids was significantly reduced and the octoploid cells disappeared after 2 months. The changes are similar to those seen after repeated injections of the bladder carcinogen dibutylnitrosamine, but less pronounced. Since cyclophosphamide is a strong alkylating agent it is possible that, in the doses used, it is also a weak carcinogen for hte bladder epithelium. This must be tested in direct, long-term treatment experiments. Bladder cancers in humans receiving cyclophosphamide therapy have been described.     

The proliferative state of clonogenic cells in the Lewis lung tumour after treatment with cytotoxic agents

The proportion of clonogenic cells from the Lewis lung carcinoma which are in S-phase of the cell cycle has been measured as the fraction killed by a short exposure to hydroxyurea in vitro. Estimates of the proportions of S-phase cells before and 30 min after doses of gamma-radiation of 1000--2000 rad suggest no alternation in the cell cycle age distribution due to these doses of radiation. As the survivors of these high doses of radiation are predominantly hypoxic, the results imply that hypoxic cells have the same cell cycle age distribution as oxygenated cells in Lewis lung tumours. After treatment with cyclophosphamide or CCNU, the proportion of S-phase cells among the survivors exceeds the faction of S-phase cells in untreated populations. This increase is consistent with a relative resistance of S-phase cells to alkylating agents and nitrosoureas.     

The mediator of cellular immunity. IV. Cooperation between lymphocytes and mononuclear phagocytes

Acquired resistance to an intravenous infection with Listeria monocytogenes involves the interaction of two cell types: specifically committed lymphocytes and monocyte-derived macrophages. This interaction was revealed in experiments using the polyfunctional alkylating agent, cyclophosphamide. Cyclophosphamide is toxic for both lymphocytes and blood monocyte antecedents. Rats treated with cyclophosphamide were immunized adoptively with cells obtained from the thoracic duct lymph of Listeria-immune donors. But such animals benefited from a lymphocyte injection only while they could assemble monocyte-derived macrophages in an inflammatory exudate. The results imply that blood monocytes provide an essential element to the host's defense mechanism against intracellular bacterial parasites, and that monocyte-derived macrophages are the instruments through which cellular resistance to infection is expressed.     

Cell Hybridization Study of Resistance to Alkylating Agents

5-Aziridinyl-2,4-Dinitrobenzamide (CB 1954) has been reported to be a highly selective inhibitor of the Walker tumour, with a therapeutic index of 60 (refs. 1 and 2). This compound, however, differs from other tumour inhibitory alkylating agents in that it is monofunctional and fails to inhibit the growth of several animal tumours which respond to difunctional alkylating agents. Compounds closely related in structure to CB 1954 are either much less active or inactive against the Walker tumour³. The structural specificity and biological properties of CB 1954 indicate that its mechanism of action is different from that of the tumour inhibitory difunctional alkylating agents. Whereas the latter are thought to be cytotoxic primarily as a result of their reaction with DNA, CB 1954 may interfere with a specific stage of purine biosynthesis². We have shown by cell hybridization that, unlike resistance to a difunctional alkylating agent, cellular resistance to CB 1954 is lost on fusion with a sensitive cell.     

Genetic heterogeneity of heat shock protein synthesis as a factor determining the resistance to stressors in mammalia

The relationship between the levels of 70 kDa family heat shock protein (Hsp) synthesis and lymphocyte sensitivity to stressors was investigated. Lymphocyte cultivation in mitogen deprived culture medium and/or the cell treatment with alkylating agents have been used as a stress challenge. Model experiments with two inbred murine strains genetically contrasting by the sensitivity to alkylating agents demonstrated that the basic level of Hsp synthesis depends on genotype. The quantity Hsp70 mRNA, as well as intracellular level of the proteins, in BALB/c was significantly higher than those in C57BL/6 mice. The mice, which were characterized by higher Hsp levels, demonstrated higher resistance to alkylating agent action. The induction of surplus amount of Hsp by heat shock increased the cell resistance to an alkylating agent melphalan. Lymphocyte isolated from high Hsp producers BALB/c mice were more resistant to apoptotic signals induced by mitogen deprivation.     

Prevention of chemotherapy-induced alopecia in rodent models

Alopecia (hair loss) is experienced by thousands of cancer patients every year. Substantial-to-severe alopecia is induced by anthracyclines (e.g., adriamycin), taxanes (e.g., taxol), alkylating compounds (e.g., cyclophosphamide), and the topisomerase inhibitor etoposide, agents that are widely used in the treatment of leukemias and breast, lung, ovarian, and bladder cancers. Currently, no treatment appears to be generally effective in reliably preventing this secondary effect of chemotherapy. We observed in experiments using different rodent models that localized administration of heat or subcutaneous/intradermal injection of geldanamycin or 17-(allylamino)-17-demethoxygeldanamycin induced a stress protein response in hair follicles and effectively prevented alopecia from adriamycin, cyclophosphamide, taxol, and etoposide. Model tumor therapy experiments support the presumption that such localized hair-saving treatment does not negatively affect chemotherapy efficacy.     

Occupational exposure to anticancer drug--potential and real hazards

Many anticancer agents have been shown to be mutagenic, teratogenic and carcinogenic in experimental systems and second malignancies are known to be associated with several specific therapeutic treatments. Anticancer agents thus represent a class of occupational carcinogens, the handling of which should involve no unnecessary exposure. The available methodologies to detect possible exposures from ambient air and from biological samples are discussed, and the published data on results are reviewed. Analytical methods are available for the detection of most frequently used anticancer drugs from all groups, i.e., alkylating agents, mitotic inhibitors, antimetabolites and antibiotics. The ambient samples taken from sites of admixture of cytostatics have often shown detectable, but low concentrations of anticancer agents. Urine samples from patients under chemotherapy as well as from personnel handling the drugs occupationally in hospitals have been analyzed both chemically and for excreted mutagenicity. Both cisplatin and cyclophosphamide have been detected in the urine of patients; furthermore, cyclophosphamide was observed in the urine of nurses who formulate and deliver this drug. Urinary mutagenicity assays have given both positive and negative results in various groups of nursing and pharmacy personnel. Cytogenetic methods have, likewise, been applied for monitoring purposes. Most of the available data concerns chromosome aberrations (CA) or sister-chromatid exchanges (SCE) induced in peripheral blood lymphocytes of patients under chemotherapy. A few studies on groups occupationally exposed to anticancer drugs have given positive results, but also negative reports have appeared for these same cytogenetic parameters. No studies are as yet available on the possible carcinogenic effects of occupational handling of anticancer drugs. Two recent case-referent studies among hospital personnel have pointed to slightly increased risks of disorders in pregnancy outcome; one of the studies has shown an excess of spontaneous abortions and other malformations in children of females with a history of work with anticancer agents.     

Mutagenesis by Cytostatic Alkylating Agents in Yeast Strains of Differing Repair Capacities

Reversion of two nulcear ochre nonsense alleles and cell inactivation induced by mono-, bi-, and tri-functional alkylating agents and by UV has been investigated in stationary-phase haploid cells of yeast strains with differing capacities for DNA repair. The ability to survive alkylation damage is correlated with UV repair capacity, a UV-resistant and UV-mutable strain (RAD REV) being least and a UV-sensitive and UV-nonmutable strain (radi rev3) most sensitive. Mutagenicity of alkylating agents is highest in the former and is abolished in the latter strain. Deficiency in excision repair (rad1 rad2) or in the RAD18 function does not lead to enhanced mutability. Mutagenesis by the various agents is characterized by a common pattern of induction of locus-specific revertants and suppressor mutants. Induction kinetics are mostly linear, but UV-induced reversion in the RAD REV strain follows higher-than-linear (probably "quadratic") kinetics. The alkylating agent cyclophosphamide, usually considered inactive without metabolic conversion, reduces colony-forming ability and induces revertants in a manner similar but not identical to the other chemicals tested. These findings are taken to support the concept of mutagenesis by misrepair after alkylation, which albeit sharing common features with the mechanism of UV-induced reversion, can be distinguished therefrom.     

Mutation of p53 and consecutive selective drug resistance in B-CLL occurs as a consequence of prior DNA-damaging chemotherapy

Inactivation of p53 has been shown to correlate with poor prognosis and drug resistance in malignant tumors. Nevertheless, few reports have directly shown such effects in primary tumor cells. Here, we investigated the p53 mutational status in 138 B-CLL samples and compared these findings with drug and gamma-irradiation sensitivity profiles. p53 mutations resulted not only in a shorter survival but, notably also in selective resistance to alkylating agents, fludarabine and gamma-irradiation. In contrast, no such effect was observed for vincristine, anthracyclines and glucocorticoids. Thus, these latter compounds induce cell death at least in part by p53-independent pathways. Interestingly, p53 mutations clustered in patients who had received prior chemotherapy. In fact, we show for the first time that treatment with DNA-damaging alkylating agents correlates with occurrence of p53 mutations in a clinical setting. This finding may explain at least to some extent the development of resistance to second-line anticancer chemotherapy.     

The Proliferative State of Clonogenic Cells In the Lewis Lung Tumour After Treatment With Cytotoxic Agents

The proportion of clonogenic cells from the Lewis lung carcinoma which are in S-phase of the cell cycle has been measured as the fraction killed by a short exposure to hydroxyurea in vitro. Estimates of the proportions of Sphase cells before and 30 min after doses of γ-radiation of 1000–2000 rad suggest no alternation in the cell cycle age distribution due to these doses of radiation. As the survivors of these high doses of radiation are predominantly hypoxic, the results imply that hypoxic cells have the same cell cycle age distribution as oxygenated cells in Lewis lung tumours. After treatment with cyclophosphamide or CCNU, the proportion of S-phase cells among the survivors exceeds the faction of S-phase cells in untreated populations. This increase is consistent with a relative resistance of S-phase cells to alkylating agents and nitrosoureas.     

Short-term morphological response of the rat testis to administration of five chemotherapeutic agents.

As cancer survival rates improve, there is increasing concern about the adverse effects of chemotherapeutic agents on male fertility. Five chemotherapeutic agents (amethopterin, AP or methotrexate; doxorubicin, DX; cytoxan or cyclophosphamide, CP; cisplatinum, CDDP; and 5-fluorouracil, 5-FU) which belong to three different categories of chemotherapeutic agents (antimetabolite, antibiotic, alkylating agent, alkylating agent, antimetabolite, respectively) were given systemically to adult rats to determine the short-term morphological patterns of response in the testis, and the testes were examined by light microscopy. Morphological patterns of response were found to be highly characteristic for each agent, and some shared morphological responses were evident. All except one chemotherapeutic agent (5-FU) caused spermatogonial damage. Among the defects seen were probable degenerating meiotic spermatocytes (CDDP), presence of micronuclei (DX), "arrested" spermatid development (5-FU), and abnormally shaped step 15 spermatids (5-FU). Damage that could be due to the effect of an agent on the Sertoli cell was failure of sperm release (5-FU, CDDP, DX, and AP), increase in the Sertoli cell lipid (5-FU), and malorientation of step 8 spermatids (5-FU, DX). The varied patterns of damage observed are a possible explanation of why the reproductive recovery potential in cancer patients undergoing chemotherapy is variable and drug-specific.