Delivery of daunorubicin to cancer cells with decreased toxicity by association with a lipidic nanoemulsion that binds to LDL receptors

A lipidic nanoemulsion termed LDE concentrates in neoplastic cells after injection into the bloodstream and thus can be used as a drug carrier to tumour sites. The chemotherapeutic agent daunorubicin associates poorly with LDE; the aim of this study was to clarify whether the derivatization of daunorubicin by the attachment of an oleyl group increases the association with LDE, and to test the cytotoxicity and animal toxicity of the new preparation. The association of oleyl-daunorubicin (oDNR) to LDE showed high yield (93 +/- 2% and 84 +/- 4% at 1:10 and 1:5 drug:lipid mass, respectively) and was stable for at least 20 days. Association with oDNR increased the LDE particle diameter from 42 +/- 4 nm to 75 +/- 6 nm. Cytotoxicity of LDE-oDNR was reduced two-fold in HL-60 and K-562 cell lines, fourteen-fold in B16 cells and nine-fold in L1210 cells when compared with commercial daunorubicin. When tested in mice, LDE-oDNR showed remarkable reduced toxicity (maximum tolerated dose > 253 mu mol kg(-1), compared with <3 mu mol kg(-1) for commercial daunorubicin). At high doses, the cardiac tissue of LDE-oDNR-treated animals had much smaller structural lesions than with commercial daunorubicin. LDE-oDNR is therefore a promising new preparation that may offer superior tolerability compared with commercial daunorubicin.

A prospective, randomized, open label, phase iii clinical trial of novottf-100a vs best standard of care chemotherapy in patients with recurrent glioblastoma

BACKGROUND: Glioblastoma, the most common adult primary malignant brain tumor, confers poor prognosis (median survival of 15 months) notwithstanding aggressive treatment. Combination chemotherapy including carmustine (BCNU) or temozolomide (TMZ) with the MGMT inhibitor O6-benzylguanine (O6BG) has been used, but has been associated with dose-limiting hematopoietic toxicity. OBJECTIVE: To assess safety and efficacy of a retroviral vector encoding the O6BG-resistant MGMTP140K gene for transduction and autologous transplantation of hematopoietic stem cells (HSCs) in MGMT unmethylated, newly diagnosed glioblastoma patients in an attempt to chemoprotect bone marrowduring combination O6BG/TMZ therapy. METHODS: Three patients have been enrolled in the first cohort. Patients underwent standard radiation therapy without TMZ followed by G-CSF mobilization, apheresis, and conditioning with 600 mg/m2 BCNU prior to infusion of gene-modified cells. Posttransplant, patients were treated with 28-day cycles of single doseTMZ (472 mg/m2) with 48-hour intravenous O6BG (120 mg/m2 bolus, then 30 mg/m2/d). RESULTS: The BCNU dose was nonmyeloablative with ANC ,500/mL for ≤3 d and nadir thrombocytopenia of 28,000/mL. Gene marking in pre-infusion colony forming units (CFUs) was 70.6%, 79.0%, and 74.0% in Patients 1, 2, and 3, respectively, by CFU-PCR. Following engraftment, gene marking in white blood cells and sorted granulocytes ranged between 0.37-0.84 and 0.33-0.83 provirus copies, respectively, by real-time PCR. Posttransplant gene marking in CFUs from CD34-selected cells ranged from 28.5% to 47.4%. Patients have received 4, 3, and 2 cycles of O6BG/TMZ, respectively, with evidence for selection of gene-modified cells. One patient has received a single dose-escalated cycle at 590 mg/m2 TMZ. No additional extra-hematopoietic toxicity has been observed thus far and all three patients exhibit stable disease at 7-8 months since diagnosis CONCLUSIONS: We believe that these data demonstrate the feasibility of achieving significant engraftment of MGMTP140K-modified cells with a well-tolerated dose of BCNU. Further follow-up will determine whether this approach will allow for further dose escalation of TMZ and improved survival.

Adjuvant dibromodulcitol and BCNU chemotherapy in anaplastic astrocytoma: results of a randomised European Organisation for Research and Treatment of Cancer phase III study (EORTC study 26882).

BACKGROUND: In a previous randomised EORTC study on adjuvant dibromodulcitol (DBD) and bichloroethylnitrosourea (BCNU) in adults with glioblastoma multiforme (GBM) and anaplastic astrocytoma (AA), a clinically significant trend towards a longer overall survival (OS) and a progression-free survival (PFS) was observed in the subgroup of AA. The aim of the present study was to test this adjuvant regimen in a larger number of AA patients. METHODS: Continuation of the previous phase III trial for newly diagnosed AA according to the local pathologist. Patients were randomised to either radiotherapy only or to radiotherapy in combination with BCNU on day 2 and weekly DBD, followed by adjuvant DBD and BCNU in cycles of six weeks for a maximum total treatment duration of one year. OS was the primary end-point. RESULTS: Patients (193 ) with newly diagnosed AA according to local pathological assessment were randomised to radiotherapy (RT) alone (n=99), or to RT plus DBD/BCNU (n=94); 12 patients were considered not eligible. At central pathology review, over half (53%) of the locally diagnosed AA cases could not be confirmed. On intent-to-treat analysis, no statistically significant differences in OS (p=0.111) and PFS (p=0.087) were observed, median OS after RT was only 23.9 months 95% confidence interval (CI), [18.4-34.0] after RT plus DBD/BCNU 27.3 months 95% CI [21.4-46.8]. CONCLUSION: No statistically significant improvement in survival was observed after BCNU/DBD adjuvant chemotherapy in AA patients. The trend towards improved survival is consistent with previous reports. Central pathology review of grade 3 tumours remains crucial.

New drugs and combinations for malignant glioma.

A new chemotherapy agent and a method for local delivery of carmustine have recently been approved for the treatment of malignant glioma. However, the increase in survival remains modest at best with only a very select patients currently benefiting truly of these treatments. Combination regimen of different alkylating agents or prior O6-alkyltransferase depletion by O6-benzylguanine or continuous temozolomide administration schedules have shown some indication for increased activity. There is preclinical rational for combining temozolomide with radiotherapy and the initial results of a phase II clinical trial were promising. Several new cytotoxic agents are currently in clinical trials in patients with recurrent glioma. More importantly, targeted therapy and antiangiogenic agents have entered the clinical development phase also for patients with glioblastoma and anaplastic astrocytoma. The optimal timing of administration of non-cytotoxic substances and their integration into the currently available treatments remains a challenge. Novel study designs and identification of surrogate markers are necessary in order to make rapid and clinically meaningful progress. This review summarises the currently available evidence of activity of the recently approved drugs against malignant glioma and mentions also agents which have failed to demonstrate a significant antitumour activity. Study endpoints are critically discussed. Combination regimens with other agents and radiation therapy are reviewed. The rational for using antiangiogenic drugs in selected ongoing trials is discussed.

Maintenance Therapy With Tumor-Treating Fields Plus Temozolomide vs Temozolomide Alone for Glioblastoma: A Randomized Clinical Trial.

IMPORTANCE: Glioblastoma is the most devastating primary malignancy of the central nervous system in adults. Most patients die within 1 to 2 years of diagnosis. Tumor-treating fields (TTFields) are a locoregionally delivered antimitotic treatment that interferes with cell division and organelle assembly. OBJECTIVE: To evaluate the efficacy and safety of TTFields used in combination with temozolomide maintenance treatment after chemoradiation therapy for patients with glioblastoma. DESIGN, SETTING, AND PARTICIPANTS: After completion of chemoradiotherapy, patients with glioblastoma were randomized (2:1) to receive maintenance treatment with either TTFields plus temozolomide (n = 466) or temozolomide alone (n = 229) (median time from diagnosis to randomization, 3.8 months in both groups). The study enrolled 695 of the planned 700 patients between July 2009 and November 2014 at 83 centers in the United States, Canada, Europe, Israel, and South Korea. The trial was terminated based on the results of this planned interim analysis. INTERVENTIONS: Treatment with TTFields was delivered continuously (>18 hours/day) via 4 transducer arrays placed on the shaved scalp and connected to a portable medical device. Temozolomide (150-200 mg/m2/d) was given for 5 days of each 28-day cycle. MAIN OUTCOMES AND MEASURES: The primary end point was progression-free survival in the intent-to-treat population (significance threshold of .01) with overall survival in the per-protocol population (n = 280) as a powered secondary end point (significance threshold of .006). This prespecified interim analysis was to be conducted on the first 315 patients after at least 18 months of follow-up. RESULTS: The interim analysis included 210 patients randomized to TTFields plus temozolomide and 105 randomized to temozolomide alone, and was conducted at a median follow-up of 38 months (range, 18-60 months). Median progression-free survival in the intent-to-treat population was 7.1 months (95% CI, 5.9-8.2 months) in the TTFields plus temozolomide group and 4.0 months (95% CI, 3.3-5.2 months) in the temozolomide alone group (hazard ratio [HR], 0.62 [98.7% CI, 0.43-0.89]; P = .001). Median overall survival in the per-protocol population was 20.5 months (95% CI, 16.7-25.0 months) in the TTFields plus temozolomide group (n = 196) and 15.6 months (95% CI, 13.3-19.1 months) in the temozolomide alone group (n = 84) (HR, 0.64 [99.4% CI, 0.42-0.98]; P = .004). CONCLUSIONS AND RELEVANCE: In this interim analysis of 315 patients with glioblastoma who had completed standard chemoradiation therapy, adding TTFields to maintenance temozolomide chemotherapy significantly prolonged progression-free and overall survival. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00916409.

Glukose-konjugierte Hemmstoffe als Strategie der gezielten Hemmung des DNA-Reparaturproteins O 6 -Methylguanin-DNA-Methyltransferase in Tumorzellen und der Einfluss von ATP-binding cassette Transportern

Das DNA-Reparaturprotein O6-Methylguanin-DNA-Methyltransferase [MGMT] ist der Hauptresistenzfaktor gegenüber der zytotoxischen Wirkung von SN1-alkylierenden Zytostatika in der Tumortherapie. Die Verwendung der MGMT-Hemmstoffe O6-Benzylguanin [O6BG] und O6-(4-Bromothenyl)guanin [O6BTG] führte zu einer Sensibilisierung des Normalgewebes, was eine Dosis-Reduktion der Zytostatika erforderlich machte und die erhoffte Therapieverbesserung verhinderte. Aus diesem Grund ist eine Strategie der selektiven Hemmung des MGMT-Proteins (Targeting-Strategie) erforderlich, um die systemische Toxizität in der Kombinationsbehandlung zu reduzieren. In dieser Arbeit wurde die Anwendbarkeit der Glukose-Konjugation als Targeting-Strategie untersucht, da Tumorzellen einen erhöhten Glukoseverbrauch aufweisen und demzufolge Glukosetransporter überexprimieren. Die Glukose-Konjugate O6BG-Glu und O6BTG-Glu inhibierten MGMT in Tumorzellen und sensibilisierten die Zellen gegenüber den alkylierenden Agenzien Temozolomid [TMZ] und Lomustin [CCNU]. Des Weiteren inaktivierten die Glukose-Konjugate die MGMT-Aktivität im Tumor eines Xenograft-Mausmodells und reduzierten das Tumorwachstum nach einer TMZ-Behandlung im gleichen Ausmass wie die Inhibitoren O6BG und O6BTG. Trotzdem war auch mit den Glukose-Konjugaten keine Steigerung der Zytostatika-Dosis im Mausmodell möglich. Die Untersuchungen der Aufnahme von O6BG-Glu und O6BTG-Glu wiederlegten eine Involvierung der Glukosetransporter. Der Einsatz von spezifischen Glukosetransporter-Inhibitoren und Kompetitions-Experimenten führte zu keiner Verminderung der MGMT-Hemmung oder Aufnahme vom radioaktiven H3-O6BTG-Glu in die Zelle. Dies legt nahe, dass die Glukose-Konjugate über einen unspezifischen Mechanismus (aktiv) in die Zellen gelangen. Der Grund für eine mögliche unselektive Aufnahme könnte im hydrophoben Alkyllinker, der für die Konjugation des Glukosemoleküls verwendet wurde, begründet sein. Dies führt zur Generierung von amphipathischen Konjugaten, die eine initiale Bindung an die Plasmamembran aufweisen und eine Aufnahme über den Flip-Flop-Mechanismus (transbilayer transport) wahrscheinlich machen. Die amphipathische Molekülstruktur der Glukose-Konjugate führte zu einer Partikelbildung in wässrigen Lösungen, die eine Reduktion der Menge an aktiven Monomeren von O6BG-Glu und O6BTG-Glu bewirken, die zur Hemmung von MGMT zur Verfügung stehen. Der zweite Teil der Arbeit befasste sich mit der Rolle von ABC-Transportern hinsichtlich einer Targeting-Strategie von MGMT-Hemmstoffen. Obwohl eine hohe Expression dieser ABC-Transporter in Tumoren zur Resistenzentwicklung gegenüber Zytostatika führt, wurde ihr Einfluss auf MGMT-Hemmstoffe oder einer MGMT-Targeting-Strategie niemals untersucht. In dieser Arbeit wurde zum ersten Mal ein aktiver Efflux von MGMT-Hemmstoffen durch ABC-Transporter nachgewiesen. Die Inhibition von ABC-Transportern bewirkte eine schnellere Inaktivierung von MGMT durch die Glukose-Konjugate. Des Weiteren zeigten Kompetitions-Experimente mit den MGMT-Hemmstoffen eine verminderte Efflux-Rate von Fluoreszenzfarbstoffen, die spezifisch von ABC-Transportern exportiert werden. ABC-Transporter reduzieren die wirksame Konzentration des Hemmstoffes in der Zelle und beeinträchtigen somit die Effektivität der MGMT-Inhibition. Eine simultane Hemmung der ABC-Transporter P-glycoprotein (P-gp), multi resistance protein 1 (MRP1) and breast cancer resistance protein (BCRP) erhöhte die Effektivität der MGMT-Hemmstoffe (O6BG, O6BTG, O6BG-Glu, O6BTG-Glu) und verstärkte auf diese Weise die TMZ-induzierte Toxizität in Tumorzelllinien. Die Involvierung von ABC-Transportern in der intrazellulären Speicherung von MGMT-Hemmstoffen ist wahrscheinlich die Ursache für die beobachteten Unterschiede in der Sensibilisierung verschiedener Tumorzelllinien gegenüber Zytostatika durch das Glukose-Konjugat O6BG-Glu. Eine Strategie, den Einfluss von ABC-Transportern zu reduzieren und zukünftliche MGMT-Targeting-Strategien effizienter umzusetzen, ist die Verwendung von O6BTG als Ausgangssubstanz. Die höhere Inhibitionsfähigkeit der Bromthiophenmoleküle vermindert die erforderliche intrazelluläre Konzentration für eine vollständige MGMT-Hemmung und reduziert auf diese Weise den Einfluss von ABC-Transportern.

Additive Hazards Models with Latent Treatment Effectiveness Lag Time

In many clinical trials to evaluate treatment efficacy, it is believed that there may exist latent treatment effectiveness lag times after which medical procedure or chemical compound would be in full effect. In this article, semiparametric regression models are proposed and studied to estimate the treatment effect accounting for such latent lag times. The new models take advantage of the invariance property of the additive hazards model in marginalizing over random effects, so parameters in the models are easy to be estimated and interpreted, while the flexibility without specifying baseline hazard function is kept. Monte Carlo simulation studies demonstrate the appropriateness of the proposed semiparametric estimation procedure. Data collected in the actual randomized clinical trial, which evaluates the effectiveness of biodegradable carmustine polymers for treatment of recurrent brain tumors, are analyzed.

Use of closed systems in the Hospital Pharmacy

Objective: In the setting of the increasing use of closed systems for reconstitution and preparation of these drugs, we intend to analyze the correct use of these systems in the Hospital Pharmacy, with the objective to minimize the risks of exposure not only for those professionals directly involved, but also for all the staff in the unit, taking also into account efficiency criteria. Method: Since some systems protect against aerosol formation but not from vapours, we decided to review which cytostatics should be prepared using an awl with an air inlet valve, in order to implement a new working procedure. We reviewed the formulations available in our hospital, with the following criteria: method of administration, excipients, and potential hazard for the staff handling them. We measured the diameters of the vials. We selected drugs with Level 1 Risk and also those including alcohol-based excipients, which could generate vapours. Outcomes: Out of the 66 reviewed formulations, we concluded that 11 drugs should be reconstituted with this type of awl: busulfan, cabazitaxel, carmustine, cyclophosphamide, eribulin, etoposide, fotemustine, melphalan, paclitaxel, temsirolimus and thiotepa; these represented an 18% of the total volume of formulations. Conclusions: The selection of healthcare products must be done at the Hospital Pharmacy, because the use of a system with an air valve inlet only for those drugs selected led to an outcome of savings and a more efficient use of materials. In our experience, we confirmed that the use of the needle could only be avoided when the awl could adapt to the different formulations of cytostatics, and this is only possible when different types of awls are available. Besides, connections were only really closed when a single awl was used for each vial. The change in working methodology when handling these drugs, as a result of this study, will allow us to start different studies about environmental contamination as a future line of work.