Romjoh 4 (3) 2014

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T H I S J O U R N A L I S I N T E R D I S C I P L I N A R Y A N D I S D E D I C A T E D T O A L L S P E C I A L I S T S I N T H E M E D I C A L F I E L D R E L A T E D T O O N C O LO GY A N D H E M A T O LO GY

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www.rom-joh.com Volume II I Issue 3 I 2014

Editorial

RomJOH susţine dezvoltarea profesională continuă a specialiştilor

Aproape la 1 an de apariţie şi prezenţă constantă atât în rândul specialiştilor cărora se adresează, cât şi în cadrul manifestărilor ştiinţifice din domeniul medical din România, revista Romanian Journal of Oncology & Hematology îşi propune să devină un punct de reper şi un instrument util în dezvoltarea profesională şi schimbul de experienţă pentru toţi specialiştii care activează în domeniul medical şi care în activitatea curentă se confruntă cu pacienţi cu afecţiuni oncologice.

Astfel, ne dorim să venim în întâmpinarea nevoii de informare şi de comunicare a tuturor specialiştilor - oncologi, hematologi, ginecologi, neonatologi, dermatologi, ORL-işti, chirurgi, urologi, gastroenterologi, pediatri, radioterapeuti, radiologi, geneticieni, pneumoftiziologi, specialişti în terapia durerii şi paliaţie etc. – prin publicarea de articole ştiinţifice cu caracter interdisciplinar, care să sprijine dezvoltarea profesională continuă a cadrelor medicale din România şi care să contribuie la o mai bună comunicare interdisciplinară între acestea, pentru creşterea calităţii vieţii pacienţilor cu afecţiuni oncologice. În acest sens, am lansat de curând şi noul site al revistei – www.rom-joh.com, care, pe lângă publicarea şi accesul facil online la articolele scrise de renumiţi specialişti atât din România, cât şi din străinătate, are de asemenea integrat Open System Journals (OJS), ce permite online submiterea de articole la revistă, corespondenţa directă cu autorii şi editorii revistei, accesarea gratuită în sistem Open Access a tuturor materialelor, citarea şi indexarea în renumite baze de date internaţionale şi accesul cititorilor şi autorilor atât din România, cât şi din întreaga lume la informaţii ştiinţifice utile şi de calitate.

Vă invităm împreună cu Comitetul editorial să ne fiţi alături prin publicarea de articole ştiinţifice cu caracter interdisciplinar pentru a contribui astfel la susţinerea şi dezvoltarea profesioniştilor din domeniul medical din România.

Vă aşteptăm, de asemenea, să ne fiţi alături pe 5 decembrie 2014, la Bucureşti, la Crystal Palace Ballroom, în cadrul evenimentului ştiinţific interdisciplinar şi translaţional Health Meeting, ediţia a II-a, unde sunt invitaţi specialişti din domeniile oncologie, ginecologie, dermatologie, terapia durerii, paliaţie şi medicină de familie, împreună cu lectori de renume din România şi asociaţii de pacienţi ce vor dezbate tema “Leziunile pre-neoplazice şi neoplazice”. Mai multe detalii despre eveniment, puteţi afla de pe site-nostru, www.msc-ro.com, la Secţiunea Events.

Echipa Media Systems Communication

International articles

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Titlul articolului

Nume autori

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O n c o l o g y & H e m at o l o g y Issue 3 I Volume 2 I September 2014 PUBLISHED UNDER THE AUSPICES OF THE NATIONAL SOCIETY FOR MEDICAL ONCOLOGY IN ROMANIA; THE ROMANIAN HEMATOLOGICAL SOCIETY; THE ROMANIAN CANCER SOCIETY “VASILE PACURAR”; THE ROMANIAN ASSOCIATION FOR THE STUDY OF PAIN

Senior Editors Prof. Dr. Florin Bădulescu (Universitatea de Medicină şi Farmacie Craiova, Craiova, România) Prof. Dr. Anca Roxana Lupu (Universitatea de Medicină şi Farmacie "Carol Davila", Bucureşti, România) Şef Lucrări Dr. Lucia Stănculeanu (Universitatea de Medicină şi Farmacie "Carol Davila", Bucureşti, România) Şef Lucrări Dr. Simona Mihuţiu (Universitatea de Medicină şi Farmacie Oradea, Oradea, România) Cerc. St. Gr. I. Dr. Grigorescu Alexandru (Institutul oncologic Prof. Dr. Alexandru Trestiorean, Bucureşti, România)

Section Editor

Prevention & Screening Asist. Univ. Mircea O. D. Lupusoru (University of Medicine and Pharmacy “Carol Davila”; Director Medical - Spitalul de Psihiatrie Titan “Dr. C-tin Gorgos”)

Romanian Editorial Board Prof. Dr. Oltean Galafteon (Universitatea of Medicină şi Farmacie Târgu Mureș, Târgu Mureș, România) Prof. Dr. Ljubomir Petrov (Universitatea of Medicină şi Farmacie „Iuliu Haţieganu”, Cluj-Napoca, România) Prof. Dr. Ioniță Hortensia (Universitatea of Medicină şi Farmacie "Victor Babeș" , Timișoara, România) Prof. Dr. Cătălina Poiană (Universitatea of Medicină şi Farmacie "Carol Davila", Bucureşti, România) Conf. Dr. Monica Dragomir (Universitatea of Medicină şi Farmacie "Carol Davila", Bucureşti, România) Conf. Dr. Coriu Daniel (Universitatea of Medicină şi Farmacie "Carol Davila", Bucureşti, România) Conf. Dr. Adriana Coliță (Universitatea of Medicină şi Farmacie "Carol Davila", Bucureşti, România) Conf. Dr. Anca Coliţă (Universitatea of Medicină şi Farmacie “Carol Davila”, Bucureşti, România) Conf. Dr. Horia Bumbea (Universitatea of Medicină şi Farmacie "Carol Davila", București, România) Conf. Dr. Elena Copaciu (Universitatea of Medicină şi Farmacie “Carol Davila”, București, România) Șef Lucrări Dr. Laura Mazilu (Facultatea de Medicină, Universitatea Ovidius, Constanţa, România) Șef Lucrări Dr. Coliță Andrei (Universitatea of Medicină şi Farmacie "Carol Davila", Bucureşti, România) Şef Lucrări Dr. Cristian Silviu Voinea (Universitatea of Medicină şi Farmacie "Carol Davila", Bucureşti, România) Şef Lucrări Dr. Diana Paun (Universitatea of Medicină şi Farmacie “Carol Davila”, Bucureşti, România) Asist. Univ. Gabriela Elena Lupusoru (University of Medicine and Pharmacy “Carol Davila”) Asist. Univ. Dr. Carsote Mara (Universitatea of Medicină şi Farmacie "Carol Davila", Bucureşti, România) Asist. Univ. Dr. Victor Gabriel Clătici (Universitatea of Medicină şi Farmacie “Carol Davila”, Bucureşti, România Asist. univ. dr. Adina Alexandru (Universitate de Medicina si Farmacie "Carol Davila", Bucuresti, Romania) Asist. Univ. Dr. Trandafir Maria Silvia (Universitatea of Medicină şi Farmacie "Carol Davila", Bucureşti, România) Asist. Univ. Dr. Ioana Soare (Universitatea Titu Maiorescu, Facultatea de Medicină, București, România) Dr. Adrian Udrea (Medisprof, Cluj-Napoca, România) Dr. Radu Niculescu (Institutul Clinic Fundeni, Bucureşti, România) Dr. Ana Maria Boeru (Asociaţia Free of Pain, Bucureşti, România) Dr. Virgil Dincă (Asociația Română pentru Studiul Durerii, Bucureşti, România)

International Editorial Board Prof. Dr. med. Anca-L. Grosu (Klinik für Strahlenheilkunde, Universität Freiburg, Freiburg, Germany) Prof. Dr. Shibo Li (University of Oklahoma Health Sciences Center, Oklahoma City, USA) Prof. Dr. Mariusz Z. Ratajczak (University of Louisville, Louisville, USA) Prof. Dr. Arnold Ganser (Hannover Medical School, Hanover, Germany) Prof. Dr. Saverio Bettuzzi (University of Parma Via Volturno, Parma, Italy) Prof. Dr. Lodovico Balducci (Moffitt Cancer Center, Tampa, USA) Prof. Dr. Leonard Wartofsky (Georgetown University School of Medicine, Washington, USA) Prof. Dr. Robert Amato (Memorial Hermann Cancer Center, Texas, USA) Prof Dr. Kevin R. Loughlin (Harvard University, Cambridge, USA) Prof. Dr. Maureen Markman (Drexel University College of Medicine, Philadelphia, USA) Prof. Dr. Stephen P. Hunger (University of Colorado School of Medicine, Colorado, USA) Prof. Dr. M.W.M. van den Brekel (Academic Medical Center Amsterdam, Amsterdam, Netherlands) Prof. Dr. M Sitki Copur (University of Nebraska Medical Center, Nebraska, USA) Prof. Dr. Derek Raghavan (UNC School of Medicine, Levine Cancer Institute, Charlotte, NC, USA) Prof. Dr. Richard J. Ablin (University of Arizona, Arizona, USA) Prof. Dr. Florian Strasser (Cantonal Hospital St. Gallen, Switzerland) Prof. Dr. Michel Rigaud (Scientific advisor - IRST, Meldola, Italy) Associate Prof. Dr. Mishu Popa McKiver (Massachusetts General Hospital, Massachusetts, USA) Assistant Prof. Dr. Alina Mihai (Univ Pittsburgh School Medicine, Pittsburgh, USA) Assistant Prof. Dr. Doru Paul (Hofstra North Shore-LIJ School of Medicine, New York, USA) Assistant Prof. Dr. Bruno Vincenzi (University Campus Bio-Medico, Rome, Italy Assistant Prof. Dr. Elizabeta C. Popa (Weill Cornell Medical College, NY, USA) Assistant Prof. Dr. Gabriela Oprea (Emory University, Atlanta, USA) Dr. Wainer Zoli (Director of the Bioscience Laboratory, IRST, Meldola, Italy) Dr. Ciprian Enachescu (Centre Hospitalier Lyon Sud, Lyon, France) Dr. Javier Martín Broto (Son Espases Hospital, Palma de Mallorca Spain) Dr. David Gómez Almaguer (Universidad Autónoma de Nuevo León, Monterrey, México) Dr. Sankalp Yadav (General Duty Medical Officer-II, Chest Clinic Moti Nagar, North Delhi Municipal Corporation, New Delhi, India)

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EVENTS

Oncogenetica şi terapiile ţintite: O şansă sporită la prelungirea duratei de viaţă

ORIGINAL ARTICLE

Prevention of coronary heart disease (CHD) in prostate cancer patients undergoing androgen deprivation therapy (ADT) Mazilu L, Parepa IR, Suceveanu AI, Catrinoiu D, Tofolean DE

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Castration-resistant prostate cancer Grigorescu AC

INTERNATIONAL ARTICLES

Bevacizumab in Association With de Gramont 5-Fluorouracil/Folinic Acid in Patients With Oxaliplatin-, Irinotecan-, and Cetuximab-Refractory Colorectal Cancer A Single-Center Phase 2 Trial Vincenzi B, Santini D, Russo A, Spoto C, Venditti O, Gasparro S, Rizzo S, Beomonte B, Caricato M, Valeri S, Coppola R, Tonini G

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Intratumoral steroidogenesis in castration-resistant prostate cancer: a target for therapy Armandari I, Hamid AR, Verhaegh G, Schalken J

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Angiotensin (1-7) Antagonist Diminished the Anti-Tumor Effect of Olmesartan in Tumor Cell Lines Grown In-vitro and In-vivo Abd-Alhaseeb MM, Zaitone SA, Abou-El-Ela SH, Moustafa YM

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Events

ONCOGENETICA ŞI TERAPIILE ŢINTITE: O ŞANSĂ SPORITĂ LA PRELUNGIREA DURATEI DE VIAŢĂ Andreea Banea

La Poiana Braşov, a avut loc ediţia a VI-a a Conferinţei Naţionale a Federaţiei Asociaţiilor Bolnavilor de Cancer din România, ce a avut ca temă principală “Oncogenetica, o şansă la viaţă?”, scopul evenimentului fiind creşterea nivelului de informare şi educare asupra oportunităţilor aduse de testările genetice şi de tratamentele personalizate.

Concluziile evenimentului au arătat că medicina personalizată poate fi definită ca tratamentul potrivit pentru pacientul potrivit, la momentul potrivit.

Dacă s-ar adopta pe scară largă principiile medicinei personalizate, bazată pe înţelegerea şi integrarea informaţiei genetice, atunci am beneficia de o medicină preventivă, nu de una reactivă, cum se întâmplă în prezent. Tratamentul optim ar fi mult mai bine selectat şi s-ar reduce prescrierea medicamentelor de tipul încercare-eroare. Cunoscând profilul genetic al pacientului, medicamentele ar fi mai sigure în administrare, datorită evitării efectelor adverse. În consecinţă, ar creşte aderenţa la tratament a pacienţilor şi ar creşte durata şi calitatea vieţii, dar s-ar controla mult mai bine costurile în sistemul sanitar.

“Progresele din ultimii ani, în domeniul oncologiei, au fost extraordinare. Atât ca mod de

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înţelegere a bolilor maligne, cât şi din punctul de vedere al tratamentului. Informaţiile sunt din ce în ce mai ample deoarece medicina evoluează, oncogenetica este un pas pentru pacientul cu cancer, duce către un tratament ţintit care oferă o şansă în plus pacientului şi reacţii adverse minore. Aici s-a vorbit şi de o abordare holistică a pacientului cu cancer, ceea ce ne-a bucurat cel mai mult este că există o unitate firească între medic-pacient, vine mai multă informaţie direct de la specialist, vine şi din mediul privat informaţia şi mâna întinsă către noi pacienţii”, a declarat Cezar Irimia, preşedinte al FABC. “Aducem în România cel mai avansat sistem informaţional de depistare a mutaţiilor genetice și identificare a celei mai eficiente terapii în cancer la nivel mondial, aşadar prezenţa noastră la

ediţia din anul acesta a conferinţei FABC, dedicată şanselor crescute la viaţă pe care oncogenetica le oferă pacienţilor români, a fost un demers firesc.

Este important ca medicii curanţi şi specialiştii oncologi, alături de pacienţii români, să aibă aceeași înţelegere în ceea ce privește medicina personalizată şi genetica moleculară; acestea le oferă şanse reale de a detecta şi iniţia schema de terapie cea mai adecvată tipului lor de tumoare, cu șanse reale de îmbunătățire a vieții și prelungire a acesteia. În contextul standardelor medicinei contemporane, importanţa diagnosticului molecular este esenţială pentru un prognostic cu acurateţe al bolii“, au declarat reprezentanţii ONCOMPASS, cel mai avansat sistem informațional la nivel mondial de identificare a celei mai eficiente terapii personalizate a cancerului.

ONCOMPASS este disponibil şi în România şi cu ajutorul acestui test inovator pacienţii cu cancer pot obţine informaţii referitoare la posibilităţile de tratament țintite disponibile la nivel mondial, personalizate tipului de tumoare, atât din cadrul medicamentelor existente pe piață, cât și din cadrul celor aflate în curs de înregistrare în diverse studii clinice în Europa și în alte regiuni ale globului. KPS, compania care deţine licenţa ONCOMPASS, intermediază includerea acestor pacienți în aceste studii, uti-

lizând o bază de date actualizată în permanenţă, referitoare la testele clinice la nivel mondial.

“Testările farmaco-genetice/genomice repre­z intă calea spre o medicină personalizată, dar e nevoie de multă rigurozitate în recomandarea lor. Astfel, sunt testări obligatorii, acolo unde rezultatele pot fi urmate de o terapie ţintită cu medicamente înregistrate şi cuprinse în ghidurile internaţionale/naţionale de diagnostic şi tratament oncologic, dar şi testări orientative, pentru cazuri selecţionate care nu răspund la terapia standard şi care pot fi urmate de ajustări terapeutice cu medicamente înregistrate, sau în curs de evaluare în studii clinice. Concluzionând, există testări farmacogenetice/genomice a căror valoare în managementul cazului oncologic este deja o certitudine şi testări de la care deocamdată avem doar aşteptări şi care nu trebuie prescrise de rutină, ci doar pentru cazuri atent selecţionate, pentru a nu induce speranţe false şi în acelaşi timp pentru a nu genera o imagine defavorabilă unui “trend” medical cu mare potenţial de viitor, şi anume individualizarea terapiilor oncologice”, a declarat dr. Delia Mateescu, din cadrul Medicover, care a susţinut prezentarea cu tema “Farmaco-genetica - certitudini şi aşteptări“.

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Original article

PREVENTION OF CORONARY HEART DISEASE (CHD) IN PROSTATE CANCER PATIENTS UNDERGOING ANDROGEN DEPRIVATION THERAPY (ADT)

PREVENTION OF CORONARY HEART DISEASE (CHD) IN PROSTATE CANCER PATIENTS UNDERGOING ANDROGEN DEPRIVATION THERAPY (ADT) PREVENŢIA BOLII CORONARIENE (CHD) LA PACIENŢII CU CANCER DE PROSTATĂ ÎN CURS DE TERAPIE DE DEPRIVARE ANDROGENICĂ (ADT) Mazilu Laura, Parepa Irinel-Raluca, Suceveanu Andra-Iulia, Catrinoiu Doina, Tofolean Doina-Ecaterina Faculty of Medicine, Ovidius University, Clinical Emergency Hospital “St. Apostle Andrew” of Constanţa Corresponding author: Laura Mazilu Oncology Department, Clinical Emergency Hospital of Constanţa, Tomis Blvd. no. 145, Constanţa, Romania, 900591 Tel: 0241503485 e-mail: lauragrigorov@gmail.com

Open Access Article

Abstract Keywords: Statins, prostate cancer, coronary heart disease

Received: 13 April 2014 Reviewed: 05 May 2014 Accepted: 10 May 2014

Cite this article: Mazilu L, Parepa IR, Suceveanu AI, Catrinoiu D, Tofolean DE. Prevention of coronary heart disease (CHD) in prostate cancer patients undergoing androgen deprivation therapy (ADT).

Rom J Oncol Hematol.

2014; 2(3):122-126.

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Introduction: In addition to risk factors for coronary heart disease (CHD) that are applicable to the general population, men with prostate cancer are at increased risk for CHD due to the use of androgen deprivation therapy (ADT). Hyperlipidemia, insulin resistance, metabolic syndrome, and CHD are all reported consequences of ADT. The aim of this study was to evaluate strategies to prevent cardiovascular events in newly diagnosed prostate cancer patients undergoing ADT. Methods: We prospectively analyzed 23 patients with prostate cancer, undergoing ADT with a luteinizing hormone-releasing hormone (LHRH/ GnRH) agonist. All patients were evaluated and monitored by a mixed team – oncologist and cardiologist. Patients were assigned to an interventional arm (n=12) which received prophylactic statin therapy with simvastatin or rosuvastatin, and an observational arm (n=11) with no associated statin treatment.

Results: After 12 months of ADT treatment, the lipid profile was normal in the prophylactic statin therapy arm (n=11) in comparison with the noninterventional arm, in which the lipid profile was normal in 3 cases (95% CI, 4.49-7.67; p<0.0001). Impaired fasting glucose levels (110-125 mg/dl) were diagnosed in 3 patients from the interventional arm, and in 2 patients from the observational arm (p=0.2635). After 12 months of ADT treatment, CHD developed in 21.73% (n=5) of men without a preexisting diagnosis of this condition, and was more frequent in the observational arm (n=4, p=0.0289).

Discussion: In our study, prophylactic statin therapy was associated with a normal lipid profile and a lower incidence of new cases of CHD after 12 months of ADT treatment. Statins are a safe option with only 8.33% of our patients developing mild adverse events.

Mazilu L, Parepa IR, Suceveanu AI, Catrinoiu D, Tofolean DE

Rezumat Cuvinte-cheie: Statine, cancer de prostată, boală coronariană

Introducere: În plus faţă de factorii de risc pentru boala coronariană (CHD), factori care sunt aplicabili populaţiei generale, pacienţii cu cancer de prostată prezintă un risc crescut pentru CHD din cauza utilizării terapiei de deprivare androgenică (ADT). Hiperlipidemia, rezistenţa la insulină, sindromul metabolic şi CHD sunt toate consecinţe ale utilizării ADT. Scopul studiului nostru a fost de a evalua strategiile de prevenire a CHD la pacienţii cu cancer de prostată nou diagnosticat, în curs de ADT. Metode: Am analizat prospectiv 23 de pacienţi cu cancer de prostată, în curs de ADT cu un agonist LHRH/GnRH. Toţi pacienţii au fost evaluaţi şi monitorizaţi de către o echipă mixtă – oncolog şi cardiolog, pe parcursul unui an de tratament. Pacienţii au fost repartizaţi într-un braţ intervenţional (n=12), care au primit tratament profilactic cu statine şi un braţ observaţional (n=11), fără tratament cu statine.

Rezultate: După 12 luni de tratament ADT, profilul lipidic a fost normal în braţul intervenţional (n=11), comparativ cu braţul observaţional, în care profilul lipidic a fost normal în doar 3 cazuri (95% CI, 4,49-7,67; p<0,0001).

Toleranţa alterată la glucoză (110-125 mg/dl) a fost diagnosticată la 3 pacienţi din braţul intervenţional şi la 2 pacienţi din braţul observaţional (p=0,2635). După 12 luni de ADT, CHD a fost diagnosticată la 21,73% din pacienţii fără un diagnostic preexistent de afectare coronariană (n=1 în braţul intervenţional, n=4 în braţul observaţional; p=0,0289 ) şi a constat în angină pectorală stabilă (n=3) şi sindroame coronariene acute (1 caz de angină pectorală instabilă şi 1 caz de sindrom coronarian acut).

Discuţie: În studiul nostru, tratamentul profilactic cu statine a fost asociat cu un profil lipidic normal şi o incidenţă mai scăzută de cazuri noi de CHD după 12 luni de tratament ADT. Tratamentul cu statine reprezintă o opţiune terapeutică fezabilă şi sigură, doar 8,33% dintre pacienţii noştri dezvoltând evenimente adverse uşoare.

Introducere Având în vedere prevalenţa crescută a cancerului de prostată la bărbații cu vârste de peste 50 de ani, bărbaţii cu risc pentru cancerul de prostată reprezintă aceeaşi populaţie de pacienţi cu risc de sindrom metabolic, diabet zaharat şi boală coronariană (CHD) (1).

Factorii majori de risc pentru CHD includ vârsta >45 ani, sexul masculin, istoricul familial pozitiv, nivelul crescut al LDL-colesterolului, nivelul scăzut al HDL-colesterolului, hipertensiunea arterială, diabetul zaharat şi consumul de tutun. În plus faţă de aceşti factori de risc pentru CHD, factori aplicabili populaţiei generale, bărbații cu cancer de prostată prezintă risc crescut pentru CHD ca urmare a utilizării terapiei de deprivare androgenică (ADT) (1) . Hiperlipidemia, rezistenţa la insulină, sindromul metabolic şi sindromul coronarian acut, toate reprezintă consecinţe raportate ale ADT. Studiile clinice prospective au demonstrat că ADT poate creşte riscul bolilor cardiovasculare prin creşterea greutăţii corporale, reducerea sensibilităţii la insulină şi/sau ca urmare a dislipidemiei secundare (2). ADT scade semnificativ masa

musculară şi creşte ţesutul adipos (2-7). Aceste modificări ale masei musculare şi ale ţesutului adipos par a fi în primul rând un efect negativ precoce, majoritatea lor devenind aparente în primele luni de terapie (2,8,9).

ADT creşte, de asemenea, nivelurile serice ale colesterolului şi trigliceridelor, iar majoritatea modificărilor observate pe termen lung ale lipidelor serice sunt evidente în primele 3 luni de tratament (2,5,10,11).

Rezistenţa la insulină este o anomalie metabolică frecventă, care stă la baza diabetului zaharat tip 2 şi este prevalentă la aproximativ 1/4 din pacienţii de sex masculin non-diabetici (2,12). Unele studii au raportat hiperinsulinemia ca şi factor de risc independent pentru boala cardiovasculară (2,13,14) . ADT creşte nivelurile plasmatice ale insulinei à jeun, niveluri care reprezintă un marker de rezistenţă la insulină la pacienţii cu cancer de prostată (2,4,15). Un studiu prospectiv efectuat pe pacienţi de sex masculin nediabetici a evidenţiat faptul că ADT creşte semnificativ (26%) nivelurile plasmatice ale insulinei à jeun, şi scade sensibilitatea la insulină (13%) (2,11).

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Original article

PREVENTION OF CORONARY HEART DISEASE (CHD) IN PROSTATE CANCER PATIENTS UNDERGOING ANDROGEN DEPRIVATION THERAPY (ADT)

Figura 1. Profilul lipidic după 12 luni de ADT

Figura 2. Incidenţa CHD după 12 luni de ADT

Mai multe studii recente au sugerat o asociere a ADT cu analogii LHRH (cu sau fără antiandrogen) sau orhiectomie bilaterală şi creşterea incidenţei şi mortalităţii prin boli cardiovasculare (2,16-20).

Scopul acestui studiu a fost de a evalua strategiile de prevenire a evenimentelor cardiovasculare la pacienţii cu cancer de prostată nou diagnosticat, în curs de ADT.

Metode Am analizat prospectiv 23 de pacienţi cu cancer de prostată în curs de ADT cu un agonist LHRH/GnRH. Pacienţii cu diabet preexistent sau cu profil lipidic/glicemic anormal au fost excluşi din studiu. Toţi pacienţii au fost evaluaţi şi monitorizaţi de către o echipă mixtă – medic oncolog şi cardiolog.

Profilul lipidic (colesterol total, LDL-colesterol, HDL-colesterol şi trigliceride), profilul glicemic, valorile tensiunii arteriale (TA) şi greutatea corporală

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au fost evaluate la începutul studiului şi apoi analizate la fiecare 3 luni.

Pacienţii au fost repartizaţi într-un braţ intervenţional (n=12), care a primit tratament profilactic cu statine – simvastatină 20-40mg/zi sau rosuvastatină 10 mg/zi şi un braţ observaţional (n=11), fără tratament cu statine. Pacienţii din braţul intervenţional au fost testaţi pentru nivelurile serice ale transaminazelor după 1 lună de tratament cu statine (pentru a evidenţia nivelul crescut al transaminazelor secundar tratamentului cu statine).

De asemenea, toţi pacienţii au fost consiliaţi cu privire la modificările stilului de viaţă – dietă, scădere în greutate, activitate fizică, iar cei care au continuat să fumeze au fost consiliaţi pentru a opri fumatul şi au fost îndrumaţi către programe de renunţare la fumat.

Toţi pacienţii cu hipertensiune arterială (HTA) preexistentă sau nou diagnosticaţi au primit medicaţie anti-hipertensivă (ACEis/ARBs,

Mazilu L, Parepa IR, Suceveanu AI, Catrinoiu D, Tofolean DE

Figura 3. Incidenţa CHD după 12 luni de ADT, comparativ între cele 2 braţe.

– intervenţional, respectiv observaţional

Figura 4. Cazuri noi de HTA/agravarea HTA preexistentă la 12 luni de ADT

blocante ale canalelor de Ca), pentru a menţine valorile TA în limitele recomandate de ghiduri.

Datele au fost analizate cu ajutorul Graph Pad InStat si Graph Prism 5.

Rezultate Tratamentul profilactic cu statine a fost întrerupt după 6 luni de tratament într-un singur caz, ca urmare a nivelului crescut al transaminazelor serice (8,33%).

După 12 luni de tratament ADT, profilul lipidic a fost normal în braţul de terapie profilactică cu statine (n=11), comparativ cu braţul observațional, în care profilul lipidic a fost normal în 3 cazuri (95% CI, 4.49-7.67, r2=0,86, p<0,0001) (fig. 1).

Majoritatea modificările observate ale lipidelor serice au devenit evidente din primele 3 luni de tratament (n=6, p=0,0786) şi au constat în creşterea colesterolului seric total, a LDL-colesterolului, HDLcolesterolului şi trigliceridelor.

După 12 luni de tratament nivelul mediu al trigliceridelor serice a crescut cu 30% (p=0,0004).

Greutatea corporală medie a crescut cu până la 2,9% după 12 luni de tratament ADT. Creşterea nivelurilor glicemiei à jeun (110-125mg/dl) a fost diagnosticată la 3 pacienţi din braţul intervenţional şi la 2 pacienţi din braţul observaţional (p=0.2635) şi toţi pacienţii au primit tratament antiagregant plachetar (în general aspirină, 81mg/zi) pentru tratamentul statusului protrombotic şi reducerea riscului de CHD. Creşterea riscului de diabet a fost evidentă după 3-6 luni de la iniţierea ADT. După 12 luni de ADT, CHD s-a dezvoltat la 5 pacienţi fără afectare/diagnostic preexistent şi a constat în angină pectorală stabilă (n=3) şi sindroame coronariene acute (1 caz de angină pectorală instabilă şi 1 caz de sindrom coronarian acut – STEMI) şi a fost mai frecventă în braţul observaţional (n=4, p=0,0289) (fig. 2 şi fig. 3). Incidenţa cazurilor noi de hipertensiune arterială sau agravarea cazurilor preexistente a fost mai mică în braţul intervenţional (3 September 2014

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Original article

PREVENTION OF CORONARY HEART DISEASE (CHD) IN PROSTATE CANCER PATIENTS UNDERGOING ANDROGEN DEPRIVATION THERAPY (ADT)

versus 5 cazuri, p=0,1587) şi toţi pacienţii au primit terapie antihipertensivă pentru a reduce TA la valori <130-140/80-90mmHg (fig. 4).

Discuţie Studiul nostru a demonstrat, similar altor studii, creşterea riscului de boală cardiovasculară la pacienţii cu cancer de prostată în curs de ADT (2,16-20).

Riscul de boală cardiovasculară la pacienţii din studiu a fost un risc compozit, rezultat prin creşterea greutăţii corporale (până la 2,9% după 12 luni de ADT), reducerea sensibilităţii la insulină (creşterea nivelurilor glicemiei à jeun) şi dislipidemiei secundare. Creşterea riscului de diabet a fost evidentă după 3-6 luni de la iniţierea ADT. Similar datelor din literatură (2,5,10,11) majoritatea modificările observate ale lipidelor serice au devenit evidente din primele 3 luni de tratament şi au constat în creşterea colesterolului seric total, a LDL-colesterolului, HDL-colesterolului şi trigliceridelor. Studiile arată că ADT, în general, creşte şi nu scade HDL-colesterolul şi nu modifică valorile TA (2,5,8), dar în studiul nostru a existat un număr de 8 cazuri de HTA nou diagnosticată, numărul de cazuri fiind mai mic în braţul intervenţional, probabil datorită efectului protector exercitat de statine împotriva disfuncţiei endoteliale (21). În studiul nostru tratamentul profilactic cu statine a fost asociat cu un profil lipidic normal şi o incidenţă mai scăzută a cazurilor noi de CHD după 12 luni de

tratament ADT. Statinele reprezintă o opţiune sigură, doar 8,33% dintre pacienţii noştri dezvoltând evenimente adverse uşoare. Pacienţii trebuie încurajaţi să adopte un stil de viaţă sănătos, inclusiv renunţarea la fumat, reducerea excesului ponderal şi exercițiul fizic.

La iniţierea ADT, trebuie efectuate glicemia à jeun sau un test de toleranţă orală la glucoză şi profilul lipidic. Aceste teste ar trebui repetate la fiecare 3 luni în primul an de ADT, deoarece modificările legate de tratament au tendinţa de a se dezvolta în primele câteva luni de tratament.

Administrarea pe termen lung a ADT pentru tratamentul cancerului de prostată creşte riscul de sindrom metabolic, diabet şi CHD. Oncologii trebuie să fie pe deplin conştienţi de riscurile cardiovasculare pentru a evita sau a preveni efectele adverse cardiovasculare iar cardiologii trebuie să ajute oncologii prin efectuarea de evaluări relevante în alegerea terapiei, fiind prin urmare nevoie de cooperare între aceste două specialităţi, în vederea unui tratament optim al pacienţilor cu cancer de prostată.

Conflict of Interests: None.

This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

Bibliografie 1. Kintzel PE et al. Increased Risk of Metabolic Syndrome, Diabetes Mellitus, and Cardiovascular Disease in Men Receiving Androgen Deprivation Therapy for Prostate Cancer. Pharmacotherapy. 2008; 28(12):1511-1522.

2. Levine GN, D’Amico AV, Berger P et al. Androgen-deprivation therapy in prostate cancer and cardiovascular risk: A science advisory from the American Heart Association, American Cancer Society, and American Urological Association: Endorsed by the American Society for Radiation Oncology.

Circulation. 2010; 121:833-840.

3. Tayek JA, Heber D, Byerley LO et al. Nutritional and metabolic effects of gonadotropin-releasing hormone agonist treatment for prostate cancer.

Metabolism. 1990; 39:1314-1319.

4. Smith JC, Bennett S, Evans LM et al. The effects of induced hypogonadism on arterial stiffness, body composition, and metabolic parameters in males with prostate cancer. J Clin Endocrinol Metab. 2001; 86:4261-4267.

5. Smith MR, Finkelstein JS, McGovern FJ et al. Changes in body composition during androgen deprivation therapy for prostate cancer. J Clin Endocrinol Metab. 2002; 87:599-603.

6. Berruti A, Dogliotti L, Terrone C, Cerutti S, Isaia G, Tarabuzzi R, Reimondo G, Mari M, Ardissone P, De Luca S, Fasolis G, Fontana D, Rossetti SR, Angeli A, Gruppo Onco Urologico Piemontese (G.O.U.P.), Rete Oncologica Piemontese. Changes in bone mineral density, lean body mass and fat content as measured by dual energy x-ray absorptiometry in patients with prostate cancer without apparent bone metastases given androgen deprivation therapy. J Urol. 2002; 167:2361-2367.

7. Smith MR. Changes in fat and lean body mass during androgen-deprivation therapy for prostate cancer. Urology. 2004; 63:742-745.

8. Smith MR, Lee H, McGovern F et al. Metabolic changes during gonadotropinreleasing hormone agonist therapy for prostate cancer: differences from the classic metabolic syndrome. Cancer. 2008; 112:2188-2194.

9. Lee H, McGovern K, Finkelstein JS, Smith MR. Changes in bone mineral density and body composition during initial and long-term gonadotropin releasing hormone agonist treatment for prostate carcinoma. Cancer. 2005; 104:1633-1637.

10. Eri LM, Urdal P, Bechensteen AG. Effects of the luteinizing hormonereleasing hormone agonist leuprolide on lipoproteins, fibrinogen and

126

plasminogen activator inhibitor in patients with benign prostatic hyperplasia.

J Urol. 1995; 154:100-104.

11. Smith MR, Lee H, Nathan DM. Insulin sensitivity during combined androgen blockade for prostate cancer. J Clin Endocrinol Metab. 2006; 91:1305-1308.

12. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2008; 31(Suppl. 1):S55-S60.

13. Despres JP, Lamarche B, Mauriege P et al. Hyperinsulinemia as an independent risk factor for ischemic heart disease. N Engl J Med. 1996; 334:952-957.

14. Pyorala M, Miettinen H, Laakso M, Pyorala K. Hyperinsulinemia predicts coronary heart disease risk in healthy middle-aged men: the 22-year follow-up results of the Helsinki Policemen Study. Circulation.

1998; 98:398-404.

15. Dockery F, Bulpitt CJ, Agarwal S, Donaldson M, Rajkumar C. Testosterone suppression in men with prostate cancer leads to an increase in arterial stiffness and hyperinsulinaemia. Clin Sci (Lond). 2003; 104:195-201.

16. Keating NL, O’Malley AJ, Smith MR. Diabetes and cardiovascular disease during androgen deprivation therapy for prostate cancer. J Clin Oncol.

2006;24:4448-4456.

17. Saigal CS, Gore JL, Krupski TL, the Urologic Diseases in America Project et al.

Androgen deprivation therapy increases cardiovascular morbidity in men with prostate cancer. Cancer. 2007;110:1493-1500.

18. D’Amico AV, Denham JW, Crook J et al. Influence of androgen suppression therapy for prostate cancer on the frequency and timing of fatal myocardial infarctions. J Clin Oncol. 2007; 25:2420-2425.

19. Tsai HK, D’Amico AV, Sadetsky N, Chen MH, Carroll PR. Androgen deprivation therapy for localized prostate cancer and the risk of cardiovascular mortality. J Natl Cancer Inst. 2007;99:1516-1524.

20. D’Amico AV, Chen MH, Renshaw AA, Loffredo M, Kantoff PW. Causes of death in men undergoing androgen suppression therapy for newly diagnosed localized or recurrent prostate cancer. Cancer. 2008;113:3290-3297.

21. Mason RP, Walter MF, Jacob RF. Effects of HMG-CoA reductase inhibitors on endothelial function: role of microdomains and oxidative stress. Circulation.

2004; 109(21Suppl.1):II34-41.

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Original article

Castration-resistant prostate cancer

CASTRATION-RESISTANT PROSTATE CANCER CANCERUL DE PROSTATĂ REZISTENT LA CASTRARE Alexandru C. Grigorescu Cercetător ştiinţific gradul I, mdic primar oncologie medical, Institutul Oncologic Bucureşti Corresponding author: CSI Dr. Alexandru C. Grigorescu e-mail: alexgrigorescu2004@yahoo.com

Open Access Article

Abstract Keywords: Prostate cancer, treatment, metastasis

Prostate cancer is the most common cancer in men in the United States and in the world compete for first place with lung cancer. The incidence and mortality of prostate cancer is high, especially with an aging population. We intend to discuss about some aspect of diagnosis, staging and treatment of prostate cancer, emphasizing the castration-resistant prostate cancer (CRPC). Definition of castration-resistant prostate cancer is important to diagnose this clinical entity and to initiate appropriate treatment. Thus CRPC is defined as an evolution of PSA or metastasis, most frequent bone localized, patient having the corresponding values ​​of testosterone castration. CRPC is complex treatment including radiotherapy (radium 223), immunotherapy (Sipuleucel-T), hormonal manipulation and chemotherapy. Hormonal manipulation is already classic but the new treatment compounds: abiraterone and enzalutamide bring an increase in survival and a positive impact on symptoms. CRPC benefit from classical chemotherapy plus a new efficient cytostatic Cabazitaxel used today after developing resistance to docetaxel.

Rezumat Cuvinte-cheie: cancer de prostată, tratament, metastaze Received: 05 Sept 2014 Reviewed: 10 Sept 2014 Accepted: 15 Sept 2014 Cite this article: Grigorescu AC. Castration-resistant prostate cancer.

Rom J Oncol Hematol.

2014; 2(3):128-130.

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Cancerul de prostată este cel mai frecvent cancer la bărbat în Statele Unite, iar în lume îşi dispută locul întâi cu cancerul bronhopulmonar.

Incidenţa şi mortalitatea prin cancer de prostată este ridicată mai ales prin îmbătrânirea populaţiei. Ne propunem să discutăm despre câteva aspecte ale diagnosticului, stadializării şi tratamentului cancerului de prostată, accentuând asupra cancerului de prostată rezistent la castrare (CRPC). Definiţia cancerului de prostată rezistent la castrare este importantă pentru a putea diagnostica această entitate clinică şi pentru a iniţia un tratament adecvat. Astfel, CRPC se defineşte ca o evoluţie a PSA sau a metastazelor, cel mai frecvent osoase, la valori ale testosteronului corespunzând castrării. Tratamentul CRPC este complex cuprinzând radioterapia (radium 223), manipularea hormonală şi chimioterapia, imunoterapia (Sipuleucel-T). Manipularea hormonală este deja un tratament clasic, dar noii compuşi - abiraterona şi enzalutamida - aduc o creştere în supravieţuire şi un impact pozitiv asupra simptomatologiei. La chimioterapia clasică se adaugă astăzi şi cabazitaxelul, un citostatic eficient după apariţia rezistenţei la docetaxel.

Grigorescu AC

Introducere La nivel mondial, neoplasmul de prostată reprezintă al doilea cel mai frecvent tip de cancer diagnosticat la bărbați, în timp ce în Europa este cel mai frecvent diagnostic de cancer la bărbați.

Prevalența globală a cancerului de prostată în 2008 a fost 21,1 la 100.000 de persoane, cu o rată de deces de 4,6 la 100.000 (echivalentul a 258.000 de decese); iar în Europa, incidența acestui tip de cancer în 2008 a fost de 110,5 la 100.000. Prevalența cancerului de prostată va crește în continuare, o dată cu îmbătrânirea populației din țările europene. Deși rata de supraviețuire la 5 ani în cancerul de prostată este 87,2%, se estimează că 10-20% dintre pacienți vor progresa către stadiul rezistent la castrare într-o perioadă de 5 ani. Dintre aceștia, mai mult de 84% vor avea metastaze la momentul diagnosticului(1).

Diagnosticul Diagnosticul cancerului de prostată se pune prin biopsie de prostată. Decizia pentru a face biopsia se ia pe baza creşterii valorilor PSA şi a tuşeului rectal care relevă semnele clinice ale unei tumori de prostată. Este important a se corela valoarea globală a PSA cu free PSA, velocitatea PSA şi densitatea PSA. Cancerul de prostată poate fi stadializat după gradul de risc. Pacienţii care au comorbidităţi importante sau nu se încadrează pentru un tratament cu intenţie de radicalitate nu trebuie investigaţi complet în vederea stadializării. Stadializarea clinică se face prin tuşeu rectal, ecografie,

RMN şi prin analiza PSA. Categoriile de risc sunt următoarele: risc scăzut la cei cu T1-2a, Gleason mai mic decât 7 şi PSA mai mic decât 10, risc crescut când există T3-4, Gleason mai mare decât 7 şi PSA peste 20 şi riscul intermediar între cele două.

Definiția noţiunii de cancer de prostată rezistent la castrare Cancerul de prostată rezistent la castrare (CRPC) este definit de progresia bolii în ciuda terapiei de deprivare androgenică (ADT) şi poate să se manifeste printr-o creștere continuă a concentrațiilor serice ale antigenului specific prostatic (PSA), progresia bolii preexistente, apariția de noi metastaze, sau combinaţia acestor aspecte evolutive.

Cancerul de prostată avansat a fost cunoscut sub mai multe denumiri de-a lungul anilor, inclusiv cancer de prostată hormono-rezistent (HRPC) sau androgen insensibil. Cel mai recent, termenii “castrat-rezistent” sau “castrat recurent” au fost introduşi cu realizarea că producția de androgeni intracrină și paracrină joacă un rol important în rezistența celulelor cancerului de prostată la tratamentul de supresie a testosteronului(2).

Grupul de studiu al cancerului de prostată (PCWG2) a definit CRPC în baza metastazelor detectabile (clinic sau prin imagistică) și dacă testosteronului seric este în intervalul de castrare prin orhiectomie chirurgicală sau terapia medicală(3).

Cancerul de prostată rezistent la castrare prezintă un spectru de boli variind de la creşterea nivelului PSA fără metastaze sau simptome în ciuda ADT, până la prezenţa metastazelor și a September 2014

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Original article deteriorării semnificative simptomatice. Prognosticul este asociat cu mai multi factori, printre care starea de performanță, prezența de dureri osoase, gradul de extindere a metastazelor osoase, precum și nivelurile serice ale fosfatazei alcaline. Metastaze osoase apar la 90% dintre bărbaţii cu CRPC și pot produce morbiditate semnificativă, inclusiv durere, fracturi patologice, compresie medulară și insuficiență medulară.

Efectele paraneoplazice sunt, de asemenea, comune, inclusiv anemie, scădere în greutate, oboseală, hipercoagulabilitate și susceptibilitate crescute la infecţii(4).

Tratament Sunt multiple mijloace terapeutice incluzând terapia imună ( Sipuleucel-T) radioterapia (radium 223), terapia hormonală.

Vom discuta mai mult despre terapia hormonală care este apanajul oncologului medical.

La pacienții tratați cu monoterapie, utilizând agonişti LH-RH sau la cei la care s-a practicat orhiectomia, se poate recomanda blocada totală de androgeni cu antagoniști de testosteron, cum ar fi bicalutamida.Acest tratament poate avea o rată de răspuns de 30-35%.

Pentru pacienții care au suferit blocada totală androgenică și prezintă semne de progresie, anti-androgenul poate fi întrerupt în încercarea de a obține un răspuns de retragere antiandrogenică.

Răspunsul la această manipulare hormonală apare la 20%-30% dintre pacienți. Alte opțiuni ar putea include o schimbare cu un antiandrogen diferit, cum ar fi nilutamida sau flutamida, sau utilizarea de ketoconazol 7. Pentru toate aceste modalități, au fost raportate reduceri tranzitorii ale PSA la aproximativ 30% dintre pacienți.

Pentru că receptorul androgenic rămane activ la majoritatea pacienților care au dezvoltat boala rezistentă la castrare, grupuri cum ar fi American Society of Clinical Oncology (ASCO), Comprehensive National Cancer Network (NCCN) recomandă ca ADT ar trebui să fie continuată.

Chimioterapia Societatea Europeană de Oncologie Medicală (ESMO) recomandă ca primă linie de chimioterapie, monochimioterapia cu docetaxel care poate fi administrat în doze la 2 sau la 3 săptămâni.

Castration-resistant prostate cancer

În linia a doua de chimioterapie se poate folosi mitoxantronul sau recentul citostatic cu acţiune la nivelul tubulinei, cabazitaxelul asociat cu prednison, care în studii clinice s-a dovedit mai eficient decât mitoxantronul asociat cu prednison(5).

Noi agenţi terapeutici În ultimii ani s-au dezvoltati mai mulţi agenţi terapeutici noi care acţionează specific asupra receptorilor androgenici sau a producţiei de androgeni.

Compuşii care s-au impus în practica clinică sunt abiraterona şi enzalutamida.

Abiraterona A fost aprobata în urma rezultatelor obţinute în studiul COU-AA-301, un studiu de fază III- versus placebo.

Acest produs este indicat pentru utilizare în asociere cu prednison ca un tratament pentru cancerul de prostata metastatic rezistent la castrare. A primit aprobare din partea FDA şi EMA în 2011(6).

Abiraterona se administrează în asociere cu prednisonul.

Enzalutamida Enzalutamida este un antagonist al receptorilor androgenici, care inhibă proliferarea celulelor neoplazice ale cancerului de prostată, cu inducerea apoptozei celulelor neoplazice și regresie tumorală.

Nu prezintă activitate agonistă asupra receptorilor androgenici.

Studiul AFFIRM a demonstrat că, în comparație cu BSC (best standard of care), enzalutamida a determinat creșterea semnificativă a supraviețuirii generale (valoare mediană) cu 4,8 luni și a perioadei fără progresia bolii (confirmată radiologic) cu 5,4 luni, cu reducerea semnificativă a răspunsului PSA cu 54%, în condițiile în care au fost raportate mai puține evenimente adverse grave comparativ cu BSC și semnificativ mai puține cazuri de deteriorare a calității vieții pacienților. Enzalutamida este de asemenea aprobată de FDA şi EMA pentru tratamentul cancerului de prostată rezistent la castrare(7).

Conflict of Interests: None.

This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

Bibliografie 1. Ferlay J et al, Cancer incidence and mortality patterns in Europe: incidence for 40 countries in 2012. European Journal of Cancer (2013) 49, 1374– 1403.

2. Mostaghel EA, Page ST, Lin DW, et al. Intraprostatic androgens and androgenregulated gene expression persist after testosterone suppression: therapeutic implications for castration-resistant prostate cancer. Cancer Res.2007;67:5033–41.

3. Scher HI, Halabi S, Tannock I, et al. Design and end points of clinical trials for patients with progressive prostate cancer and castrate levels of testosterone: recommendations of the Prostate Cancer Clinical Trials Working Group. J Clin Oncol. 2008;26:1148–59) .

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4. Curr Oncol. Sep 2010; 17(Suppl 2): S72–S79., 5.

5. PMCID: PMC2935714,Current management of castrate-resistant prostate cancer, S.J. Hotte, MD MSc* and F. Saad, MD† 6. http://www.esmo.org/Guidelines/Genitourinary-Cancers/Prostate-Cancer “ZYTIGA (abiraterone acetate) tablet [Janssen Biotech, Inc.]”. DailyMed. Janssen Biotech, Inc. September 2013. Retrieved 24 January 2014.

7. http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_ Information/human/002321/WC500112858.pd

Nume autori

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131

International articles

Bevacizumab in Association With de Gramont 5-Fluorouracil/Folinic Acid in Patients With Oxaliplatin-, Irinotecan-, and Cetuximab-Refractory Colorectal Cancer

BEVACIZUMAB IN ASSOCIATION WITH DE GRAMONT 5-FLUOROURACIL/FOLINIC ACID IN PATIENTS WITH OXALIPLATIN-, IRINOTECAN-, AND CETUXIMAB-REFRACTORY COLORECTAL CANCER A SINGLE-CENTER PHASE 2 TRIAL Bruno Vincenzi, MD1; Daniele Santini, MD1; Antonio Russo, MD2; Chiara Spoto, MD1; Olga Venditti, MD1; Simona Gasparro, MD1; Sergio Rizzo, MD2; Bruno Beomonte Zobel, MD3; Marco Caricato, MD4; Sergio Valeri, MD4; Roberto Coppola, MD4; and Giuseppe Tonini, MD1 Corresponding author: Antonio Russo, MD, Section of Medical Oncology, Department of Surgery and Oncology, Universita` di Palermo, Via del Vespro 129, 90127 Palermo, Italy; Fax: (011) 39-091-6554529; lab-oncobiologia@usa.net 1Department of Medical Oncology, Campus Bio-Medico University, Rome, Italy; 2Section of Medical Oncology, Department of Surgery and Oncology, University of Palermo, Palermo, Italy; 3Department of Radiology, Campus Bio-Medico University, Rome, Italy; 4Department of General Surgery, Campus Bio-Medico University, Rome, Italy

Open Access Article Published online July 22, 2009 in Wiley InterScience DOI: 10.1002/cncr.24540, www.interscience.wiley.com Published 15 October 2009 in Cancer

Abstract Keywords:

Received: 11 Nov 2008 Reviewed: 25 March 2009 Accepted: 27 March 2009 Cite this article: Vincenzi B, Santini D, Russo A, Spoto C, Venditti O, Gasparro S, Rizzo S, Beomonte B, Caricato M, Valeri S, Coppola R, Tonini G. Bevacizumab in Association With de Gramont 5-Fluorouracil/ Folinic Acid in Patients With Oxaliplatin-, Irinotecan-, and Cetuximab-Refractory Colorectal Cancer.

Rom J Oncol Hematol.

2014; 2(3):132-138.

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bevacizumab, de Gramont, colorectal cancer, 5-fluorouracil, folinic acid

BACKGROUND: The aim of the current study was the investigation of the value of bevacizumab þ 5-fluo- rouracil(5–FU)/folinic acid in patients with advanced colorectal cancers who have exhausted standard chemotherapy options. METHODS: The authors included 48 heavily pretreated patients (colon:rectum, 33:15; men:women, 23:25; median age, 63 years; range, 27-79 years) whose disease had progressed during or within an oxaliplatin-based first-line chemotherapy, an irinotecan-based second-line regimen, and a thirdline treatment with cetuximab plus weekly irinotecan. Bevacizumab was given at a dose of 5 mg/kg.

5-FU/folinic acid was administered according to the de Gramont schedule. RESULTS: The response rate was 6.25%, and 30.4% of patients demonstrated stable disease as the best response. The median time to disease progression was 3.5 months (95% confidence interval [95% CI], 2.3-6.9 months), and the median survival time was 7.7 months (95% CI, 3.9-11.9 months). The most common grade 3 to 4 side toxicities (graded according to the National Cancer Institute Common Toxicity Criteria [version 2.0]) were: diarrhea (20.8%), fatigue (14.5%), and stomatitis (12.5%). Grade 3 to 4 hemorrhage occurred in 8 patients (16.6%), including 4 cases of bleeding in the gastrointestinal tract. Other relatively common adverse events such as hypertension, thrombosis, and bowel perforation were reported in 50%, 18.7%, and 4.16%, of patients respectively.

CONCLUSIONS: The data from the current study suggest a modest but significant clinical benefit of bevacizumab þ de Gramont schedule in heavily pretreated colorectal cancer patients. Cancer 2009;115:4849–56.

VC 2009 American Cancer Society.

Vincenzi B, Santini D, Russo A, Spoto C, Venditti O, Gasparro S, Rizzo S, Beomonte B, Caricato M, Valeri S, Coppola R, Tonini G

Bevacizumab is a humanized immunoglobulin G1 murine antibody directed against all isoforms of vascular endothelial growth factor (VEGF)-A.1 To our knowledge to date, it is the most clinically advanced monoclonal antibody (MoAb) targeting the VEGF signaling pathway and the only 1 currently approved for use in the treatment of metastatic colorectal cancer (MCRC).

A randomized phase 2 trial (AVF0780) investigated the safety and efficacy of 2 dose levels of bevacizumab in combination with 5-fluorouracil (5–FU)/leucovorin in patients with MCRC.2 The 2 treatment arms that included bevacizumab (at doses of 5 mg/kg or 10 mg/kg, respectively) resulted in higher risk ratios (40% and 24%, respectively) and a longer median time to disease progression (9 months and 7.2 months, respectively) and median overall survival (OS) (21.5 months and 16.1 months, respectively) compared with the control arm comprised of 5-FU/leucovorin alone (5.2 months and 13.6 months, respectively).

However, because higher clinical efficacy was noted in the 5-mg/kg arm compared with the 10mg/kg arm, the 5-mg/kg dose of bevacizumab was chosen for further clinical study. Although bevacizumab was generally well tolerated, this trial identified several important safety signals, including an increased incidence of thromboembolic complications, hypertension, proteinuria, bleeding complications in the form of epistaxis, headache, fever, and rash. In general, however, these adverse events were either clinically insignificant or were easily managed.

Some phase 3 trials have confirmed the preliminary efficacy data published by Kabbinavar et al.2 In a pivotal randomized phase 3 study, previously untreated patients with advanced colorectal cancer (CRC) who received bevacizumab and weekly irinotecan plus bolus 5-fluorouracil/leucovorin (IFL) regimen had longer progressionfree survival (PFS) (10.6 months vs 6.2 months; P < .00001) and survived significantly longer (20.3 months vs 15.6 months; P ¼ .00003) than those receiving IFL chemotherapy alone plus placebo.3 The only adverse event that occurred with greater frequency with the anti-VEGF regimen was grade 3 (graded according to the National Cancer Institute Common Toxicity Criteria [version 2.0]) hypertension, which was managed effectively with oral medications.

In addition to being combined with either 5-FU/ leucovorin or the bolus weekly IFL schedule, bevacizumab has been studied with oxaliplatin-based chemotherapy in the second-line setting. In the study published by Giantonio et al, patients with advanced CRC, who were previously treated with 5-FU—based therapy and

irinotecan for advanced or recurrent disease after adjuvant chemotherapy, were randomized to 1 of 3 treatment arms, including FOLFOX-4, FOLFOX-4 and bevacizumab, and bevacizumab alone.4 The results of this trial demonstrated that the addition of bevacizumab to oxaliplatin, 5–FU, and leucovorin improves the duration of survival for patients with previously treated MCRC that was refractory to irinotecan-based chemotherapy. In contrast to the randomized first-line trial, Chen et al failed to demonstrate any benefit in terms of response rate, finding that the association of bevacizumab and 5-FU/ leucovorin was associated with rare objective responses.5 The main purpose of the current study was to evaluate the efficacy and safety of the association of bevacizumab and 5-FU/folinic acid in an extremely pretreated but homogeneous population of CRC patients.

MATERIALS AND METHODS Patients We considered patients eligible if they were aged >18 years and had stage IV, histologically confirmed, colorectal adenocarcinoma (grading determined according to the American Joint Committee on Cancer staging system).

Other criteria for eligibility were: an Eastern Collaborative Oncology Group (ECOG) performance staus of <2 and adequate hematologic function (hemoglobin of >9 g/dL, neutrophil count of >1500/mm 3, and platelet count of >100,000/mm 3), renal function (serum creatinine <1.5 times the upper limit of normal), and liver function (total bilirubin <1.5 times the upper limit of normal range; aspartate aminotransferase and alanine aminotransferase <5 times the upper limit of normal).

To be eligible, patients must also have previously received 1 oxaliplatin-based chemotherapy regimen (capecitabine þ oxaliplatin or FOLFOX IV regimen) and 1 irinotecan-based chemotherapy (leucovorin, 5-FU, and irinotecan [FOLFIRI] regimen or irinotecan alone) for at least 2 months. All patients were included if progression of disease was documented during receipt of these regimens or within 3 months thereafter.

The capecitabine plus oxaliplatin (XELOX) regimen was administered as follows: oxaliplatin at a dose of 70 mg/m2 as continuous infusion for 12 hours (8:00 AM to 8:00 PM) on Days 1 and 8 plus chronomodulated capecitabine at a dose of 1750 mg/m2/day orally (8:00 AM: 25% of total dose; 6:00 PM: 25% of total dose; and 11:00 PM: 50% of total dose) on Days 1 through 14 every 21 days.6 September 2014

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FOLFOX IV consisted of leucovorin (200 mg/ m 2/ d) followed by a 5-FU bolus (400 mg/m 2/d) and 22-hour infusion (600 mg/m 2/d) for 2 consecutive days every 2 weeks with oxaliplatin at a dose of 85 mg/m 2 as a 2-hour infusion on Day 1. 7 FOLFIRI consisted of irinotecan at a dose of 180 mg/m2 as a 90-minute infusion on Day 1 and leucovorin at a dose of 400 mg/m2 as a 2-hour infusion during irinotecan therapy, immediately followed by a 5-FU bolus of 400 mg/m2 and 46hour continuous infusion of 2.4 to 3 g/m2 every 2 weeks.8 Three-weekly irinotecan was comprised of irinotecan at a dose of 350 mg/m2. Finally, after progression to and an oxaliplatin-based and irinotecan-based chemotherapy, all patients were treated with cetuximab plus weekly irinotecan according to the following schedule: cetuximab was given at an initial dose of 400 mg/m2, followed by weekly infusions of 250 mg/m2, and irinotecan was administered weekly at the dose of 90 mg/m2.9 Disease progression was documented by computed tomography (CT) or magnetic resonance imaging (MRI). At least 1 unidimensionally measurable lesion was required. Epidermal growth factor receptor (EGFR) expression in the primary tumor or in at least 1 metastatic lesion was performed. All the patients signed a consent form.

Study Design and Treatment The current study was a single-center, phase 2 trial conducted from March 2004 to February 2006. Bevacizumab was given at the dose of 5 mg/kg. De Gramont chemotherapy was comprised of folinic acid (200 mg/m2/d) followed by a 5-FU bolus (400 mg/m2/d) and 22-hour infusion (600 mg/m2/d) for 2 consecutive days every 2 weeks.

Dexamethasone was given at the dose of 16 mg before each course. A standard antiemetic drug was always given in the premedication and in the following days, at the physician’s discretion.

All the patients were to be treated until disease progression or unacceptable toxic Bevacizumab þ de Gramont in CRC Patients/ Vincenzi et al effects occurred. In the case of disease progression, further anticancer treatments were allowed.

Tumor response was evaluated every 8 weeks with the use of consistent imaging techniques (CT or MRI). Assessment was performed by the investigators, who used Response Evaluation Criteria in Solid Tumors (RECIST).10 Toxic effects were assessed according to the National Cancer Institute Common Toxicity Criteria (version 2.0).

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Modifications of bevacizumab dose were not planned, and the drug was stopped if grade 3 to 4 adverse events possibly related to bevacizumab were recorded. Modifications in the doses of the de Gramont regimen were made in cases of hematologic or nonhematologic toxic effects.

The present trial was approved by the institutional review board of our institution, and written informed consent was obtained from all participating patients.

Statistical Plan and Analysis This study used Simon’s Minimax 2-stage design11 to test the null hypothesis that the true overall response rate was 5% (which would not be clinically meaningful), as opposed to the alternative hypothesis that the true overall response rate was 10%. Up to 33 patients were planned for each cohort to assess the overall response rate with 85% power and a ¼ .05. If 2 objective tumor responses were observed in the cohort, an additional 15 patients would be enrolled onto that cohort in stage 2.

The primary endpoint was the rate of confirmed radiologic tumor response, as assessed by a local committee, in the intent-to-treat population. Secondary endpoints were the evaluation of time to disease progression, OS, safety profile, and the median time to response. All analyses were performed following an intent–to–treat analysis method. The time to disease progression was calculated as the period from the date of the initiation of treatment to the first observation of disease progression or to death from any cause within 60 days after the initiation of treatment or the most recent tumor assessment. The OS time was calculated as the period from the date treatment was initiated until death from any cause or until the date of the last follow-up, at which point data were censored. Time to disease progression and OS were both determined by the Kaplan-Meier product-limit method.12 The difference in terms of time to disease progression and OS according to anticancer treatment delays or termination was evaluated by the log-rank test.13 The cutoff point for survival data was July 2007; for safety data, it was July 2006. SPSS statistical software (version 14.00; SPSS, Chicago, Ill) was used for statistical analysis. A P value of <.05 was considered to indicate statistical significance.

RESULTS Between March 2004 and February 2006, 48 consecutive patients were enrolled in this singlecenter phase 2 trial. The main characteristics of the patient population are summarized in Table 1. The median number of courses administered was 5 (range, 2-13 courses). Forty-six patients

Vincenzi B, Santini D, Russo A, Spoto C, Venditti O, Gasparro S, Rizzo S, Beomonte B, Caricato M, Valeri S, Coppola R, Tonini G

were evaluated for the declared study efficacy endpoints and 48 for the safety analysis.

Efficacy Analysis For the intent-to-treat analysis, 46 patients were evaluated for efficacy (2 patients were removed from the study early because the patients refused to continue anticancer therapy and were not evaluable for both time to disease progression and OS). The best objective responses were achieved as follows: 0 (0%) complete responses, 3 (6.5%; 95% confidence interval [95% CI], 1.96.5%) partial responses, 14 (30.4%; 95% CI, 22.541.7%) cases of stable disease, and 30 (65.2%; 95% CI, 44.7-71.8%) instances of disease progression. Therefore, the overall response rate was 6.5% (95% CI, 4.3-10.4%), and the disease control rate (partial response þ stable disease) was 36.9% (95% CI, 25.8-44.8%). The median time to disease progression was 3.5 months (95% CI, 2.3-6.9 months), and the median OS time was 7.7 months (95% CI, 3.9-11.9 months).

No patients received any further anticancer treatment after they withdrew from therapy for disease progression.

Comparing patients with an ECOG performance status of 2 (25% of the total study population) with the others revealed no differences in terms of response rate. However, a slight but significant difference in terms of time to disease progression (2.6 months vs 3.8 months; P ¼ .03) and OS (6.0 months vs 8.9 months; P ¼ .007) was noted.

Moreover, we compared patients defined as responders to at least 1 (first–line, second–line, or third– line) anticancer treatment (39 patients) with nonresponders (7 patients), and did not identify any differences with regard to response rate, time to disease progression, or OS (data not shown).

Adverse Events All patients were evaluated for safety analysis. Leukopenia and neutropenia were the most common hematologic toxicities, with an incidence of 54.1% and 64.5%, respectively. However, grade 3 to 4 neutropenia was recorded only in 6 patients (12.5%), and it did not cause any dose reductions or treatment discontinuation. No patients required the administration of granulocyte–colony-stimulating factor to recover after a neutropenic event. In 2 patients, neutropenic fever required hospitalization and infusion of antibiotics.

The most common nonhematologic toxicities were diarrhea (grade 3-4 in 20.8% of patients), fatigue (grade 3-4 in 14.5% of patients), and oral mucositis (grade 3-4 in 12.5% of patients). Safety results are summarized in Table 2.

Table 1. Baseline Characteristics of the Patients Patient Characteristics

No. of Patients

Total

48 (100%)

Men/women

23/25 (47.2%/52.08%)

Age, y Median

68

Range

31-74

ECOG performance status 0

19 (39.5%)

1

17 (35.4%)

2

12 (25%)

Primary tumor site Colon

33 (68.7%)

Rectum

15 (31.2%)

No. of metastatic sites 1

12 (25%)

2

23 (47.9%)

‡3

13 (27.08%)

First-line regimen XELOX

26 (54.1%)

FOLFOX

22 (45.8%)

Second-line regimen FOLFIRI

38 (79.1%)

Three-weekly irinotecan

10 (20.8%)

Third-line regimen Cetuximab plus weekly irinotecan

48 (100%)

ECOG indicates Eastern Cooperative Oncology Group; XELOX, capecitabine plus oxaliplatin; FOLFOX, leucovorin followed by a 5-fluorouracil bolus; FOLFIRI, leucovorin, 5-fluorouracil, and irinotecan.

Overall, 21 patients experienced a delay or change in dosing (of 5-FU) as a result of adverse events during the study. In particular, treatment was delayed in 10 patients because of bevacizumab-related toxicities, and the 5-FU dose was reduced or treatment delayed in 11 patients because of 5-FU–related toxicities.

Because of nonhematologic toxicities, the 5-FU dose was reduced (25% dose reduction) in 9 patients (18.7%). Because of the persistence of diarrhea in 2 of the 9 patients, 5-FU was discontinued, and treatment was continued with bevacizumab only. In only 2 patients, the 5-FU dose was reduced for neutropenic fever. Grade 3 to 4 hemorrhage was reported September 2014

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Table 2. Adverse Events Related to Treatment Recorded in 48 Patients* Side Effects No. of Patients With Toxicity All Grades

Table 3. Adverse Events Possibly Related to Bevacizumab Recorded in 48 Patients* Side Effects No. of Patients With Toxicity All Grades

Grade 3-4

Hemorrhage

Hematologic Anemia

12 (25%)

5 (10.4%)

Leukopenia

26 (54.1%)

2 (4.1%)

Neutropenic

31 (64.5%)

6 (12.5%)

Thrombocytopenia

13 (27.08%)

3 (6.2%)

Nonhematologic

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Grade 3-4

Gastrointestinal

8 (16.6%)

4 (8.3%)

Nose

13 (27%)

3 (6.2%)

Other

4 (8.3%)

1 (2%)

Cardiovascular events Hypertension

24 (50%)

6 (12.5%)

Thrombosis/embolism

9 (18.7%)

3 (6.2%)

Diarrhea

29 (60.4%)

10 (20.8%)

Fatigue

28 (58.3%)

7 (14.5%)

Oral mucositis

18 (37.5%)

6 (12.5%)

Nausea/vomiting

6 (12.5%)

0 (0%)

Liver toxicity

8 (16.6%)

2 (4.1%)

Gastrointestinal perforation

2 (4.1%)

2 (4.1%)

Hypersensitivity reaction

1 (2.08%)

0 (0%)

Gastrointestinal fistula

5 (10.4%)

3 (6.2%)

Arterial events Cardiac ischemia

0 (0%)

0 (0%)

Cerebral vascular events

1 (2%)

1 (2%)

Other adverse events

* Toxicity was according to the National Cancer Institute Common Toxicity Criteria (version 2.0).

* Toxicity was according to the National Cancer Institute Common Toxicity Criteria (version 2.0).

in 8 patients (16.6%), with 4 events (8.3%) occurring in the gastrointestinal tract. The rate of venous thrombosis was 18.7%, with 3 (6.2%) cases of pulmonary thromboembolism reported; in all 3 cases, hospitalization was required with- Bevacizumab Ăž de Gramont in CRC Patients/Vincenzi et al out a fatal event. Data regarding adverse events possibly related to bevacizumab are summarized in Table 3.

Bowel perforation was rare (2 patients). In 1 patient, bowel perforation was diagnosed by a leak of oral contrast into the pelvis after a standard CT scan performed to restage disease after 2 months of treatment, but the perforation appeared to be contained and treated with intravenous antibiotics.

In 3 cases, grade 3 to 4 fistulas were identified, with 1 fatal outcome after a surgical procedure needed to evacuate a local abdominal abscess (because of the urgency of the intervention, the interval between the last bevacizumab administration and surgery was inadequate: only 2 weeks). In the other 2 cases, surgery for the drainage of a pelvic abscess was required, with complete resolution of the clinical presentation after 35 days and 45 days, respectively.

Other than the previously mentioned 2 patients who decided to withdraw from therapy, only 4 patients were excluded from the study because of toxicity (the 2 patients who developed bowel

perforations and 2 patients who developed fistulas). Comparing patients with an ECOG performance status of2 (25% of our total population) with the remaining patient population revealed no significant differences with regard to the incidence of adverse events.

Influence of Dose Reduction/ Delay of Treatment on Anticancer Efficacy As stated earlier, a reduction of dose or a delay was required in 21 patients during treatment.

We analyzed the efficacy of treatment in this subgroup, comparing it with the efficacy in the group of patients who better tolerated treatment. The response rate in the group with a treatment delay or change in dosing was lower than in the group without (19.04% vs 50%, respectively).

This difference was statistically significant, with a P value of .046. Furthermore, a statistically significant difference also was recorded in terms of time to disease progression, with a median time to disease progression in the group of patients who required a treatment delay or change in dosing of 2 months versus 4 months in the group that did not (P Âź .03) (Table 4).

DISCUSSION The efficacy of oncology drug regimens traditionally has been assessed by their potency to

Vincenzi B, Santini D, Russo A, Spoto C, Venditti O, Gasparro S, Rizzo S, Beomonte B, Caricato M, Valeri S, Coppola R, Tonini G

Table 4. Influence of Treatment Delay or Change in Dosing on Disease Control* Disease Control

PR1SD/Total (%)

P

No treatment delay or change in dosing

13/25 (52%)

.046

Treatment delay or change in dosing

4/21 (19.04%)

TTP, median mo (95% CI) No treatment delay or change in dosing

4.00 (3.6-6.7)

Treatment delay or change in dosing

2.00 (1.3-3.4)

.03

OS, median mo (95% CI) No treatment delay or change in dosing

9.0 (8.3-10.5)

Treatment delay or change in dosing

4.5 (4.0-9.1)

.07

PR indicates partial response; SD, stable disease; TTP, time to disease progression; 95% CI, 95% confidence interval; OS, overall survival. * Efficacy evaluated in 46 patients. shrink existing tumors and, ideally, to prolong PFS and OS. Tumor response can be easily evaluated in small trials, and data from small trials may provide early evidence that an investigational agent warrants further testing. In clinical practice, the observation of a tumor response reassures the patient and the oncologist that the selected therapy is active in the malignant disease. The common use of tumor response criteria as a measure of efficacy in CRC has persisted despite multiple analyses demonstrating a weak correlation between tumor response and OS.14 This concept is supported even more by the introduction into oncology of novel drugs without intrinsic direct cytotoxic activity, such as antiangiogenic agents, suggesting that tumor response could be re-evaluated as a key marker of efficacy in patients with CRC.15 This theory is supported by the recent article

by Grothey et al,15 in which the authors evaluated the survival benefit, both in terms of PFS and OS, associated with tumor response in 2 clinical trials, 1 containing bevacizumab in the experimental arm3 and 1 that did not.16 By this analysis, the authors clearly demonstra­ted that even patients with advanced CRC who did not achieve a response according to traditional criteria significantly benefited from being treated with the superior regimen and had the same magnitude of benefit as responders, regardless of whether this regimen was chemotherapy alone or included the antiangiogenic agent bevacizumab.

All these data support the hypothesis that disease control may be translated into survival benefit, even if patients in an experimental arm do not demonstrate an increase in response rate.

The data presented in the current trial indicate that treating heavily resistant CRC patients

may be possible without severe toxicities, even if some secondary effects possibly related to bevacizumab have been recorded. This result is very interesting in particular because, to the best of our knowledge, the current study is the first to be performed in a population of patients treated with irinotecan-based, oxaliplatin-based, and cetuximab-based anticancer agents. Moreover, the identification of a disease control rate of 36.9% appears to suggest some anticancer activity in this very heavily pretreated population. However, we must note that, to the best of our knowledge, no data from randomized clinical trials are actually available regarding the potential role of bevacizumab-based anticancer therapy in such a population and, most likely even more important, there are no data regarding quality of life in patients receiving this treatment versus patients who do not. The key finding in this trial is that introducing a bevacizumab-based therapy in a very late phase of therapy in CRC patients may yet play a role in contributing to tumor control.

Moreover, the use of bevacizumab plus the de Gramont schedule as fourth-line therapy (as first bevacizumab use) could be reserved for patients for whom anti-angiogenic therapy has previously been contraindicated for different reasons (such as instable blood hypertension, a recent episode of arterial thromboembolism, recent episode of bleeding, or recent bowel perforation).Once these contraindications have been resolved or stabilized, these patients may yet benefit from bevacizumab-based therapy. Moreover, there is a substantial difference reported by Chen et al5; in the current study, all patients had been previously treated with an additional third-line therapy (cetuximab-based therapy). This is a clear demonstration that bevacizumab-based therapy can September 2014

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produce an interesting rate of disease control, time to disease progression, and OS when admi­ nistered to patients refractory to anti-EGFR MoAb therapy.

Preclinical studies have demonstrated that a murine MoAb against VEGF can inhibit the growth of human tumor xenografts when given alone or with chemotherapy.17,18 A humanized variant of this antibody (bevacizumab) has clinical acti­vity in human cancer and increases survival when added to standard chemotherapy in patients with MCRC.3 Mice who received active antibody demonstra­ ted a 90% reduction in tumor volume at the highest dose. These findings correspond well with the paradigm that tumors require neovascularization for growth.19 A consequence of this biologic action of VEGF in vivo could be that the blockage of VEGF-dependent angiogenesis leads to prolonged disease control in cancers of different histologies.

On this basis, we found the rationale to propose to our heavily treated patients a palliative Bevacizumab b de Gramont in CRC Patients/ Vincenzi et al therapy containing bevacizumab.

Clearly, we understand that such treatment may be related to a significant increase in cost in this patient population. Therefore, a detailed cost analysis of bevacizumab-based anticancer treatment in heavily pretreated CRC patients could be very useful for understanding the economic impact of this treatment. Moreover, the safety profile also needs to be considered. The incidence of grade 3 to 4 hypertension in the phase 3 study of

patients receiving bevacizumab plus chemotherapy as first-line anticancer therapy for advanced CRC by Hurwitz et al was 11%.3 Consequently, the incidence of this side effect overlapped the incidence reported in previous first-line clinical trials. The incidence of grade 3 to 4 hemorrhage was noted in 16% of patients in the current study versus 5% for the study by Chen et al5; this discrepancy could be, at least partially, ascribed to the finding that patients in the current study were more heavily pretreated.

One of the main concerns in this trial is represented by the percentage of patients who went on to receive fourth-line chemotherapy. According the results of the Medical Research Council FOCUS trial, approximately 24% to 27% of patients with metastatic CRC receive third or further lines of chemotherapy.20 Considering the relatively recent introduction of biologic agents in the treatment of this patient population, this percentage is destined to increase in the coming years.

In conclusion, to our knowledge, the current study is the first to demonstrate some anticancer activity of bevacizumab þ de Gramont schedule in patients who had received all other anticancer drugs available for the treatment of MCRC, with an acceptable safety profile.

Conflict of Interests: None.

This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

References 1. Presta LG, Chen H, O’Connor SJ, et al. Humanization of an anti-vascular endothelial growth factor monoclonal antibody for the therapy of solid tumors and other disorders. Cancer Res. 1997;5:4593-4599.

2. Kabbinavar FF, Schulz J, McCleod M, et al. Addition of bevacizumab to bolus fluorouracil and leucovorin in first-line metastatic colorectal cancer: results of a randomized phase II trial. J Clin Oncol. 2005;23:3697-3705.

3. Hurwitz H, Fehrenbacher L, Novotny W, et al. Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med. 2004;350:23352342.

4. Giantonio BJ, Catalano PJ, Meropol NJ, et al. Bevacizumab in combination with oxaliplatin, fluorouracil, and leucovorin (FOLFOX4) for previously treated metastatic colorectal cancer: results from the Eastern Cooperative Oncology Group Study E3200.

J Clin Oncol. 2007;25:15391544.

5. Chen HX, Mooney M, Boron M, et al. Phase II multicenter trial of bevacizumab plus fluorouracil and leucovorin in patients with advanced refractory colorectal cancer: an NCI Treatment Referral Center trial TRC-0301. J Clin Oncol. 2006;24:3354-3360.

6. Santini D, Vincenzi B, La Cesa A, et al. Continuous infusion of oxaliplatin plus chronomodulated capecitabine in 5fluorouracil-and irinotecan-resistant advanced colorectal cancer patients. Oncology. 2005;69:27-34.

7. Andre T, Bensmaine MA, Louvet C, et al. Multicenter phase II study of bimonthly high-dose leucovorin, fluorouracil infusion, and oxaliplatin for metastatic colorectal cancer resistant to the same leucovorin and fluorouracil regimen. J Clin Oncol.

1999;17:3560-3568.

8. Saltz LB, Cox JV, Blanke C, et al. Irinotecan plus fluorouracil and leucovorin for metastatic colorectal cancer. Irinotecan Study Group. N Engl J Med. 2000;343:905914.

9. Vincenzi B, Santini D, Rabitti C, et al. Cetuximab and irinotecan as third-line therapy in advanced colorectal cancer patients: a single centre phase II trial. Br J Cancer.

2006;94:792-797.

10. Therasse P, Arbuck SG, Eisenhauer EA, et al. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and

138

Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst. 2000;92:205-216.

11. Simon R. Optimal 2-stage designs for phase II clinical trials. Control Clin Trials.

1989;10:1-10.

12. Kaplan E, Meier P. Non parametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457-481.

13. Peto R, Pike MC,ArmitageP,etal. Design andanalysisof randomized clinical trials requiring prolonged observation of each patient. II. Analysis and examples. Br J Cancer. 1977;35:1-39.

14. Buyse M, Thirion P, Carlson RW, Burzykowski T, Molenberghs G, Piedbois P. Re: A model to select chemotherapy regimens for phase III trials for extensive-stage smallcell lung cancer. J Natl Cancer Inst. 2001;93:399-401.

15. Grothey A, Hedrick EE, Mass RD, et al. Response-independent survival benefit in metastatic colorectal cancer: a comparative analysis of N9741 and AVF2107. J Clin Oncol. 2008;26:183-189.

16. Goldberg RM, Sargent DJ, Morton RF, et al. A randomized controlled trial of fluorouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer. J Clin Oncol. 2004;22:23-30.

17. Ferrara N, Gerber HP, LeCouter J. The biology of VEGF and its receptors. Nat Med. 2003;9:669-676.

18. Dickson PV, Hamner JB, Sims TL, et al. Bevacizumabinduced transient remodeling of the vasculature in neuroblastoma xenografts results in improved delivery and efficacy of systemically administered chemotherapy. Clin Cancer Res. 2007;13:39423950.

19. Folkman J. Tumor angiogenesis: therapeutic implications. N Engl J Med. 1971;285:1182-1186.

20. Seymour MT, Maughan TS, Ledermann JA, et al. Colorectal Clinical Studies Group.

Different strategies of sequential and combination chemotherapy for patients with poor prognosis advanced colorectal cancer (MRC FOCUS): a randomised controlled trial. Lancet. 2007;370:143-152.

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Intratumoral Steroidogenesis in Castration-Resistant Prostate Cancer: A Target for Therapy

INTRATUMORAL STEROIDOGENESIS IN CASTRATION-RESISTANT PROSTATE CANCER: A TARGET FOR THERAPY Inna Armandari1, Agus Rizal Hamid1,2, Gerald Verhaegh1,3, Jack Schalken1,3 1Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands 2Department of Urology, Ciptomangunkusumo Hospital, University of Indonesia Faculty of Medicine, Jakarta, Indonesia 3Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands Corresponding author: Jack Schalken Department of Urology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands E-mail: Jack.Schalken@radboudumc.nl / Tel: +31-24-3614146 / Fax: +31-24-3541222

Open Access Article

Abstract Keywords:

Published in Prostate Int 2014;2(3):105-113 http://p-international.org/ pISSN: 2287-8882 â&#x20AC;˘ eISSN: 2287-903X http://dx.doi. org/10.12954/ PI.14063 Copyright Š 2014 Asian Pacific Prostate Society (APPS)

Castration-resistant prostatic neoplasms, Enzyme inhibitors, Steroidogenesis, Molecular targeted therapy

Received: 26 July 2014 Accepted after revision: 21 August 2014 Cite this article: Armandari I, Hamid AR, Verhaegh G, Schalken J. Intratumoral steroidogenesis in castration-resistant prostate cancer: a target for therapy .

Rom J Oncol Hematol.

2014; 2(3):140-149.

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Development of castration-resistant prostate cancer (CRPC) in a low androgen environment, arising from androgen deprivation therapy (ADT), is a major problem in patients with advanced prostate cancer (PCa). Several mechanisms have been hypothesized to explain the progression of PCa to CRPC during ADT, one of them is so called persistent intratumoral steroidogenesis. The existence of intratumoral steroidogenesis was hinted based on the residual levels of intraprostatic testosterone (T) and dihydrotestosterone (DHT) after ADT. Accumulating evidence has shown that the intraprostatic androgen levels after ADT are suicient to induce cancer progression. Several studies now have demonstrated that PCa cells are able to produce T and DHT from diferent androgen precursors, such as cholesterol and the adrenal androgen, dehydroepiandrosterone (DHEA). Furthermore, up-regulation of genes encoding key steroidogenic enzymes in PCa cells seems to be an indicator for active intratumoral steroidogenesis in CRPC cells. Currently, several drugs are being developed targeting those steroidogenic enzymes, some of which are now in clinical trials or are being used as standard care for CRPC patients. In the future, novel agents that target steroidogenesis may add to the arsenal of drugs for CRPC therapy.

INTRODUCTION Prostate cancer (PCa) is rated to be the second most prevalent malignancy in males worldwide.

According to GLOBOCAN, in 2008 there were about 903,500 new cases of PCa and 258,400 deaths of PCa worldwide (1). he dependence of PCa on androgens, such as testosterone (T) and

dihydrotestosterone (DHT), during early carcinogenesis and progression to metastatic disease has been broadly reported, and therefore androgen deprivation therapy (ADT) is given to reduce T and DHT levels (2). During ADT, a reduction of serum T levels up to 90% is achieved after 2 to 4 weeks of treatment. However, most of the patients will develop a recurrence under low androgen levels,

Armandari I, Hamid AR, Verhaegh G, Schalken J

that is called castration-resistant prostate cancer (CRPC) (3).

Several mechanisms have been suggested to cause the progression of PCa to CRPC under ADT conditions, including hypersensitivity of the androgen receptor (AR) signaling pathway to androgens, enrichment or accumulation of androgen-insensitive stem cells, and activation of intratumoral steroidogenesis (4). Among these, the intratumoral steroidogenesis pathway has recently gained much attention and support. Although serum T levels decrease during ADT, it was shown that the intraprostatic androgen levels in CRPC patients was equal before and after ADT (5-8). Based on this fact, it was hypothesized, and later shown, that PCa cells are able to produce androgens itself via steroidogenesis (9), either by producing T and DHT from weak adrenal androgens (e.g., dehydroepiandrosterone (DHEA)) (10) or by de novo androgen synthesis starting from cholesterol (11). It was also shown that several enzymes responsible for androgen synthesis are up regulated in CRPC tissue (12-14). Due to the importance of intratumoral steroidogenesis to support the progression PCa to CRPC, new drugs are being developed that target the steroidogenic process, and hence may become new treatment options for CRPC. In this review, we will highlight the role of intratumoral steroidogenesis in CRPC and the status quo of developing novel targeted therapies for CRPC.

Intratumoral Steroidogenesis in CRPC Tissue T and DHT are the main androgens for prostate cell diferentiation and homeostasis (15). T is synthesized in Leydig cells, while DHT is mainly produced in prostate tissue. In primary and metastatic PCa, the dependence of prostate cells on androgens persists, and androgens now directly support tumor cell proliferation, and hence tumor growth (16) . It was hypothesized that diminishing serum androgen levels should lead to inhibition of PCa cell growth, and thus ADT was recommended for advanced or metastatic PCa (17). Unfortunately, the lower serum androgen levels obtained during ADT were not accompanied by a reduction of intraprostatic androgen levels within the tumor. In many studies, serum and intraprostatic T and DHT levels prior and after ADT have been measured (Table 1) (5-8,18,19) .

Serum T levels are reduced signiicantly from 410–465 ng/dL to 11.5–13.4 ng/dL after ADT (7). In contrast, intraprostatic T levels after ADT (0.74–1.44 ng/g tissue) (6,8) were equal to that prior to ADT (0.07–1.3 ng/g tissue) (18,19). A decline in both serum and prostatic DHT levels were reported after ADT (7). Prior to ADT, serum DHT levels ranged from 43.5–55.68 ng/dL, and after ADT, the serum DHT levels were dropped to 3.48–3.98 ng/dL (7). Prior to ADT, intraprostatic DHT levels ranged from 4.6–6.4

ng/g tissue (7), and after ADT, prostatic DHT levels were reduced approximately 75% (1.0–1.9 ng/g tissue) (7). Still, in vitro and in vivo data indicate that these low intraprostatic DHT levels are sufficient to stimulate expression of androgen-regulated genes, and to support AR-mediated tumor-cell growth and survival (20). In conclusion, current ADT strategies are not suicient to reduce intraprostatic T and DHT to levels that can no longer activate AR signaling in prostate cancer cells (21).

Although serum T and DHT levels are suppressed after ADT, serum levels of adrenal androgen precursors, such as DHEA (Table 1), remain constant after ADT (60–211 ng/dL vs. 90–203 ng/dL before ADT) and was found to be the most abundant adrenal androgen in PCa tissue (5,22,23). Measurement of intraprostatic DHEA levels are ~35 ng/g tissue in untreated PCa patients, while in ADT treated patients, intraprostatic DHEA levels are even slightly increased to ~48 ng/g tissue (24). In the later study, androstenedione (AD) and androstenediol levels in PCa tissue after ADT were also shown to be similar to those in untreated PCa. AD and androstenediol levels in untreated PCa versus after ADT are ~0.125 ng/g tissue versus ~0.06 ng/g tissue and ~2.5 ng/g tissue versus ~3.5 ng/g tissue, respectively (24). In summary, after ADT, the total androgen pool in the circulation is reduced by only 59% (25). he remaining 41% of androgens, including DHEA, are still available in the prostate for the synthesis of T and DHT, which can stimulate prostate cancer after castration.

THE MECHANISM OF INTRATUMORAL STEROIDOGENESIS IN CRPC Many studies have unraveled that intratumoral steroidogenesis could be initiated from weak adrenal androgens, such as DHEA or even by de novo androgen synthesis starting from cholesterol (10,11) . hese androgen precursors are then converted to androgens, T and DHT. In the next part, we will discuss the possible mechanism of CRPC cells to synthesize androgens.

Cholesterol is the natural precursor for androgen synthesis. It was reported that cholesterol levels could influence PCa progression. Xenograft tumors (derived from the LNCaP PCa cell line) in mice on a hypercholesterolemic diet were bigger and contained higher intratumoral T levels, compared to xenograft tumors in mice on a low fat/no cholesterol diet (11). he enzymes required for de novo steroidogenesis from cholesterol, such as cytochrome P (CYP) 11A, CYP17A, and 3β-hydroxysteroid dehydrogenase (3βHSD) 1 were detected in LNCaP tumors in these mice fed on a hypercholesterol diet. A high expression of CYP17A, the key enzyme for de novo androgen synthesis, in tumor tissue was also correlated signiicantly with cholesterol levels (11). In a study using September 2014

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Table 1. Levels of T and DHT in serum and prostate tissue Conditions Before ADT After ADT

Serum (ng/dL)

Prostate tissue (ng/g tissue)

T

DHT

DHEA

T

DHT

DHEA

410–465 11.5–13.4

43.5–55.68 3.48–3.98

90–203 60–211

0.07–1.34 0.74–1.44

4.6–6.4 1.0–1.9

~35 ~48

T, testosterone; DHT, dihydrotestosterone; DHEA, dehidroepiandroseterone; ADT, androgen deprivation therapy.

patient tissue samples, metastatic CRPC exhibited signiicant increases in the expression levels of the FASN, CYP17A1, 3βHSD1, and 3βHSD2 genes when compared to primary PCa (8). Also, immunohistochemical staining for the CYP11A1, CYP17A1, and 17β-hydroxysteroid dehydrogenase (17βHSD) 3 enzymes in lymph node metastasis showed a moderately higher staining intensity compared to primary PCa samples, indicating that all these enzymes are up-regulated in metastatic CRPC tissue (26) . he results above support the existence of intratumoral de novo steroidogenesis from cholesterol.

Subsequently, de novo synthesized androgen precursors need to be converted into active androgens. In PCa, the mechanism or pathway, by which androgen precursors are converted into T and DHT is under extensive investigation. Many studies have shown that in CRPC cells the androgens, T and DHT, can be synthesized via the classical and/ or the backdoor pathways (27). Figure 1 illustrates the mechanism of intratumoral steroidogenesis in CRPC tissue and the steroidogenic enzymes that are involved in each particular pathway.

In the classical pathway, DHT, as a final androgen product, is produced by reduction of T, a reaction catalyzed by the 5α-reductase (SRD5A) enzyme (Figure 1; blue arrow). he classical pathway plays an essential role in intratumoral steroidogenesis and can be initiated from DHEA. In one of our studies (10), we have shown that DuCaP cells, a CRPC cell line model, are able to use DHEA as an androgen precursor. DuCaP cells were able to proliferate in DHEA-supplemented medium, an environment that resembles ADT. Furthermore, T and DHT were detected in the medium soon after DHEA addition. hese results suggested that these CRPC cells were able to convert DHEA into T and DHT, at levels suicient to support cell growth.

Several studies reported the up-regulation of key steroidogenic enzymes involved in DHT synthesis via the classical pathway in prostate cancer tissue. In an in vivo study using LN-CaP xenograft, examination of tumor homogenate of castrated mice revealed an increased expression of SRD5A1, an enzyme involved in the conversion of T into DHT (28). In clinical CRPC samples, expression of aldo-keto reductase family 1 (AKR1) C3 and 17βHSD3 was increased, but SRD5A2 expression was decreased (13). Similar results were found in metastatic CRPC samples that displayed up-regulation of AKR1C3 tran-

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script levels, and down-regulation of SRD5A2 expression (8). In line with these indings in tissue samples, higher transcript expression levels of AKR1C3, SRD5A1, and SRD5A3 were found in circulating tumor cells (CTC) derived from primary PCa. In CTC derived from CRPC patients, up-regulation of AKR1C3 and SRD5A1 transcript was detected. However, in both CTC samples, SRD5A2 transcript levels were decreased (12).

Since the SRD5A isoforms all possess similar SRD5A activity, elevated SRD5A1 and/or SRD5A3 transcript levels suggest that PCa and CRPC cells actively convert T into DHT (12).

Beside the classical pathway, the backdoor pathway provides an alternative production of DHT that bypasses the need of T as an intermediate (Figure 1; red arrow). he backdoor pathway is primarily active during organogenesis in the fetus to produce suicient amounts of DHT for male sex development, whereas it is less active in the adult male (29).

Active intratumoral steroidogenesis via the backdoor pathway was demonstrated by the high conversion rate of androstenedione (AD) into DHT in CRPC cell lines and tissues from CRPC patients (30).

By treating CRPC cell lines with ( H)-AD and ( H)-T, followed by HPLC analysis, the conversion pathway, either AD → androstanedione (5α-dione) → DHT or AD → T → DHT, could be measured. he outcome of these studies showed that AD is more rapidly and uniformly converted into DHT via the backdoor pathway (i.e., via 5α-dione) than via the classical pathway (i.e., via T). Similarly, fresh CRPC metastases exhibited robust conversion of AD → 5α-dione → DHT (30). In the same study, the essential role of SRD5A1 in the backdoor pathway synthesis of DHT was shown by knockdown of the SRD5A1 gene in LNCaP and LAPC4 cells. Accumulation of AD after SRD5A1 knockdown suggested that the conversion of AD into DHT was blocked (30) . In an in vivo study, high DHT levels up to 28 folds compared to control levels, were detected in tumors of CWR22R-bearing athymic mice after androstanediol dipropionate injection at the tumor site (31). High conversion of androstanediol into DHT was correlated with increased mRNA and protein levels of 17βHSD6, an enzyme required for DHT synthesis. hese studies suggest that the backdoor pathway is remarkably active in PCa, and may be responsible for PCa progression to CRPC (31).

In summary, multiple studies have shown that intratumoral steroidogenesis in CRPC cells is active.

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Figure 1.

The illustration of intratumoral steroidogenesis pathway in castration-resistant prostate cancer tissue.

T and DHT can be produced from cholesterol or DHEA via either the classical pathway, indicated by blue arrows or using the backdoor pathway, indicated by red arrows. The conversion of cholesterol into intermediate products is indicated by black arrows. Steroidogenic enzymes involved in each conversion are indicated in blue capital letters. T, testosterone; DHT, dihydrotestosterone; DHEA, dehidroepiandroseterone

Both cholesterol and adrenal androgens, such as DHEA, are potential sources for the intratumoral synthesis of DHT. Albeit the possibility of using multiple routes for androgen synthesis, the conversion of DHEA via the backdoor pathway seems to be the major route to produce DHT. Regardless the pathway used for DHT synthesis, the same set of genes/enzymes are needed for the conversion of androgen precursors into DHT, and all of these genes, AKR1C3, 17βHSD3, and SRD5A1/3, were found up-regulated in PCa cells.

THERAPEUTIC IMPLICATION AND TARGETED THERAPY The up-regulation of steroidogenic enzymes as shown in previous section is essential to maintain persistent intratumoral steroidogenesis and

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become attractive targets for therapy. Numerous compounds have been and are being developed to inhibit steroidogenic enzyme activity, yet only few of them accepted by the U.S. Food and Drug Administration (FDA) for clinical application. One of the approved steroidogenic enzyme inhibitors for the treatment of CRPC is the CYP17A inhibitor, abiraterone, while some other inhibitors are still under intensive development, such as inhibitors of AKR1C3, 17βHSD3, and SRD5A. he current status of development of these inhibitors is discussed below.

1. CYP17A inhibitors he CYP17A enzyme plays an important role in androgen biosynthesis. It possesses 17α-hydroxylase

Armandari I, Hamid AR, Verhaegh G, Schalken J

and C17,20-lyase activities, with the C17,20-lyase being the key enzyme that involves in DHEA biosynthesis by the adrenal glands and the testes as well as several conversions during intratumoral steroidogenesis. Because of the central role of CYP17A in androgen synthesis (Figure 1), it was hypothesized that speciic inhibition of CYP17A enzyme activity may lead to clinical antitumor responses (32).

Abiraterone is the only CYP17A inhibitor approved by the FDA (April 2011) for the treatment of metastatic CRPC that previously received docetaxel-based chemotherapy (32). It is formulated as the prodrug of abiraterone acetate, a nonsteroid, highly selective, and irreversible CYP17A inhibitor (33). Strikingly, its nonspecific CYP17A inhibition leads to rise in mineralocorticoids (34). herefore, addition of prednisone or prednisolone as mineralocorticoid receptor antagonist during abiraterone therapy is needed to prevent mineralocorticoid excess syndrome (i.e., hypertension, hypokalemia, and lower-limb edema) (35).

In preclinical studies, intraperitoneal administration of abiraterone acetate in a rodent model resulted in inhibition of CYP17A activity as shown by reduced weight of the ventral prostate (36). Approval of abiraterone by the FDA was based on the outcome of a multinational phase III clinical trial that included 1,195 CRPC patients who previously received chemotherapy. In this study, oral administration of 1,000 mg abiraterone with 5-mg prednisone prolonged the patient overall survival by an average of 14.8 months and increased the prostate-speciic antigen (PSA) response rate by 29% (37). Nowadays, oral abiraterone acetate (Zytiga, Janssen Biotech Inc., Horsham, PA, USA) is used in combination with prednisone or prednisolone in Europe and the United States for metastatic CRPC previously treated with docetaxel-containing chemotherapy (38).

Recently, a novel selective CYP17A inhibitor with more potent inhibition of C17,20-lyase over 17α-hydroxylase activities was developed, namely TAK-700 (Orteronel, Takeda Ltd., Osaka, Japan) (39). It is a nonsteroidal, reversible 17,20-lyase inhibitor that is five-fold more selective to inhibit C17,20-lyase activity than 17α-hydroxylase activity (40). By selectively inhibiting C17,20-lyase activity, the need of prednisone supplementation would be reduced because of less inluence on mineralocorticoid synthesis (39). Administration of TAK-700 to intact male rats resulted in a reduction of serum T levels and prostate weight (41). In a recent phases 1 and 2 trial in metastatic CRPC patients, doseescalating toxicities were observed. In the phase 2 eicacy study, treatment with 400-mg TAK-700, supplemented with 5-mg prednisone, signiicantly reduced PSA, T, and circulating DHEA-sulfate levels.

A phase 3 study in chemotherapy naïve and postdocetaxel metastatic CRPC patients is ongoing

(42). In summary, inhibition of the CYP17A enzyme is an approved treatment for metastatic CRPC, and further improvements of inhibitory compounds and treatment schedules are ongoing.

2. AKR1C3 inhibitors The AKR1C enzyme family is involved in normal androgen metabolism and in intratumoral steroidogenesis. There are three AKR1C isoforms, namely AKR1C1, AKR1C2, and AKR1C3. Both AKR1C1 and AKR1C2 are involved in the inactivation of DHT, whereas AKR1C3 converts AD and androstanedione into active T and DHT, respectively (Figure 1) (43). A recent study reported that high AKR1C3 levels were detected in a subset of CRPC patients and related to tumor progression. herefore, AKR1C3 could be used as a biomarker to monitor active intratumoral steroidogenesis in CRPC and considered as a potential therapeutic target (10).

However, development of selective AKR1C3 inhibitors is challenging due to its > 86% sequence identity with the other human members of the AKR1C subfamily, AKR1C1 and AKR1C2. Inhibition of AKR1C1 and 2 activities would inhibit DHT turnover, and hence promote proliferative signaling in the prostate. The first AKR1C3 inhibitors were developed in 2005 from nonsteroidal anti-inlammatory drugs analogs, particularly indomethacin (44). Later, additional selective AKR1C3 compound were developed based on N-phenylanthranilic acid, such as 3-((4-(trifluoromethyl) phenyl)amino)benzoic acid and 3-((4-nitronaphthalen-1-yl)amino)benzoic acid (45-47) . hese compounds showed AKR1C3 selective inhibition in biochemical assays (46,47), but, so far, none of the developed compounds has been tested in CRPC cell line and tumor models. Therefore, the effect of AKR1C3 inhibitors on CRPC still remains to be elucidated and awaits the development of highly selective AKR1C3 inhibitors and extensive pre-clinical testing.

3. 17βHSD3 inhibitors The 17βHSD3 enzyme converts AD and androstanedione into T and DHT, respectively during androgen synthesis (Figure 1) (43). In PCa, involvement of 17βHSD3 in intratumoral steroidogenesis was proven using LNCaP cell line transfected with pCEP4.17βHSD3. Incubation of stable LNCaP(HSD3) clone with AD eiciently stimulated cell proliferation, suggesting the active conversion of available AD by the cells (48). Besides, high levels of the 17βHSD3 expression in prostatic tissue derived from primary PCa and lymph node metastasis were observed, indicating its role in PCa and advance disease (26). Therefore, development of 17βHSD3 inhibitors may be beneicial in reducing disease progression and promoting survival of CRPC patients.

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Intratumoral Steroidogenesis in Castration-Resistant Prostate Cancer: A Target for Therapy

17βHSD3 inhibitors could be developed from diferent compound structures. Coumarin compounds, such as oxazolidinediones and thiazolidinediones, were reported to exhibit 17βHSD3 inhibitory activity at low nanomolar concentrations, with acceptable selectivity over other 17β-HSD isoenzymes (49,50). he STX2171 compound is another novel selective nonsteroidal 17βHSD3 inhibitor that has an IC50 of ~200 nM in a whole-cell assay in vitro (48,51). In a preclinical study, STX2171 was able to signiicantly reduce plasma T levels and xenografted tumor growth in castrated male MF-1 mice supplemented with the androgen precursor AD (51). hus, the development of selective inhibitors of 17βHSD3 show promising results, but the speciicity and eicacy of these new compounds needs to be validated in preclinical studies before going into clinical trials.

months, 9 had stable disease, and 2 had partial response, indicating that dutasteride had restricted biochemical response in CRPC (62).

The limited efect of dutasteride, that only inhibits SRD5A1 and 2, could be caused by high expression of SRD5A3 observed in CRPC tissue samples (53) . The existence of SRD5A3 may actively convert androgen precursors into DHT as was shown in an in vivo study using castration-resistant CWR22 xenograft bearing mice. Incubation of tumor lysates with higher concentrations of dutasteride than clinically achieved demonstrated persistent biosynthesis of DHT most likely by uninhibited SRD5A3 activity (53). In summary, inhibition of SRD5A enzyme activity, so far, has shown limited therapeutic efects on CRPC. Novel SRD5A3 inhibitors are required to be combined with dutasteride to completely block SRD activity in CRPC cells.

4. SRD5A inhibitors

FUTURE DIRECTIONS

Other essential enzymes involved in intratumoral steroidogenesis are SRD5A1, SRD5A2, and SRD5A3, all 3 belonging to the SRD5A family. The SRD5A1 and SRD5A2 are able to catalyze the conversion of T into DHT, whilst recombinant SRD5A3 protein is also able to do so in in vitro assays (43,52,53).

Inhibition of DHT synthesis by SRD5A inhibitors ofers novel therapeutic options in CRPC therapy, because most of the SRD5A enzyme isoforms are expressed at higher levels in PCa cells compared to normal prostate cells (30). Two SRD5A inhibitors are available in the clinic, namely finasteride and dutasteride that were approved by the FDA for the treatment of benign prostatic hyperplasia (BPH) (54,55) . Finasteride inhibits SRD5A type 2, while dutasteride selectively inhibits SRD5A type 1 and 2 enzymes (56,57). Dutasteride is a 45 times more potent in inhibiting SRD5A1 and two times more potent in inhibiting SRD5A2 compared to Finasteride (57).

Finasteride was shown to be ineffective in PCa and CRPC treatment with no diference in local recurrence or distant metastasis (58). Currently, studies focus on the use of dutasteride, marketed under the trade name Avodart (GlaxoSmithKlinex, Brentford, UK), to reduce intratumoral androgen levels (59,60) . By inhibiting both SRD5A1 and SRD5A2, a reduction of intra-tumoral DHT is expected and may lead to tumor suppression (52). In a doubleblinded, randomized, parallel-group trial, dutasteride lowered intraprostatic DHT levels by 93% after 4 months of treatment. he reduced DHT level with dutasteride was accompanied by a reciprocal increase in serum and intra-prostatic T levels, suggesting that dutasteride provides near-maximal suppression of intraprostatic DHT levels in PCa patients (61). On the other hand, in CRPC patient, a phase II study of dutasteride reported that 14 out of 25 evaluable men had disease progression by 2

The progression of primary PCa into CRPC during ADT remains a major hurdle to improve overall survival of PCa patients. Intratumoral steroidogenesis is an essential mechanism leading to disease progression (i.e., resistance to ADT). Intratumoral steroidogenesis fuels PCa cells with suicient amounts of active androgens, T and DHT, in the low androgenic environment during ADT. The key steroidogenic enzymes that are up-regulated in CRPC become novel attractive targets for therapy to lower intraprostatic androgen levels.

In the last decade, several enzyme inhibitors have been developed that inhibit speciic enzymes involved in intratumoral steroidogenesis. Clinical trials showed promising results, and the CYP17A inhibitor, abiraterone, now is approved for the treatment of chemotherapy resistant CRPC. However, targeting single enzyme activity may be of limited use, due to the tumor’s ability to use different androgen precursor sources and steroidogenesis pathways to maintain T and DHT levels. herefore, combination therapies, using inhibitors of diferent enzymes may be the most optimal strategy to reduce intra-tumoral T and DHT levels, and hence to combat CRPC (63). Moreover, combination therapy might allow the use of lower doses of enzyme inhibitors with subsequent reductions in side and/or toxic efects. At the end, preclinical and clinical studies are still needed to investigate individual and combinations of enzyme inhibitors for reducing intratumoral androgen levels in CRPC patients.

Conflict of Interests: None.

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References 1. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011;61:69-90.

2. Cannata DH, Kirschenbaum A, Levine AC. Androgen deprivation therapy as primary treatment for prostate cancer. J Clin Endocrinol Metab 2012;97:360-5.

3. Amaral TM, Macedo D, Fernandes I, Costa L. Castration-resistant prostate cancer: mechanisms, targets, and treatment. Prostate Cancer 2012;2012:327253.

4. Azzouni F, Mohler J. Biology of castration-recurrent prostate cancer. Urol Clin North Am 2012;39:435-52.

5. Nishiyama T, Hashimoto Y, Takahashi K. he inluence of androgen deprivation therapy on dihydrotestosterone levels in the prostatic tissue of patients with prostate cancer. Clin Cancer Res 2004;10:7121-6.

6. Titus MA, Schell MJ, Lih FB, Tomer KB, Mohler JL. Testosterone and dihydrotestosterone tissue levels in recurrent prostate cancer. Clin Cancer Res 2005;11:4653-7.

7. Nishiyama T, Ikarashi T, Hashimoto Y, Wako K, Takahashi K. The change in the dihydrotestosterone level in the prostate before and after androgen deprivation therapy in connection with prostate cancer aggressiveness using the Gleason score. J Urol 2007;178(4 Pt 1):1282-8.

8. Montgomery RB, Mostaghel EA, Vessella R, Hess DL, Kalhorn TF, Higano CS, et al. Maintenance of intratumoral androgens in metastatic prostate cancer: a mechanism for castration-resistant tumor growth. Cancer Res 2008;68:4447-54.

9. Mostaghel EA, Nelson PS. Intracrine androgen metabolism in prostate cancer progression: mechanisms of castration resistance and therapeutic implications. Best Pract Res Clin Endocrinol Metab 2008;22:243-58.

10. Hamid AR, Pfeiffer MJ, Verhaegh GW, Schaafsma E, Brandt A, Sweep FC, et al. Aldo-keto reductase family 1 member C3 (AKR1C3) is a biomarker and therapeutic target for castration-resistant prostate cancer. Mol Med 2013;18:1449-55.

11. Mostaghel EA, Solomon KR, Pelton K, Freeman MR, Montgomery RB. Impact of circulating cholesterol levels on growth and intratumoral androgen concentration of prostate tumors. PLoS One 2012;7:e30062.

12. Mitsiades N, Sung CC, Schultz N, Danila DC, He B, Eedunuri VK, et al. Distinct patterns of dysregulated expression of enzymes involved in androgen synthesis and metabolism in metastatic prostate cancer tumors.

Cancer Res 2012;72:6142-52.

13. Pfeiffer MJ, Smit FP, Sedelaar JP, Schalken JA. Steroidogenic enzymes and stem cell markers are upregulated during androgen deprivation in prostate cancer. Mol Med 2011;17:657-64.

14. Stanbrough M, Bubley GJ, Ross K, Golub TR, Rubin MA, Penning TM, et al. Increased expression of genes converting adrenal androgens to testosterone in androgen-independent prostate cancer. Cancer Res 2006;66:2815-25.

15. van der Sluis TM, Vis AN, van Moorselaar RJ, Bui HN, Blankenstein MA, Meuleman EJ, et al. Intraprostatic testosterone and dihydrotestosterone.

Part I: concentrations and methods of determination in men with benign prostatic hyperplasia and prostate cancer. BJU Int 2012;109:176-82.

16. Imamoto T, Suzuki H, Yano M, Kawamura K, Kamiya N, Araki K, et al. he role of testosterone in the pathogenesis of prostate cancer. Int J Urol 2008;15:472-80.

17. Mottet N, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, et al. EAU guidelines on prostate cancer. Part II: Treatment of advanced, relapsing, and castration-resistant prostate cancer. Eur Urol 2011;59:572-83.

18. Gleave M, Qian J, Andreou C, Pommerville P, Chin J, Casey R, et al. he efects of the dual 5alpha-reductase inhibitor dutasteride on localized prostate cancer: results from a 4-month pre-radical prostatectomy study.

Prostate 2006;66:1674-85.

19. Heracek J, Hampl R, Hill M, Starka L, Sachova J, Kuncova J, et al. Tissue and serum levels of principal androgens in benign prostatic hyperplasia and prostate cancer. Steroids 2007;72: 375-80.

20. Marks LS, Mostaghel EA, Nelson PS. Prostate tissue androgens: history and current clinical relevance. Urology 2008;72: 247-54.

21. Ishizaki F, Nishiyama T, Kawasaki T, Miyashiro Y, Hara N, Takizawa I, et al. Androgen deprivation promotes intratumoral synthesis of dihydrotestosterone from androgen metabolites in prostate cancer. Sci Rep 2013;3:1528.

22. Narimoto K, Mizokami A, Izumi K, Mihara S, Sawada K, Sugata T, et al.

Adrenal androgen levels as predictors of outcome in castration-resistant prostate cancer patients treated with combined androgen blockade using lutamide as a second-line anti-androgen. Int J Urol 2010;17:337-45.

23. Labrie F. DHEA, important source of sex steroids in men and even more in women. Prog Brain Res 2010;182:97-148.

148

24. Arai S, Miyashiro Y, Shibata Y, Tomaru Y, Kobayashi M, Honma S, et al. Efect of castration monotherapy on the levels of adrenal androgens in cancerous prostatic tissues. Steroids 2011;76:301-8.

25. Labrie F. Blockade of testicular and adrenal androgens in prostate cancer treatment. Nat Rev Urol 2011;8:73-85.

26. Bennett NC, Hooper JD, Lambie D, Lee CS, Yang T, Vesey DA, et al.

Evidence for steroidogenic potential in human prostate cell lines and tissues. Am J Pathol 2012;181:1078-87.

27. Auchus ML, Auchus RJ. Human steroid biosynthesis for the oncologist. J Investig Med 2012;60:495-503.

28. Locke JA, Guns ES, Lubik AA, Adomat HH, Hendy SC, Wood CA, et al. Androgen levels increase by intratumoral de novo steroidogenesis during progression of castration-resistant prostate cancer. Cancer Res 2008;68:6407-15.

29. Fukami M, Homma K, Hasegawa T, Ogata T. Backdoor pathway for dihydrotestosterone biosynthesis: implications for normal and abnormal human sex development. Dev Dyn 2013;242:320-9.

30. Chang KH, Li R, Papari-Zareei M, Watumull L, Zhao YD, Auchus RJ, et al. Dihydrotestosterone synthesis bypasses testosterone to drive castrationresistant prostate cancer. Proc Natl Acad Sci U S A 2011;108:13728-33.

31. Mohler JL, Titus MA, Bai S, Kennerley BJ, Lih FB, Tomer KB, et al.

Activation of the androgen receptor by intratumoral bioconversion of androstanediol to dihydrotestosterone in prostate cancer. Cancer Res 2011;71:1486-96.

32. Vasaitis TS, Bruno RD, Njar VC. CYP17 inhibitors for prostate cancer therapy. J Steroid Biochem Mol Biol 2011;125:23-31.

33. Rowlands MG, Barrie SE, Chan F, Houghton J, Jarman M, McCague R, et al. Esters of 3-pyridylacetic acid that combine potent inhibition of 17 alphahydroxylase/C17,20-lyase (cytochrome P45017 alpha) with resistance to esterase hydrolysis. J Med Chem 1995;38:4191-7.

34. Potter GA, Barrie SE, Jarman M, Rowlands MG. Novel steroidal inhibitors of human cytochrome P45017 alpha (17 alpha-hydroxylase-C17,20lyase): potential agents for the treatment of prostatic cancer. J Med Chem 1995;38:2463-71.

35. Attard G, Reid AH, Yap TA, Raynaud F, Dowsett M, Settatree S, et al. Phase I clinical trial of a selective inhibitor of CYP17, abiraterone acetate, conirms that castration-resistant prostate cancer commonly remains hormone driven. J Clin Oncol 2008;26:4563-71.

36. Barrie SE, Potter GA, Goddard PM, Haynes BP, Dowsett M, Jarman M. Pharmacology of novel steroidal inhibitors of cytochrome P450(17) alpha (17 alpha-hydroxylase/C17-20 lyase). J Steroid Biochem Mol Biol 1994;50:267-73.

37. de Bono JS, Logothetis CJ, Molina A, Fizazi K, North S, Chu L, et al.

Abiraterone and increased survival in metastatic prostate cancer. N Engl J Med 2011;364:1995-2005.

38. Scott LJ, Yang LP, Lyseng-Williamson KA. Abiraterone acetate: a guide to its use in metastatic castration-resistant prostate cancer. Drugs Aging 2012;29:243-8.

39. Kaku T, Hitaka T, Ojida A, Matsunaga N, Adachi M, Tanaka T, et al.

Discovery of orteronel (TAK-700), a naphthylmethylimidazole derivative, as a highly selective 17,20-lyase inhibitor with potential utility in the treatment of prostate cancer. Bioorg Med Chem 2011;19:6383-99.

40. Yamaoka M, Hara T, Hitaka T, Kaku T, Takeuchi T, Takahashi J, et al.

Orteronel (TAK-700), a novel non-steroidal 17,20-lyase inhibitor: efects on steroid synthesis in human and monkey adrenal cells and serum steroid levels in cynomolgus monkeys. J Steroid Biochem Mol Biol 2012;129:11528.

41. Hara T, Kouno J, Kaku T, Takeuchi T, Kusaka M, Tasaka A, et al. Efect of a novel 17,20-lyase inhibitor, orteronel (TAK-700), on androgen synthesis in male rats. J Steroid Biochem Mol Biol 2013;134:80-91.

42. Dreicer R, MacLean D, Suri A, Stadler WM, Shevrin D, Hart L, et al. Phase I/II trial of orteronel (TAK-700)--an investigational 17,20-lyase inhibitor-in patients with metastatic castration-resistant prostate cancer. Clin Cancer Res 2014;20:1335-44.

43. Miller WL, Auchus RJ. he molecular biology, biochemistry, and physiology of human steroidogenesis and its disorders. Endocr Rev 2011;32:81-151.

44. Byrns MC, Steckelbroeck S, Penning TM. An indomethacin analogue, N-(4-chlorobenzoyl)-melatonin, is a selective inhibitor of aldo-keto reductase 1C3 (type 2 3alpha-HSD, type 5 17beta-HSD, and prostaglandin F synthase), a potential target for the treatment of hormone dependent and hormone independent malignancies. Biochem Pharmacol 2008;75:484-93.

45. Bauman DR, Rudnick SI, Szewczuk LM, Jin Y, Gopishetty S, Penning TM. Development of nonsteroidal anti-inlammatory drug analogs and steroid

Armandari I, Hamid AR, Verhaegh G, Schalken J

carboxylates selective for human aldo-keto reductase isoforms: potential antineoplastic agents that work independently of cyclooxygenase isozymes.

Mol Pharmacol 2005;67:60-8.

46. Adeniji AO, Twenter BM, Byrns MC, Jin Y, Winkler JD, Penning TM. Discovery of substituted 3-(phenylamino)benzoic acids as potent and selective inhibitors of type 5 17β-hydroxysteroid dehydrogenase (AKR1C3).

Bioorg Med Chem Lett 2011;21: 1464-8.

47. Chen M, Adeniji AO, Twenter BM, Winkler JD, Christianson DW, Penning TM. Crystal structures of AKR1C3 containing an N-(aryl)amino-benzoate inhibitor and a bifunctional AKR1C3 inhibitor and androgen receptor antagonist. herapeutic leads for castrate resistant prostate cancer. Bioorg Med Chem Lett 2012;22:3492-7.

48. Day JM, Tutill HJ, Foster PA, Bailey HV, Heaton WB, Sharland CM, et al. Development of hormone-dependent prostate cancer models for the evaluation of inhibitors of 17betahydroxysteroid dehydrogenase type 3.

Mol Cell Endocrinol 2009;301:251-8.

49. Harada K, Kubo H, Tomigahara Y, Nishioka K, Takahashi J, Momose M, et al.

Coumarins as novel 17beta-hydroxysteroid dehydrogenase type 3 inhibitors for potential treatment of prostate cancer. Bioorg Med Chem Lett 2010;20:272-5.

50. Harada K, Kubo H, Tanaka A, Nishioka K. Identification of oxazolidinediones and thiazolidinediones as potent 17β-hydroxysteroid dehydrogenase type 3 inhibitors. Bioorg Med Chem Lett 2012;22:504-7.

51. Day JM, Foster PA, Tutill HJ, Schmidlin F, Sharland CM, Hargrave JD, et al. STX2171, a 17β-hydroxysteroid dehydrogenase type 3 inhibitor, is efficacious in vivo in a novel hormone-dependent prostate cancer model.

Endocr Relat Cancer 2013;20:53-64.

52. Vis AN, Schroder FH. Key targets of hormonal treatment of prostate cancer. Part 2: the androgen receptor and 5alphareductase. BJU Int 2009;104:1191-7.

53. Titus MA, Li Y, Kozyreva OG, Maher V, Godoy A, Smith GJ, et al.

5α-reductase type 3 enzyme in benign and malignant prostate. Prostate 2014;74:235-49.

54. McConnell JD, Roehrborn CG, Bautista OM, Andriole GL Jr, Dixon CM, Kusek JW, et al. he long-term efect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003; 349:2387-98.

55. Roehrborn CG, Barkin J, Siami P, Tubaro A, Wilson TH, Mor-rill BB, et al.

Clinical outcomes after combined therapy with dutasteride plus tamsulosin or either monotherapy in men with benign prostatic hyperplasia (BPH) by baseline characteristics: 4-year results from the randomized, doubleblind Combination of Avodart and Tamsulosin (CombAT) trial. BJU Int 2011;107:946-54.

56. Rasmusson GH, Reynolds GF, Steinberg NG, Walton E, Patel GF, Liang T, et al. Zasteroids: structure-activity relationships for inhibition of 5 alphareductase and of androgen receptor binding. J Med Chem 1986;29:2298315.

57. Frye SV. Discovery and clinical development of dutasteride, a potent dual 5alpha-reductase inhibitor. Curr Top Med Chem 2006;6:405-21.

58. Andriole G, Lieber M, Smith J, Soloway M, Schroeder F, Kadmon D, et al. Treatment with finasteride following radical prostatectomy for prostate cancer. Urology 1995;45:491-7.

59. Nacusi LP, Tindall DJ. Targeting 5α-reductase for prostate cancer prevention and treatment. Nat Rev Urol 2011;8:378-84.

60. Thompson IM, Goodman PJ, Tangen CM, Lucia MS, Miller GJ, Ford LG, et al. he inluence of inasteride on the development of prostate cancer. N Engl J Med 2003;349:215-24.

61. Rittmaster R, Hahn RG, Ray P, Shannon JB, Wurzel R. Efect of dutasteride on intraprostatic androgen levels in men with benign prostatic hyperplasia or prostate cancer. Urology 2008;72:808-12.

62. Shah SK, Trump DL, Sartor O, Tan W, Wilding GE, Mohler JL., Agarwal N, Sonpavde G, Sternberg CN. Novel molecular tar-Phase II study of Dutasteride for recurrent prostate cancer gets for the therapy of castrationresistant prostate cancer. Eur during androgen deprivation therapy. J Urol 2009;181:621-6. Urol 2012;61:950-60.

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Angiotensin (1-7) Antagonist Diminished the Anti-Tumor Effect of Olmesartan in Tumor Cell Lines Grown In-vitro and In-vivo

ANGIOTENSIN (1-7) ANTAGONIST DIMINISHED THE ANTI-TUMOR EFFECT OF OLMESARTAN IN TUMOR CELL LINES GROWN IN-VITRO AND IN-VIVO Mohammad M. Abd-Alhaseeb1*, Sawsan A. Zaitone2, Soad H. Abou-El-Ela3, and Yasser M. Moustafa2 1Department of Pharmacology and Toxicology, Faculty of Pharmacy and Pharmaceutical Industries, Sinai University, Arish, Egypt 2Department of Pharmacology and Toxicology, Faculty of Pharmacy, Suez Canal University, Ismailia, Egypt 3Department of Biochemistry, Faculty of Pharmacy and Pharmaceutical Industries, Sinai University, Arish, Egypt Corresponding author: Mohammad M. Abd-Alhaseeb, Department of Pharmacology and Toxicology, Faculty of Pharmacy and Pharmaceutical Industries, Sinai University, Arish, Egypt, Tel: 002-010-07699126; Fax: 002-068-3336847; E-mail: m.abdelhasseb@su.edu.eg

Open Access Article

Abstract Keywords: Anti-tumor, angiotensin (1-7) antagonist, olmesartan, cancer, cell line Published in Enliven Archive 2014, Volume 1, Issue 1 www.enlivenarchive.org Copyright: @ 2014 Dr. Mohammad M. Abd-Alhaseeb

Received: 06 August 2014 Reviewed: 08 September 2014 Accepted: 12 September 2014 Cite this article: Abd-Alhaseeb M, Zaitone SA, Abou-El-Ela SH, Moustafa YM. Angiotensin (1-7) Antagonist Diminished the Anti-Tumor Effect of Olmesartan in Tumor Cell Lines Grown In-vitro and In-vivo.

Rom J Oncol Hematol.

2014; 2(3):150-158.

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Olmesartan is a selective angiotensin II type 1 receptor (AT1R) antagonist. It achieves blood pressure reduction in a dose-dependent manner through arterial vasodilation and reduced sodium retention. Secondly, olmesartan exhibits anti-angiogenic activity through inhibition of Insulin growth factor, vascular endothelial growth factor and their receptors and this effect was mediated through the Ang (1-7). The current study was to investigate the antitumor effect of olmesartan; first, the cytotoxic activity of olmesartan and/or Ang (1-7) antagonist on MCF-7 cell line using 3-[4, 5-dimethylthiazole-2-yl]-2, 5-diphenyltetrazolium bromide (MTT) assay was explored. Then EAC solid tumor grown in vivo was employed to determine the impact of concurrent administration of an Ang (1–7) agonist or antagonist on the anti-tumor effect of olmesartan. In addition, the impact of concurrent administration of olmesartanon the cytotoxic activity of sorafenib in MCF-7 cell line or its antitumor effect in EAC solid tumor grown in vivo was investigated. It was observed that the cell viability was reduced by approximately 40% after sorafenib (250 μg/ml) treatment. On the other hand, olmesartan did not show any cytotoxic effect except when higher concentrations were used. IC50 value for sorafenib in MCF-7 was 250.9 μg/ml, while the IC50 value for olmesartan was 674.8 μg/ml. Ang (1-7) antagonist increased the IC50 value of olmesartan from 674.8 μg/ml to 722 μg/ml. The high cytotoxic concentration of olmesartan in combination with sorafenib failed to enhance the cytotoxicity more than the sorafenib itself. Sorafenib (30 mg/kg/day), olmesartan (3, 10 or 30 mg/kg/day) or their combination significantly (P<0.05) reduced tumor volume and the relative tumor volume compared to EAC-Control group. Similarly, concurrent administration of the Ang (1-7) agonist with olmesartan (30 mg/kg) significantly (P<0.05) reduced tumor volume and the relative tumor volume compared to EAC-control group or olmesartan (30 mg/kg) group. Moreover, the administration of Ang (1-7) antagonist with olmesartan reduced the anti-tumor effect of olmesartan. In conclusion, olmesartan (30 mg/kg) posses anti-tumor activity. This anti-tumor activity did not depend on the direct cytotoxic activity but might be attributed to antiangiogenic activity as proven in a previous work from our lab. The anti-tumor effect of olmesartan was, at least in part, mediated through the Ang (1-7) receptor. In addition, the present results showed that olmesartan (30 mg/kg) potentiated the anti-tumor effect of sorafenib.

Abd-Alhaseeb MM, Zaitone SA, Abou-El-Ela SH, Moustafa YM

Figure 1.

Effect of sorafenib and olmesartan on cell viability in MCF-7 cells. A) Effect of sorafenib against MCF-7 cells. B) Effect of olmesartan against MCF-7 cells. Cell viability was measured using MTT assay. Values are expressed as mean value of cell viability (% of control) ± S.D. of four experiments and analyzed using Chi-square test. *Significantly different from control at P<0.05

Figure 2.

The half maximal inhibitory concentrations of sorafenib and olmesartan in MCF-7 cells.

A) IC50 value for sorafenib in MCF-7 cells.

B) IC50 value for olmesartan in MCF-7 cells.

Cell viability was measured using MTT assay. IC50: The half maximal inhibitory concentration.

Introduction The Renin-angiotensin system (RAS) is a hormone system that is activated when the enzyme renin is released and cleaves the parent compound angiotensinogen to the decapeptide angiotensin I (Ang I). The catabolism of Ang I is a point of divergence in the system, leading to the production of the bioactive peptide hormones, angiotensin II (Ang II) and angiotensin (1-7) (Ang (1-7)). These peptide products differ in their carboxy termini which leads to counter-regulatory actions mediated by high affinity binding to distinct membrane-spanning receptors (1). Ang (1-7) exerts its actions through a G protein-coupled receptor encoded by the mas gene (2). Ang (1–7) appears to have an inhibitory influence on many of the events induced by Ang II (3).

Ang (1–7) has a depressor, vasodilator, apoptotic and anti-proliferative actions. Ang (1–7) was suggested to inhibit angiogenesis (4), although further investigations are needed to confirm these effects in a wider range of pathological/physiological conditions. Ang (1–7) may be generated directly from Ang II by the enzymatic activity of angiotensin con-

verting enzyme two (ACE2) or from Ang I, via angiotensin (1–9), a pathway that utilizes both ACE2 and angiotensin converting enzyme (ACE) (5). ACE2 was found in many tissues with high concentrations in the heart, kidney and gastrointestinal tract (6).

In addition, ACE2 expression was reported in animal models of liver injury and in human cirrhosis and was associated with increasing plasma and tissue levels of Ang (1–7) (7). Olmesartan is a selective angiotensin II type 1 receptor (AT1R) antagonist. It achieves blood pressure reduction in a dose-dependent manner through arterial vasodilation and reduced sodium retention (8).

In addition, olmesartan exhibits anti-angiogenic activity through inhibition of Insulin growth factor, vascular endothelial growth factor and their receptors and this effect was mediated through the Ang (1-7) (9). Sorafenib is a multi-kinase inhibitor taken orally and approved in the treatment of metastatic renal cell carcinoma (10).

It has been reported that olmesartan potentiated the anti-angiogenic effect of sorafenib in Ehrlich’s ascites carcinoma (EAC) solid tumor grown in vivo in mice (9). So, the objective of the current September 2014

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Angiotensin (1-7) Antagonist Diminished the Anti-Tumor Effect of Olmesartan in Tumor Cell Lines Grown In-vitro and In-vivo

study was to investigate the anti-tumor effect of olmesartan; beginning with exploring the cytotoxic activity of olmesartan and/or Ang (1-7) antagonist on MCF-7 cell line using 3-(4, 5-dimethylthiazole-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay.

Then, EAC solid tumor grown in vivo was employed to determine the impact of concurrent administration of an Ang (1–7) agonist or antagonist on the anti-tumor effect of olmesartan. Finally, investigate the impact of concurrent administration of olmesartan on the cytotoxic activity of sorafenib in MCF-7 cell line or its anti-tumor effect in EAC solid tumor grown in vivo.

Methods and Materials Cell Culture and Drug Treatment The MCF-7 human breast adenocarcinoma cell line was purchased from American Type Culture Collection (ATCC, Manassas, VA, USA). It was maintained in Dulbecco’s Modified Eagle’s Medium containing 10% fetal bovine serum, 100 units/mL penicillin, and 100 mg/mL streptomycin.

Cells were incubated in a humidified, 5% CO2 atmosphere at 37°C. MTT Assay for Cell Viability MTT assay is based on the ability of active mitochondrial dehydrogenase enzyme of living cells to cleave the tetrazolium rings of the yellow MTT and form dark blue insoluble formazan crystals which is largely impermeable to cell membranes, resulting in its accumulation within healthy cells. The effect of olmesartan and/or sorafenib and Ang (1-7) antagonist on cell viability was determined using MTT assay.

In MTT assay 0.5×105 cells per well were plated in 96-well culture plates. After an overnight incubation, cells were treated with 20 μl of different concentrations of olmesartan and/or sorafenib for 48 h at 37°C. The cells were then treated with 40 μl of MTT (Sigma-Aldrich, MO, USA) and Incubated for 4 h at 37°C. The medium was then discarded, and 180 μl of acidified isopropanol (Sigma-Aldrich, MO, USA) was added to dissolve formazan crystals. Absorption values at 570 nm were determined with Multiskan MS microplate reader (Labsystems, Finland). The cell viability of olmesartan and/or sorafenib-treated cells was calculated as the percentage of cell viability compared to untreated cells. In addition, IC50 values were calculated from the equation of the curve.

Anti-Tumor Activity of Olmesartan and/or Sorafenib in Ehrlich’s Ascites Carcinoma Solid Tumor Grown in Mice Female Swiss albino mice, each weighing 20-25 g were obtained from the modern veterinary office for laboratory animals (Cairo, Egypt). EAC cell line was purchased from Tumor Biology Department, National Cancer Institute (Cairo University, Egypt).

EAC cells were injected intradermally (2.5 × 106 EAC cells in 0.1 ml saline/animal) at the two sites bilaterally on the lower ventral side after shaving

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this area. After 7 days, mice were randomly divided into eight groups, ten animals each. All treatments were given for 21 days and the treatment regimens were as follows: Group I: mice treated with DMSO (5 mL/kg/day, p.o.), and served as the EAC-control group. Group II: mice treated with sorafenib (30 mg/kg/day, p.o.) (11). Group III-V: mice treated with olmesartan (3, 10 or 30 mg/kg/ day, p.o.), respectively (12). Group VI: mice treated with a combination of sorafenib (30 mg/kg/day, p.o.) and olmesartan (30 mg/ kg/day, p.o.). Group VII: mice treated with olmesartan (30 mg/kg/day, p.o.) and the angiotensin (1-7) agonist (30 μg/kg/ day, i.p.) (13). Group VIII: mice were treated with olmesartan (30 mg/kg/day, p.o.) and the angiotensin (1-7) antagonist (A-779 peptide) (3.3 mg/ kg/trice weekly, i.p.) (14). In general, olmesartan and sorafenib were administered daily by gastric gavage in a volume of 5 mL/kg. Whereas, the angiotensin (1-7) agonist or the angiotensin (1-7) antagonist were administered intraperitoneally.

At the end of the experiment, the animals were sacrificed with cervical dislocation.

The tumors were separated from the surrounding muscles and dermis; tumor volumes were measured with vernier calipers and calculated by the following formula: 0.5 X2Y, where X and Y are the minor and major axes, respectively (15). In addition, the relative tumor volumes were calculated by dividing the mean tumor volumes of the treated groups by the mean tumor volume of the control group (16).

All experimental protocols were approved by The Research Ethics Committee at the Faculty of Pharmacy, Suez Canal University (License number 20146A10).

Drugs and Chemicals Olmesartan medoxomil was obtained from Daiichi Sankyo Pharmaceutical Co. (Tokyo, Japan) and dissolved at a concentration of 100 mM in dimethyl sulphoxide (DMSO, Sigma-Aldrich, MO, USA) as a stock solution. It was then further diluted to working concentrations with cell culture medium in in-vitro study and with water in in-vivo study.

Sorafenib tosylate was purchased from Bayer Health Care (Leverkusen, Germany). Ang (1-7) agonist and antagonist were purchased from Bachem AG (Bubendorf, Zurich, Switzerland). All other chemicals were purchased from SigmaAldrich (MO, USA). Statistical Analysis In-vitro results were expressed as mean ± standard deviation (SD). Results were analysed in terms of IC50 values, and differences noted across the cell-line panel and within individual cell lines were tested for statistical significance using Chi-square test.

On the other hand data from in-vivo results were expressed as mean ± standard error of mean (SEM) and was analyzed using one-way analysis of variance (ANOVA), followed by Bonferroni’s post hoc test at P<0.05. Statistical analysis was

Nume autori

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Angiotensin (1-7) Antagonist Diminished the Anti-Tumor Effect of Olmesartan in Tumor Cell Lines Grown In-vitro and In-vivo

Figure 3.

Effect of angiotensin (1-7) antagonist (A-779 peptide) on IC50 value of sorafenib and olmesartan using MCF-7 cells. A) Effect of sorafenib with the A-779 peptide against MCF-7 cells. B) Effect of olmesartan with A-779 peptide against MCF-7 cells. Cell viability was measured using MTT assay.

IC50: The half maximal inhibitory concentration performed using SPSS software, version 22 (SPSS Software, SPSS Inc., Chicago, USA). Results Efect on MCF-7 Cell Line First, we determined the cytotoxic effect of sorafenib and olmesartan on MCF7 breast cancer cells using MTT assay. MCF-7 cells were treated with various concentrations of sorafenib and olmesartan.

After sorafenib treatment, cell viability was reduced by approximately 40% (Figure 1A). On the other hand, olmesartan did not show any cytotoxic effect except when higher concentrations were used (Figure 1B).

IC50 value for sorafenib in MCF-7 was 250.9 μg/ ml, while the IC50 value for olmesartan was 674.8 μg/ml (Figure 2A and 2B). On the other hand, the Ang (1-7) antagonist (A-779 peptide) showed a safe effect on the same cell line up to 50 μg/ml, so that the used concentration (10 μg/ml) was completely safe with viability percent > 85%. In the low concentration range up to 100 μg/ml of sorafenib or olmesartan, the 10 μg/ml of peptide decreased the IC50 of sorafenib from 250.9 μg/ ml to 125.9 μg/ml.

On the other hand, the peptide (10 μg/ml) treatment in combination with olmesartan increased the IC50 value from 674.8 μg/ml to 722 μg/ml (Figure 3A and 3B).

Discussion The combination of olmesartan and sorafenib, with different concentrations of both, showed different effects (Figure 4). Olmesartan itself at highest used concentration (500 μg/ml) - without sorafenib - enhanced cytotoxicity from about 90% of cell viability - at olmesartan concentration 62.5 μg/ml - into only 60% of cell viability. However such high cytotoxic concentration of olmesartan in combination with sorafenib failed to enhance the cytotox icity more than the sorafenib itself (Figure 4).

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Figure 4. Cytotoxic effect of fixed concentrations of olmesartan and/or sorafenib against MCF-7 cell line. Cell viability was measured using MTT assay

Efect on Tumor Volume Administration of sorafenib (30 mg/kg/day), olmesartan (3, 10 or 30 mg/kg/day) or their combination significantly (P<0.05) reduced tumor volume compared to EAC-Control group (Figure 5A). Similarly, concurrent administration of the Ang (1-7) agonist with olmesartan (30 mg/kg) significantly (P<0.05) reduced tumor volume compared to EAC-control group or olmesartan (30 mg/kg) group. Moreover, the administration of Ang (1-7) antagonist with olmesartan reduced the antitumor effect of olmesartan (Figure 5B).

Efect on the Relative Tumor Volume The administration of sorafenib (30 mg/kg/day), olmesartan (3, 10 or 30 mg/kg/day) or their combination showed a significant (P<0.05) decrease in the % relative tumor volume when compared to EACcontrol group (Figure 6A).

Similarly, concurrent administration of the Ang (1-7) agonist with olmesartan (30 mg/kg) significantly (P<0.05) reduced the % relative tumor volume compared to EAC-Control group or olmesar-

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Angiotensin (1-7) Antagonist Diminished the Anti-Tumor Effect of Olmesartan in Tumor Cell Lines Grown In-vitro and In-vivo

tan (30 mg/kg) group. Further, the administration of Ang (1-7) antagonist with olmesartan reduced the antitumor effect of olmesartan (Figure 6B).

There are increasing evidences for in-vivo and invitro models of angiogenesis indicating a regulatory role of Ang II and its receptors in new vessel formation (17).

Ang II has been reported to promote tumor growth and angiogenesis (18). Therefore, angiotensin receptor blockers have been considered a noteworthy anticancer and anti-angiogenesis therapeutic option (18). Angiotensin II type 1 receptor is often up-regulated during the progression from normal to malignant phenotypes, indicating at the very least a correlation between the RAS and tumour progression (3).

Therefore, AT1R blockers have been considered as an anti-angiogenic therapeutic option (19).

Ang (1–7) appears to have an inhibitory influence on many of the events induced by Ang II (3). Ang (1–7) has a depressor, vasodilator, apoptotic and antiproliferative actions.

Ang (1–7) is also suggested to inhibit angiogenesis (4). In the current study, olmesartan showed a cytotoxic activity and reduced the cell viability of MCF-7 cells with IC50 value of 675 μg/ml; however this is considered a high cytotoxic concentration. Therefore, we suggested that the anti-tumor effect of olmesartan is not a result of direct toxicity.

Consistently, it has been reported that the antitumor effect of ARBs is not a result of direct toxicity but of an anti-angiogenic effect (20,21). In addition, it has been reported that in the MCF-7 cell line, Ang II increased the basal protein kinase activity and so increased growth of MCF-7 cells.

Consequently, ARBs decreased growth of MCF7 cells through inhibition of protein kinase activity not due to cytotoxic activity (22). Another study came in parallel with the present findings as candesartan, type of ARBs, did not induce direct cytotoxicity in in-vitro human bladder cancer cells (20).

In addition, the current results demonstrated that the Ang (1-7) antagonist increased the IC50 value of olmesartan indicated the antagonist effect exerted by the Ang (1-7) antagonist on olmesartan. In agreement with the previous results, it has been reported that the specific Ang (1–7) receptor antagonist (A-779 peptide) prevented the effects of ARBs and Ang (1–7) itself (4).

On the other hand, sorafenib showed a higher cytotoxic activity against MCF-7 cell lines with IC50 value of 250 μg/ml; that indicated the higher cytotoxicity of sorafenib over olmesartan. In agreement with the previous results, it has been reported that sorafenib showed a broad cytotoxic activity against various tumor cell lines in-vitro and in xenograft models (23).

Additionally, the current study showed that olmesartan at the highest used concentration

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(500 μg/ml) enhanced cytotoxicity from about 90% of cell viability into only 60% of cell viability.

Therefore, olmesartan showed a little cytotoxic activity. In agreement with the previous results, it has been reported that the ARBs showed a mild cytotoxic activity on tumor cell lines (21). This is the first time to examine the cytotoxic effect of olmesartan and/ or sorafenib on MCF-7 cells. The current results showed that the highest cytotoxic concentration of olmesartan in combination with sorafenib failed to enhance the cytotoxicity more than the sorafenib itself indicating no in-vitro synergistic effect in the cytotoxicity between the two compounds despite of the toxicity of each one separately.

The in-vivo anti-tumor activity of olmesartan was evaluated in the present study by determination of tumor volume and the relative tumor volume in EAC solid tumor grown in mice.

The current study showed that olmesartan reduced the tumor volume and relative tumor volume assuming that this was linked to the angiostatic effect of olmesartan which resulted in tumor growth impairment. In agreement with the previous results, it has been reported that candesartan reduced tumor volume in a xenograft model of bladder cancer (20).

Furthermore, consistently with the previous results losartan reduced cell growth of in-vivo models of cancer (24). Also, telmisartan, caused marked inhibition of prostate cancer cells in concentration-dependent and timedependent manner (18).

The current results showed that the combination of olmesartan (30 mg/ kg) with the Ang (1-7) agonist reduced the tumor volume and the relative tumor volume. On the other hand, the Ang (1-7) antagonist (A-779 peptide) antagonized the antitumor effect of olmesartan.

Therefore, we suggested that the anti-tumor effect of olmesartan is mediated through the Ang (17) receptors. In agreement with the previous results it has been reported that the Ang (1-7) antagonist antagonized the anti-tumor effect of Ang (1-7) agonist and ARBs in human lung cancer cell model (25).

The current study also showed that sorafenib reduced tumor volume and the relative tumor volume. In agreement with the previous results, it has been reported that sorafenib reduced tumor size and tumor weight in hepatocellular carcinoma (26).

In addition, it has been reported that sorafenib reduced tumor weight and tumor volume in neuroblastoma model of cancer (27). Another study came in parallel with the results in the current study, it showed that sorafenib reduced tumor weight in human liver cancer model (28). Moreover, the current study showed that olmesartan (30 mg/kg) potentiated the anti-tumor effect of sorafenib.

The combined therapy reduced tumor volume and the relative tumor volume and this effect was attributed to the anti-angiogenic effect of the com-

Abd-Alhaseeb MM, Zaitone SA, Abou-El-Ela SH, Moustafa YM

Figure 5.

Effect of sorafenib and olmesartan on tumor volume of EAC solid tumor grown in mice. A) Effect of sorafenib (30 mg/kg), olmesartan (3, 10 or 30 mg/kg) and their combination on the mean tumor volume of EAC solid tumor growing grown in mice. B) Effect of concurrent administration of an Ang (1-7) agonist (30 μg/kg/day, i.p.) or an Ang (1-7) antagonist (3.3 mg/kg/trice/week, i.p.) and olmesartan on the mean tumor volume of EAC solid tumor grown in mice. EAC: Ehrlich’s ascites carcinoma. Values are expressed as the mean ± S.E.M. and data were analyzed using one-way ANOVA followed by Bonferroni’s posthoc test at P<0.05.*Significantly different from the EAC-control. ΔSignificantly different from sorafenib monotherapy. •Significantly different from olmesartan (3 mg/kg) group. €Significantly different from olmesartan (10 mg/kg) group.$Significantly different from olmesartan (30 mg/kg) group. ◊Significantly different from the combination of olmesartan and Ang (1-7) agonist

Figure 6.

Effect of sorafenib and olmesartan on the relative tumor volume of EAC solid tumor grown in mice.

A) Effect of sorafenib (30 mg/kg), olmesartan (3, 10 or 30 mg/kg) and their combination on the relative tumor volume of EAC solid tumor grown in mice. B) Effect of concurrent administration of an Ang (1-7) agonist (30 μg/kg/ day, i.p.) or an Ang (1-7) antagonist (3.3 mg/kg/trice/week, i.p.) and olmesartan on the relative tumor volume of EAC solid tumor grown in mice. EAC: Ehrlich’s ascites carcinoma. Values are expressed as the mean ± S.E.M. and data were analyzed using one-way ANOVA followed by Bonferroni’s post-hoc test at P<0.05. *Significantly different from the EACcontrol. ΔSignificantly different from sorafenib monotherapy. •Significantly different from olmesartan (3 mg/kg) group. €Significantly different from olmesartan (10 mg/kg) group. $Significantly different from olmesartan (30 mg/kg) group. ◊Significantly different from the combination of olmesartan and Ang (1-7) agonist bined therapy. Similarly, it has been reported in previous study that the combined therapy of olmesartan and sorafenib produced an anti-angiogenic activity that was confirmed by reducing tumor weight of EAC solid tumor grown on mice (9).

Conclusion In conclusion, the present results showed that olmesartan (30 mg/kg) posses anti-tumor activity. This anti-tumor activity did not depend on the direct cytotoxic activity but might be attributed to antiangiogenic activity as proven in a previous work from our lab.

The anti-tumor effect of olmesartan was, at least

in part, mediated through the Ang (1-7) receptor. In addition, the present results showed that olmesartan (30 mg/kg) potentiated the anti-tumor effect of sorafenib.

Therefore, the present study highlights the beneficial role of olmesartan as an adjuvant medication to sorafenib in the treatment of cancer.

Conflict of Interests: None.

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International articles

Angiotensin (1-7) Antagonist Diminished the Anti-Tumor Effect of Olmesartan in Tumor Cell Lines Grown In-vitro and In-vivo

References 1. Ferrario CM, Jessup J, Gallagher PE, Averill DB, Brosnihan KB, et al. (2005) Effects of renin-angiotensin system blockade on renal angiotensin-(1-7) forming enzymes and receptors. Kidney Int 68: 21892196.

2. Santos RA, Simoes e Silva AC, Maric C, Silva DM, Machado RP, et al. (2003) Angiotensin-(1-7) is an endogenous ligand for the G proteincoupled receptor Mas. Proc Natl Acad Sci U S A 100: 8258-8263.

3. Ager EI, Neo J, Christophi C (2008) The renin-angiotensin system and malignancy. Carcinogenesis 29: 1675-1684.

4. Machado RD, Santos RA, Andrade SP (2001) Mechanisms of angiotensin-(1-7)-induced inhibition of angiogenesis. Am J Physiol Regul Integr Comp Physiol 280: R994-R1000.

5. Herath CB, Warner FJ, Lubel JS, Dean RG, Jia Z, et al. (2007) Upregulation of hepatic angiotensin-converting enzyme 2 (ACE2) and angiotensin-(1-7) levels in experimental biliary fibrosis. J Hepatol 47: 387-395.

6. Donoghue M, Hsieh F, Baronas E, Godbout K, Gosselin M, et al. (2000) A novel angiotensin-converting enzyme-related carboxypeptidase (ACE2) converts angiotensin I to angiotensin 1-9. Circ Res 87: E1-9.

7. Paizis G, Tikellis C, Cooper ME, Schembri JM, Lew RA, et al. (2005) Chronic liver injury in rats and humans upregulates the novel enzyme angiotensin converting enzyme 2. Gut 54: 1790-1796.

8. Mire DE, Silfani TN, Pugsley MK (2005) A review of the structural and functional features of olmesartan medoxomil, an angiotensin receptor blocker. J Cardiovasc Pharmacol 46: 585-593.

9. Abd-Alhaseeb MM, Zaitone SA, Abou-El-Ela SH, Moustafa YM (2014) Olmesartan potentiates the anti-angiogenic effect of sorafenib in mice bearing Ehrlich’s ascites carcinoma: role of angiotensin (1-7). PloS one 9: e85891.

10. Ratain MJ, Eisen T, Stadler WM, Flaherty KT, Kaye SB, et al. (2006) Phase II placebo-controlled randomized discontinuation trial of sorafenib in patients with metastatic renal cell carcinoma. J Clin Oncol 24: 25052512.

11. Huynh H, Lee JW, Chow PK, Ngo VC, Lew GB, et al. (2009) Sorafenib induces growth suppression in mouse models of gastrointestinal stromal tumor. Mol Cancer Ther 8: 152-159.

12. Tsuda M, Iwai M, Li JM, Li HS, Min LJ, et al. (2005) Inhibitory effects of AT1 receptor blocker, olmesartan, and estrogen on atherosclerosis via anti-oxidative stress. Hypertension 45: 545-551.

13. Fraga-Silva RA, Costa-Fraga FP, De Sousa FB, Alenina N, Bader M, et al. (2011) An orally active formulation of angiotensin-(1-7) produces an antithrombotic effect. Clinics 66: 837-841.

14. Jawien J, Toton-Zuranska J, Gajda M, Niepsuj A, Gebska A, et al.

(2012) Angiotensin-(1-7) receptor Mas agonist ameliorates progress of atherosclerosis in apoE-knockout mice. J Physiol Pharmacol 63: 77-85.

15. Attia MA, Weiss DW (1966) Immunology of spontaneous mammary carcinomas in mice. V. Acquired tumor resistance and enhancement in strain A mice infected with mammary tumor virus. Cancer Res 26: 17871800.

158

16. Wild R, Dings RP, Subramanian I, Ramakrishnan S (2004) Carboplatin selectively induces the VEGF stress response in endothelial cells: Potentiation of antitumor activity by combination treatment with antibody to VEGF. Int J Cancer 110: 343-351.

17. Carbajo-Lozoya J, Lutz S, Feng Y, Kroll J, Hammes HP, et al. (2012) Angiotensin II modulates VEGF-driven angiogenesis by opposing effects of type 1 and type 2 receptor stimulation in the microvascular endothelium. Cell Signal 24: 1261-1269.

18. Funao K, Matsuyama M, Kawahito Y, Sano H, Chargui J, et al. (2008) Telmisartan is a potent target for prevention and treatment in human prostate cancer. Oncology Rep 20: 295-300.

19. Abali H, Gullu IH, Engin H, Haznedaroglu IC, Erman M, et al. (2002) Old antihypertensives as novel antineoplastics: angiotensin-I-converting enzyme inhibitors and angiotensin II type 1 receptor antagonists. Med Hypotheses 59: 344-348.

20. Kosugi M, Miyajima A, Kikuchi E, Horiguchi Y, Murai M (2006) Angiotensin II type 1 receptor antagonist candesartan as an angiogenic inhibitor in a xenograft model of bladder cancer. Clinical Can Res 12: 2888-2893.

21. Kosaka T, Miyajima A, Takayama E, Kikuchi E, Nakashima J, et al.

(2007) Angiotensin II type 1 receptor antagonist as an angiogenic inhibitor in prostate cancer. The Prostate 67: 41-49.

22. Loewenthal H, Jahn G (1932) Übertragung-Suersuche Mit Carcinomatöser Mause-Asciteslussigleit Und İhr Verhalten Gegen Physikalische Und Chemische Einwirkungen. Zeitschrift für Krebsforschung 37: 439-447.

23. Yu C, Friday BB, Lai JP, Yang L, Sarkaria J, et al. (2006) Cytotoxic synergy between the multikinase inhibitor sorafenib and the proteasome inhibitor bortezomib in vitro: induction of apoptosis through Akt and c-Jun NH2-terminal kinase pathways. Mol Cancer Ther 5: 2378-2387.

24. Arrieta O, Guevara P, Escobar E, Garcia-Navarrete R, Pineda B, et al. (2005) Blockage of angiotensin II type I receptor decreases the synthesis of growth factors and induces apoptosis in C6 cultured cells and C6 rat glioma. Br J Cancer 92: 1247-1252.

25. Soto-Pantoja DR, Menon J, Gallagher PE, Tallant EA (2009) Angiotensin-(1-7) inhibits tumor angiogenesis in human lung cancer xenografts with a reduction in vascular endothelial growth factor. Mol Cancer Ther 8: 1676-1683.

26. Kong J, Kong F, Gao J, Zhang Q, Dong S, et al. (2014) YC-1 enhances the anti-tumor activity of sorafenib through inhibition of signal transducer and activator of transcription 3 (STAT3) in hepatocellular carcinoma. Mol Cancer 13: 7.

27. Kakodkar NC, Peddinti RR, Tian Y, Guerrero LJ, Chlenski A, et al.

(2012) Sorafenib inhibits neuroblastoma cell proliferation and signaling, blocks angiogenesis, and impairs tumor growth. Pediatr Blood Cancer 59: 642-647.

28. Kusano H, Ogasawara S, Akiba J, Nakayama M, Ueda K, et al. (2013) Antiproliferative effects of sorafenib and pegylated IFNalpha2b on human liver cancer cells in vitro and in vivo. International journal of oncology 42: 1897-1903.

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