Primary central nervous system lymphoma: Phase I evaluation of infusional bromodeoxyuridine with whole brain accelerated fractionation radiation therapy after chemotherapy

Pathways of the Dissociative Electron Attachment Observed in 5- and 6-Azidomethyluracil Nucleosides: Nitrogen (N2) Elimination vs Azide Anion (N3-) Elimination

5-Azidomethyl-2'-deoxyuridine (5-AmdU, 1) has been successfully employed for the metabolic labeling of DNA and fluorescent imaging of live cells. 5-AmdU also demonstrated significant radiosensitization in breast cancer cells via site-specific nitrogen-centered radical (π-aminyl (U-5-CH2-NH•), 2, and σ-iminyl (U-5-CH═N•), 3) formation. This work shows that these nitrogen-centered radicals are not formed via the reduction of the azido group in 6-azidomethyluridine (6-AmU, 4). Radical assignments were performed using electron spin resonance (ESR) in supercooled solutions, pulse radiolysis in aqueous solutions, and theoretical (DFT) calculations. Radiation-produced electron addition to 4 leads to the facile N3- loss, forming a stable neutral C-centered allylic radical (U-6-CH2•, 5) through dissociative electron attachment (DEA) via the transient negative ion, TNI (U-6-CH2-N3•-), in agreement with DFT calculations. In contrast, TNI (U-5-CH2-N3•-) of 1, via facile N2 loss (DEA) and protonation from the surrounding water, forms radical 2. Subsequently, 2 undergoes rapid H-atom abstraction from 1 and produces the metastable intermediate α-azidoalkyl radical (U-5-CH•-N3). U-5-CH•-N3 converts facilely to radical 3. N3- loss from U-6-CH2-N3•- is thermodynamically controlled, whereas N2 loss from U-5-CH2-N3•- is dictated by protonation from the surrounding waters and resonance conjugation of the azidomethyl side chain at C5 with the pyrimidine ring.

Quasi-Free Electron-Mediated Radiation Sensitization by C5-Halopyrimidines

Substitution of the thymidine moiety in DNA by C5-substituted halogenated thymidine analogues causes significant augmentation of radiation damage in living cells. However, the molecular pathway involved in such radiosensitization process has not been clearly elucidated to date in solution at room temperature. So far, low-energy electrons (LEEs; 0-20 eV) under vacuum condition and solvated electrons (esol-) in solution are shown to produce the σ-type C5-centered pyrimidine base radical through dissociative electron attachment involving carbon-halogen bond breakage. Formation of this σ-type radical and its subsequent reactions are proposed to cause cellular radiosensitization. Here, we report time-resolved measurements at room temperature, showing that a radiation-produced quasi-free electron (eqf-) in solution promptly breaks the C5-halogen bond in halopyrimidines forming the σ-type C5 radical via an excited transient anion radical. These results demonstrate the importance of ultrafast reactions of eqf-, which are extremely important in chemistry, physics, and biology, including tumor radiochemotherapy.

Current Landscape and Future Prospects of Radiation Sensitizers for Malignant Brain Tumors: A Systematic Review

BACKGROUND

Radiation therapy (RT) is the cornerstone of management of malignant brain tumors, but its efficacy is limited in hypoxic tumors. Although numerous radiosensitizer compounds have been developed to enhance the effect of RT, progress has been stagnant. Through this systematic review, we provide an overview of radiosensitizers developed for malignant brain tumors, summarize their safety and efficacy, and evaluate areas for possible improvement.

METHODS

Following PRISMA guidelines, PubMed, EMBASE, Cochrane, and Web of Science were searched using terminology pertaining to radiosensitizers for brain tumor RT. Articles reporting clinical evidence of nonantineoplastic radiosensitizers with RT for malignant central nervous system tumors were included. Data of interest were presumed mechanism of action, median overall survival (OS), progression-free survival (PFS), and adverse events.

RESULTS

Twenty-two unique radiosensitizers were identified. Only 2/22 agents (fluosol with oxygen, and efaproxiral) showed improvement in OS in patients with glioblastoma and brain metastasis, respectively. A larger study was not able to confirm the latter. Improved PFS was reported with use of metronidazole, sodium glycididazole, and chloroquine. There was a wide range of toxicities, which prompted change of schedule or complete discontinuation of 9 agents.

CONCLUSIONS

Progress in radiosensitizers for malignant CNS tumors has been limited. Only 2 radiosensitizers have shown limited improvement in survival. Alternative strategies such as synthetic drug design, based on a mechanism of action that is independent of crossing the blood-brain barrier, may be necessary. Use of drug development strategies using new technologies to overcome past challenges is necessary.

Mechanisms Responsible for High Energy Radiation Induced Damage to Single-Stranded DNA Modified by Radiosensitizing 5-Halogenated Deoxyuridines

Experimental studies showed that high energy radiation induced base release and DNA backbone breaks mainly occur at the neighboring 5' nucleotide when a single-stranded DNA is modified by radiosensitizing 5-halogenated deoxyuridines. However, no mechanism can be used to interpret these experimental observations. To better understand the radiosensitivity of 5-halogenated deoxyuridines, mechanisms involving hydrogen abstraction by the uracil-5-yl radical from the C2' and C3' positions of an adjacent nucleotide separately followed by the C3'-O3' or N-glycosidic bond rupture and the P-O3' bond breakage are investigated in the DNA sequence 5'-TU(•)-3' employing density functional theory calculations in the present study. It is found that hydrogen abstractions from both positions are comparable with the one from the C2' site slightly more favorable. The N-glycosidic bond cleavage in the neighboring 5' nucleotide following the internucleotide C2'-Ha abstraction is estimated to have the lowest activation free energies, indicating that the adjacent 5' base release dominates electron induced damage to single-stranded DNA incorporated by 5-halogenated deoxyuridines. Relative to the P-O3' bond breakage after the internucleotide C3'-H abstraction, the C3'-O3' bond rupture in the neighboring 5' nucleotide following the internucleotide C2'-Ha abstraction is predicted to have a lower activation free energy, implying that single-stranded DNA backbone breaks are prone to occur at the C3'-O3' bond site. The 5'-TU(•)-3' species has substantial electron affinity and can even capture a hydrated electron, forming the 5'-TU(-)-3' anion. However, the electron induced C3'-O3' bond rupture in 5'-TU(-)-3' anion via a pathway of internucleotide proton abstraction is only minor in both the gas phase and aqueous solution. The present theoretical predictions can interpret rationally experimental observations, thereby demonstrating that the mechanisms proposed here are responsible for high energy radiation induced damage to single-stranded DNA incorporated by radiosensitizing 5-halogenated deoxyuridines. By comparing with previous results, our work proves that the radiosensitizing action of 5-bromo-2-deoxyuridine is not weaker but stronger than its isomer 6-bromo-2-deoxyuridine on the basis of the available data.

An ESR and DFT study of hydration of the 2'-deoxyuridine-5-yl radical: a possible hydroxyl radical intermediate

The mechanism of radiation-induced frank strand break formation in irradiated 5-bromo-2'-deoxyuridine (BrdU)-labelled DNA is still unclear despite the proven radiosensitizing properties of BrdU. Combination of ESR spectroscopy and quantum chemical modelling points to a simple reaction between the uridine-5-yl radical and water molecules that produces the genotoxic hydroxyl radical.

Electron induced single strand break and cyclization: a DFT study on the radiosensitization mechanism of the nucleotide of 8-bromoguanine

Cleavage of the O-P bond in 8-bromo-2'-deoxyguanosine-3',5'-diphosphate (BrdGDP), considered as a model of single strand break (SSB) in labelled double-stranded DNA (ds DNA), is investigated at the B3LYP/6-31++G(d,p) level. The thermodynamic and kinetic characteristics of the formation of SSB are compared to those related to the 5',8-cycloguanosine lesion. The first reaction step, common to both damage types, which is the formation of the reactive guanyl radical, proceeds with a barrier-free or low-barrier release of the bromide anion. The guanyl radical is then stabilized by hydrogen atom transfer from the C3' or C5' sites of the 2'-deoxyribose moiety to its C8 center. The C3' path, via the O-P bond cleavage, leads to a ketone derivative (the SSB model), while the C5' path is more likely to yield 5',8-cycloguanosine.

Radiation therapy for primary central nervous system lymphoma

Up until the late 1970s, radiation therapy played an important role in the treatment of primary central nervous system lymphoma (PCNSL) but more recently its role has changed due to the increased use of systemic chemotherapy. In this article, the current status of radiotherapy for PCNSL and optimal forms of radiotherapy, including the treatment volume and radiation dose, are discussed. Data from nationwide Japanese surveys of PCNSL patients treated with radiation therapy suggest that the prognosis of PCNSL patients improved during the 1990s, in part due to the use of high-dose methotrexate-containing chemotherapy. The prognosis of patients treated with radiation alone also improved. Radiotherapy still seems to play an important role in the attempt to cure this disease.

Electron-induced elimination of the bromide anion from brominated nucleobases. A computational study

The enhancement of radiodamage to DNA labeled with halonucleobases is attributed to the reactive radical produced from a halonucleobase by the attachment of an electron. We examined at the B3LYP/6-31++G** level electron capture by four brominated nucleobases (BrNBs): 8-bromo-9-methyladenine, 8-bromo-9-methylguanine, 5-bromo-1-methylcytosine, and 5-bromo-1-methyluracil followed by the release of the bromide anion and a nucleobase radical. We demonstrate that neutral BrNBs in both gas and aqueous phases are better electron acceptors than unsubstituted NBs and that resulting anion radicals, BrNBs(•-), can easily transform into the product complex of the bromide anion and the nucleobase radical ([Br(-)···NB(•)]). The overall thermodynamic stimulus for the process starting with the neutral BrNB and ending with the isolated bromide anion and the NB(•) radical is similar in the case of all four BrNBs studied, which suggests their comparable radiosensitizing capabilities.

Electron stimulated desorption of anions from native and brominated single stranded oligonucleotide trimers

We measured the low energy electron stimulated desorption (ESD) of anions from thin films of native (TXT) and bromine monosubstituted (TBrXT) oligonucleotide trimers deposited on a gold surface (T = thymidine, X = T, deoxycytidine (C), deoxyadenosine (A) or deoxyguanosine (G), Br = bromine). The desorption of H(-), CH(3)(-)/NH(-), O(-)/NH(2)(-), OH(-), CN(-), and Br(-) was induced by 0 to 20 eV electrons. Dissociative electron attachment, below 12 eV, and dipolar dissociation, above 12 eV, are responsible for the formation of these anions. The comparison of the results obtained for the native and brominated trimers suggests that the main pathways of TBrXT degradation correspond to the release of the hydride and bromide anions. Significantly, the presence of bromine in oligonucleotide trimers blocks the electron-induced degradation of nuclobases as evidenced by a dramatic decrease in CN(-) desorption. An increase in the yields of OH(-) is also observed. The debromination yield of particular oligonucleotides diminishes in the following order: BrdU > BrdA > BrdG > BrdC. Based on these results, 5-bromo-2(')-deoxyuridine appears to be the best radiosensitizer among the studied bromonucleosides.

Primary central nervous system lymphoma

Primary central nervous system lymphomas (PCNSL) are aggressive malignancies that arise in distinct anatomical sites, which display unique structural, biological and immunological conditions. So far, despite recent therapeutic advances, these malignancies exhibit one of the worst prognoses among all non-Hodgkin lymphomas (NHL). For a long time, radiotherapy (RT) has been the standard treatment, producing a response rate of 60-65% and a notable neurological improvement in most cases. However, relapse usually occurred within a few months after RT, with a median survival of 14 months and a 5-year survival of approximately 15-24%. Although the introduction of systemic chemotherapy has consistently improved survival, the prognosis of PCNSL is still dismal, with high rates of local relapse and consequent death. Defining the optimum therapeutic management is difficult because of potential selection biases in large retrospective reviews and the limited number of prospective studies. Although studies published on PCNSL are increasing, several therapeutic questions still remain unanswered after a decade of research.

Primary CNS lymphoma

Primary CNS lymphoma, an uncommon form of extranodal non-Hodgkin's lymphoma, has increased in incidence and occurs in both immunocompromised and immunocompetent hosts. Primary CNS lymphoma in immunocompetent patients is associated with unique diagnostic, prognostic and therapeutic issues and the management of this malignancy is different from other forms of extranodal non-Hodgkin's lymphoma. Characteristic imaging features should lead to suspicion of the diagnosis, avoidance of corticosteroids (if possible) and early neurosurgical consultation for stereotactic biopsy. Since primary CNS lymphoma may involve the brain, cerebrospinal fluid and eyes, diagnostic evaluation should include assessment of all of these regions as well as screening for the possibility of occult systemic disease. Resection provides no therapeutic benefit and should be reserved for the rare patient with neurological deterioration due to brain herniation. Whole-brain radiation therapy alone is insufficient for durable tumor control and is associated with a high risk of neurotoxicity in patients over 60 years of age. Neurotoxicity is typically associated with significant cognitive, motor and autonomic dysfunction and has a negative impact on quality of life. Chemotherapy and whole-brain radiation therapy together improve tumor response rates and survival compared with whole-brain radiation therapy alone. Methotrexate-based multiagent chemotherapy without whole-brain radiation therapy is associated with similar tumor response rates and survival compared with regimens that include whole-brain radiation therapy, although controlled trials have not been performed. The risk of neurotoxicity is lower in patients treated with chemotherapy alone. The incidence of HIV-related primary CNS lymphoma has decreased in the era of highly active antiretroviral therapy. Patients with HIV-associated primary CNS lymphoma have a worse prognosis but may respond to highly active antiretroviral therapy, whole-brain radiation therapy or therapies directed against the Epstein-Barr virus.

Primary central nervous system lymphoma: biological aspects and controversies in management

INTRODUCTION

This review was produced from the workshop on primary central nervous system lymphoma (PCNSL) at the European Cancer Conference (ECCO 13) in Paris in 2005. It covers the presentation and biological features of the disease (Professor Khe Hoang-Xuan). The role of chemotherapy, including the management of intraocular lymphoma and the use of high dose chemotherapy followed by autologous stem cell transplantation for PCNSL, is discussed (Dr. Andres Ferreri) as well as controversies in the use of whole brain radiotherapy (WBRT) after chemotherapy (Dr. Michele Reni). The topics covered with discussants at the workshop are also summarised.

CONCLUSION

The imaging of the brain and the histopathology including detailed immunohistochemistry is of vital importance in making an accurate diagnosis of the disease and understanding the extent of spread of the disease in the CNS. The importance of high dose methotrexate (HDMTX; dose > or = 1g/m(2)), as the most active drug in the treatment of PCNSL, is stressed. The authors recommend that HDMTX alone or in combination with other active chemotherapy agents should be used to treat PCNSL followed by whole brain radiotherapy (WBRT) unless contraindicated because of the advanced age of the patient and existing cognitive impairment. Only published protocols should be used unless the patient is to be offered a trial that has either national or international support. Baseline neuropsychological tests should be carried out before treatment and repeated during and after treatment. The risks of cognitive impairment associated with the disease, with methotrexate - containing chemotherapy and with whole brain radiotherapy should be explained to patients and relatives when obtaining informed consent. Long-term survival, with current treatment regimes, is possible with PCNSL but this appears limited to patients less than 60 years of age at presentation (mostly patients less than 50 years of age).