Progesterone antagonists block the growth of experimental mammary tumors in G0/G1

Antiprogestins in breast cancer treatment: are we ready?

Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death in females worldwide. It is accepted that breast cancer is not a single disease, but instead constitutes a spectrum of tumor subtypes with distinct cellular origins, somatic changes, and etiologies. Molecular gene expression studies have divided breast cancer into several categories, i.e. basal-like, ErbB2 enriched, normal breast-like (adipose tissue gene signature), luminal subtype A, luminal subtype B, and claudin-low. Chances are that as our knowledge increases, each of these types will also be subclassified. More than 66% of breast carcinomas express estrogen receptor alpha (ERα) and respond to antiestrogen therapies. Most of these ER+ tumors also express progesterone receptors (PRs), the expression of which has been considered as a reliable marker of a functional ER. In this paper we will review the evidence suggesting that PRs are valid targets for breast cancer therapy. Experimental data suggest that both PR isoforms (A and B) have different roles in breast cancer cell growth, and antiprogestins have already been clinically used in patients who have failed to other therapies. We hypothesize that antiprogestin therapy may be suitable for patients with high levels of PR-A. This paper will go over the experimental evidence of our laboratory and others supporting the use of antiprogestins in selected breast cancer patients.

Effect of mifepristone on proliferation and apoptosis of Ishikawa endometrial adenocarcinoma cells

OBJECTIVE

To determine the mechanism by which mifepristone improves breakthrough bleeding, the effects of mifepristone on proliferation and apoptosis of Ishikawa endometrial carcinoma cells were evaluated in the presence and absence of progestin.

DESIGN

Prospective basic research study.

SETTING

Research laboratories for reproductive health at a university medical school.

PATIENT(S)

None.

INTERVENTION(S)

Ishikawa cells were cultured in vitro. Mifepristone and/or medroxyprogesterone acetate at various concentrations were added to the cells.

MAIN OUTCOME MEASURE(S)

Determination of cell proliferation and apoptosis.

RESULT(S)

Colorimetric 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and bromodeoxyuridine (BrdU) labeling analysis demonstrated that mifepristone inhibited the growth of Ishikawa cells and percentage of BrdU-labeled cells in a time- and dose-dependent manner. Flow cytometry analysis demonstrated that mifepristone at 100 micromol/L, which completely inhibited cell proliferation, increased the proportion of cells in the S phase and diminished the cells in the G2/M phase. Apoptosis was identified by annexin-V-fluorescein isothiocyanate binding and caspase-3 activation. Immunofluorescent double labeling of Ishikawa cells in the absence or presence of mifepristone revealed that BAX protein expression increased and translocated from cytosol to mitochondria.

CONCLUSION(S)

Mifepristone inhibited cell growth by arresting cell cycle progression at S phase, induced apoptosis through caspase-3 activation, and modulated apoptosis regulatory genes BCL2/BAX and FAS/FASLG in Ishikawa cells. Together, these data imply that the improvement in breakthrough bleeding observed with mifepristone might be due to diminished volume of endometrial tissue similar to that seen with endometrial atrophy.

Progesterone-action in the decidual mesometrium of pregnancy

The mesometrial decidua is absolutely dependent on progesterone action for its maintenance and growth. Hormone action is mediated by intranuclear progesterone receptors (PR) that regulate target cell gene transcription. In early pregnancy of the rat gene expression is particularly enhanced for regulators of cell cycle progression, growth factors and their cognate receptors; cell cycle arrest proteins are suppressed. Cell survival proteins such as Bcl2 are also up-regulated. These events are associated with abundant expression of PR-A and PR-B isoforms and STAT (signal transducers and activators of transcription) family members. Proliferation of decidual cells no longer occurs after mid-pregnancy despite high levels of circulating progesterone and the decidua begins a slow process of regression, which continues to term. Regression is characterized by an increase in abundance of proteins that promote apoptosis such as p27, Bax and Caspase-3. These late pregnancy changes are associated with a relative increase in PR-C, a third form of the PR molecule, that binds progesterone but probably has limited transcriptional activity. Protein kinase C, which is suppressed by progesterone in early pregnancy, may be a key mediator of these processes.

Antitumor activity of mifepristone in the human LNCaP, LNCaP-C4, and LNCaP-C4-2 prostate cancer models in nude mice

BACKGROUND

Antiprogestins are a promising new class of mammary tumor inhibitors with a unique mechanism of action. Previously published results also suggest a tumor-inhibitory effect of antiprogestins in prostate cancer models. The objective of the present studies was to determine whether androgen-sensitive and androgen-insensitive variants of the well-characterized LNCaP human prostate cancer cell line exhibit stable differences in their sensitivity to in vivo antitumor activity of the antiprogestin, mifepristone.

METHODS

Exponentially growing LNCaP, LNCaP-C4, and LNCaP-C4-2 prostate cancer cells in culture were mixed with Matrigel and injected subcutaneously (s.c.) into the flank of 6-8-week-old male nude mice. The tumors were permitted to grow until they reached a volume of 270-300 mm(3). The animals were then randomly assigned to two groups. One group received mifepristone (50 mg/kg/day s.c.). Control animals were treated with vehicle. Tumor volume was determined every 4 days. After 28 days of treatment, the tumors were harvested and wet weights were determined.

RESULTS

The inoculated tumor cells produced progressively growing tumors in male nude mice. However, the androgen-insensitive LNCaP-C4-2 cells showed the most aggressive and most rapid growth rate and shortest time to tumor progression. The tumors derived from the LNCaP-C4 cells exhibited a higher rate of tumor growth as compared with those derived from the parental androgen-sensitive LNCaP cells. In all three models, mifepristone treatment caused a significant retardation of tumor progression: after 28 days of treatment, about 50% inhibition of tumor weight was observed in the mifepristone treatment groups (P < 0.05) compared with the corresponding control groups.

CONCLUSIONS

This is the first report demonstrating significant antitumor activity of mifepristone in both androgen-sensitive and androgen-insensitive variants of the LNCaP human prostate cancer model in nude mice. These results suggest a potential clinical benefit of the use of antiprogestins as a novel nonandrogen ablation therapeutic approach in the management of prostate cancer.

Influence of treatment with onapristone on the IGF-system in breast cancer patients

The influence of the novel antiprogestin onapristone on the serum insulin-like growth factor (IGF) system was studied in a group of 13 postmenopausal women with metastatic breast cancer. Blood samples were obtained before treatment and subsequently after 1, 2 and 3 months on therapy. IGF-I, IGF-II and IGF-binding protein (IGFBP)-2 were measured by radioimmunoassay (RIA). In addition, the IGFBP profile was evaluated by Western ligand blotting (WLB), and IGFBP-3 fragmentation determined by immunoblotting. A moderate (29%) but significant increase in IGF-I was observed after 3 months on treatment (p < 0.05). IGFBP-2 showed a significant, progressive increase during treatment when evaluated both by WLB (44% increase over baseline at 3 months) and by RIA (33% increase over baseline at 3 months). There was a non-significant trend towards an initial decrease in IGFBP-3 fragmentation. No significant alterations were observed in IGF-II or any of the binding proteins (except IGFBP-2) determined by Western ligand blotting. Due to the observation that onapristone treatment caused a moderate suppression of serum cortisol and androstenedione, we postulate the observed increase in IGF-I to be due to a slight glucocorticoid agonistic effect of the drug. On the contrary, the increase in IGFBP-2 may be related to disease progression as has been observed in patients suffering from prostatic cancer.

Progesterone and estrogen regulation of rat decidual cell expression of proliferating cell nuclear antigen

This study was an examination of the role of progesterone (P4) and estradiol-17beta (E2) as stromal cell mitogens in the decidua basalis (DB) of the rat during pregnancy. Pregnant rats were ovariectomized (Ovx) on Days 8 and 12 of pregnancy, treated with P4, E2, or both, and killed on Days 10 and 14, which correspond to times of stromal cell proliferation and regression, respectively. In some experiments, rats received pellets of the anti-progestin RU-486 on Day 9 and were killed 6, 12, and 24 h later. The mitotic index (MI) and in situ image analysis of expression of proliferating cell nuclear antigen (PCNA) were used to assess cell cycle progression. Highest expression of PCNA occurred on Days 8-12 of pregnancy, and MI was maximum; MI became zero and PCNA expression decreased dramatically thereafter (i.e., Days 14, 17, 21). Percentage of cells expressing intense PCNA on Day 10 (40%) declined to 5% after Ovx and Ovx + E2 (p < 0.05), whereas Ovx + P4 maintained PCNA. By Day 14, only 1% of stromal cells expressed intense PCNA, which was not significantly altered by Ovx, Ovx + E2, or Ovx + P4 but increased after Ovx + P4 and E2 (p < 0.05). By 6 h of RU-486, MI declined 3-fold, and intense PCNA expression was essentially lost. These changes preceded loss of histological integrity of the DB. Cells with undetectable PCNA steadily increased from 8% at 6 h to 28% by 24 h (p < 0.05). Thus RU-486 appeared to block cell cycle progression and enhanced PCNA turnover. P4 was essential for stromal cell proliferation during early pregnancy (Days 8-10), but this action was lost by Day 14.

Comparison of MIB-1 proliferation index with S-phase fraction in human breast carcinomas

The MIB-1 antibody has been raised against recombinant parts of the Ki-67 antigen and, unlike Ki-67, has wider application to routinely fixed specimens. The aim of this study was to compare the usefulness of MIB-1 with S-phase fraction (SPF) as a measure of proliferation. A total of 75 patients with operable breast cancer were studied, 44 (median age 56 years) before any treatment and 31 (median age 68 years) after primary medical hormonal therapy. Sections from formalin-fixed paraffin-embedded tissue were stained with the MIB-1 antibody and a percentage score of positively stained cells obtained. SPF was measured by flow cytometry in fine-needle aspiration samples taken from the same lesion in each patient. Median MIB-1 score was 9% and median SPF was 11.1%. A close correlation was found between MIB-1 score and SPF (rho=0.59, P<0.0001). There was a difference in the strength of the correlation found between the no treatment group and the treatment group, however, 95% confidence intervals for the rho values overlapped, indicating that there was no significant statistical difference. When analysed for ploidy status a correlation was found only in aneuploid tumours. MIB-1 immunostaining can be used as an effective method of assessing proliferation in human breast carcinomas. This can be done using simple, widely available technology and provides the opportunity to perform large-scale retrospective analyses of archival materials.

Novel mechanisms of antiprogestin action

Endocrine therapy used either prophylactically or therapeutically for the treatment of locally advanced or metastatic breast cancers offers many advantages to patients whose tumors contain functional estrogen (ER) and progesterone (PR) receptors. The range of treatments defined as endocrine include surgical ablation of endocrine glands, administration of pharmacologic doses of steroid hormones, chemical blockade of steroid hormone biosynthesis, and inhibition of endogenous steroid hormone action at the tumor with synthetic antagonists. The last of these approaches is the most widely used, making the antiestrogen tamoxifen the preferred first-line therapeutic agent for treatment of hormone-dependent metastatic breast cancer. The wide-spread use of tamoxifen reflects its efficacy and low toxicity, and the fact that it makes good physiological sense to block the local proliferative effects of estrogens directly at the breast. But are estrogens the only hormones with a proliferative impact on the breast and on breast cancers? This chapter focuses on evidence that progesterone also has proliferative actions in the breast; on preliminary data showing that progesterone antagonists may be new tools for the management of metastatic breast cancer; and on recent data suggesting that antiprogestin-occupied PR have novel mechanisms of action that bear on tissue specificity and development of hormone resistance.

Antiprogestins inhibit growth and stimulate differentiation in the normal mammary gland

Antiprogestins possess a potent antitumor activity in hormone-dependent experimental breast cancer models. Though the underlying mechanism is not clear, induction of functional differentiation seems to be a major event. This study attempts to test directly for antiproliferative and differentiation promoting activities of antiprogestins on the normal mammary gland. To this end, whole organ cultures of mammary glands from estradiol/progesterone-primed virgin mice maintained in a serum-free medium with aldosteron, prolactin, insulin, and hydrocortisone were exposed to the antiprogestin ZK114043. A 4-day treatment of organ cultures led to a strong inhibition of epithelial DNA synthesis. In parallel, ZK114043 caused alveolar cells to acquire a more differentiated phenotype distinguished by secretory active alveoli composed of single cell layers with increased fat droplet accumulation and enhanced expression of the milk proteins beta-casein and whey acidic protein (WAP). Particularly strong effects were found on the expression of mammary-derived growth inhibitor (MDGI). Both half-maximal inhibition of epithelial DNA synthesis and stimulation of MDGI mRNA expression were found at about 5 ng/ml of ZK114043. Presence in the medium of 5 micrograms/ml hydrocortisone rendered antiglucocorticoid effects of ZK114043 highly unlikely. Furthermore, prevention of action of ZK114043 by the progesterone agonist R5020 and ZK114043 stimulated expression of beta-casein and MDGI mRNA in cultured glands of 10-week-old unprimed virgin mice suggest a progesterone receptor-mediated mechanism of antiprogestin action. Two other antiprogestins, Mifepristone and Onapristone, likewise stimulated MDGI expression. The data provide direct evidence that antiprogestins act like a differentiation factor in the normal mammary gland.

The antitumor potency of progesterone antagonists is due to their differentiation potential

A new therapy for the progesterone receptor positive mammary carcinoma may be the treatment with progesterone antagonists. This new class of antihormones causes a strong inhibition of tumor growth comparable to the potency of ovariectomy in a panel of experimental mammary carcinomas. The mechanisms of the strong tumor-inhibiting action of progesterone antagonists on experimental mammary carcinomas mainly depends on a progesterone receptor mediated process leading to induction of terminal differentiation and a blockade of the cell cycle. To further characterize the antitumor mechanism of progesterone antagonists we analyzed the effects of Onapristone and ZK 112.993 on DMBA- and MNU-mammary tumors of the rat and MXT-tumors of the mouse after different therapy intervals. These hormone-dependent mammary tumors normally display intraductal growth in papillary, cribiform or solid formation, whereas after treatment periods of 2-6 weeks with progesterone antagonists they displayed dysplastic ductal and acinous formations, usually filled with secretory material. Whereas tumor size, mitotic index, and the grade of tumor malignancy decreased distinctly, the volume fraction of glandular structures in the tumors as well as the appearance of apoptosis increased 3-fold compared to the controls. In addition, the mammary glands of progesterone antagonist treated animals showed the morphological features of differentiation with the appearance of secretory activity. Interestingly, the staining pattern of some of the lectins used, especially UEA 1 binding pattern, fits to the concept of differentiation since recent studies revealed a higher degree of fucosylation only in benign lesions of human breast cancers. Therefore, these data underline the concept of a differentiation potential of progesterone antagonists on progesterone receptor positive mammary carcinomas.

The tumour-inhibiting potential of the progesterone antagonist Onapristone in the human mammary carcinoma T61 in nude mice

The progesterone antagonist Onapristone proved to possess strong tumour-inhibiting activity in a panel of experimental mammary carcinomas. Its underlying mechanism of action is due to a progesterone-receptor-mediated induction of terminal differentiation and a specific blockade of the cell cycle and is also present in the absence of progesterone as was shown in the MXT mammary tumour. To prove this further, the tumour-inhibiting activity of Onapristone was investigated in the human postmenopausal T61 mammary tumour implanted in castrated male nude mice. Whereas Onapristone given alone had no effect on growth of established tumours, after stimulation of the relatively low progesterone receptor content of this tumour line with an oestrogen, Onapristone significantly inhibited tumour growth. Thus, we suggest that Onapristone exerts its antitumour action via progesterone receptors. As there is no endogenous progesterone in these mice, the tumour-inhibiting activity of Onapristone is not primarily due to a classical antihormonal effect.

Progesterone antagonists: tumor-inhibiting potential and mechanism of action

A new approach for the treatment of breast cancer could be the use of progesterone antagonists. These compounds were originally developed for the inhibition of progesterone-dependent processes and have been shown to be effective in inhibition of nidation and interruption of pregnancy. Although the roles of progesterone and the progesterone receptor in control of cell growth remain unclear, it was found in progesterone receptor positive mammary carcinoma cell lines that the antiprogestin, Mifepristone, had an inhibitory effect on cell growth and a growth-inhibiting action on the DMBA-induced mammary carcinoma of the rat. We have shown that the progesterone antagonists, Onapristone and ZK 112993, which possess a reduced antiglucocorticoid activity compared to Mifepristone, exert a strong tumor-inhibiting effect in a panel of hormone-dependent mammary tumor models. The effects of these compounds were in some systems superior to those of tamoxifen or high dose progestins and comparable to ovariectomy. Although prerequisites for their antiproliferative potency are an affinity to the progesterone receptor as well as a sufficient number of available receptors in the tumors, the strong tumor inhibiting potential of the antiprogestins cannot be explained by a classical anti-hormonal mechanism. Surprisingly, the antitumor activity is evident in spite of elevated serum levels of ovarian and pituitary hormones. It was established by morphometric procedures that treatment with Onapristone triggers differentiation of the mitotically active polygonal tumor epithelial cell towards secretory active glandular structures and acini. All our quantitative light and electron microscopic data indicate that the antitumor action of antiprogestins is accompanied by the initiation of terminal differentiation leading to (apoptotic) cell death. Finally, our flow cytometry studies revealed an accumulation of the tumor cells in the G0G1 phase of the cell cycle, which may result from induction of differentiation since a differentiation-specific G1 arrest has already been proposed for other stem cell systems. It can be concluded from these data that the progesterone receptor antagonists differ in their mode of action from compounds used in established endocrine treatment strategies for mammary carcinoma. The ability of progesterone antagonists like Onapristone to reduce the number of cells in S-phase may offer a significant clinical advantage, since it is established that the S-phase fraction is a highly significant predictor of disease-free survival among axillary node-negative patients with diploid mammary tumors.

Involvement of the adrenal glands in the prolactin rise induced in the female rat by an antiprogestin, onapristone

The present study was undertaken to investigate our recent finding that the peripheral levels of prolactin are elevated after the treatment of intact tumor-bearing rats with antiprogestins, like ONAPRISTONE (ON) and MIFEPRISTONE (MI). In ovariectomized rats, s.c. administration of ON (10 mg/kg/day for 5 days) induced a significant increase in the peripheral levels of prolactin without stimulating uterine growth or suppressing LH secretion. Additionally, treatment with ON enhanced the estradiol-induced increase in the serum prolactin levels, suggesting different mechanism(s) for the effects of ON and estradiol on prolactin secretion. In the castrated animals treated with ON we also found a significant increase in the serum levels of aldosterone and corticosterone, but no measurable amount of estradiol and no significant change in the levels of serum androstenedione. Accordingly, we supposed that the effect of ON on prolactin secretion may be induced by suppression of the known activity of adrenal corticosteroids in inhibiting the prolactin secretion. In a further study using ovariectomized and adrenalectomized rats we, in fact, found no appreciable effect of ON on the serum prolactin levels at all. By contrast, dexamethasone (DEX) (0.15 mg/kg for 5 days, s.c.) significantly decreased the prolactin levels which were elevated after adrenalectomy. This effect of DEX was partially reversed by a simultaneous application of ON. From the present observations, it is anticipated that the increase in the peripheral prolactin levels found after treatment with ON is partly due to the antiglucocorticoid effect of the compound.