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Chang KF, Huang XF, Chang JT, Huang YC, Lo WS, Hsiao CY, Tsai NM. Cedrol, a Sesquiterpene Alcohol, Enhances the Anticancer Efficacy of Temozolomide in Attenuating Drug Resistance via Regulation of the DNA Damage Response and MGMT Expression. JOURNAL OF NATURAL PRODUCTS 2020; 83:3021-3029. [PMID: 32960603 DOI: 10.1021/acs.jnatprod.0c00580] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Glioblastoma (GBM) is a common and aggressive brain tumor with a median survival of 12-15 months. Temozolomide (TMZ) is a first-line chemotherapeutic agent used in GBM therapy, but the occurrence of drug resistance limits its antitumor activity. The natural compound cedrol has remarkable antitumor activity and is derived from Cedrus atlantica. In this study, we investigated the combined effect of TMZ and cedrol in GBM cells in vitro and in vivo. The TMZ and cedrol combination treatment resulted in consistently higher suppression of cell proliferation via regulation of the AKT and MAPK signaling pathways in GBM cells. The combination treatment induced cell cycle arrest, cell apoptosis, and DNA damage better than either drug alone. Furthermore, cedrol reduced the expression of proteins associated with drug resistance, including O6-methlyguanine-DNA-methyltransferase (MGMT), multidrug resistance protein 1 (MDR1), and CD133 in TMZ-treated GBM cells. In the animal study, the combination treatment significantly suppressed tumor growth through the induction of cell apoptosis and decreased TMZ drug resistance. Moreover, cedrol-treated mice exhibited no significant differences in body weight and improved TMZ-induced liver damage. These results imply that cedrol may be a potential novel agent for combination treatment with TMZ for GBM therapy that deserves further investigation.
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Affiliation(s)
- Kai-Fu Chang
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan, ROC
- Department of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung 40201, Taiwan, ROC
| | - Xiao-Fan Huang
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan, ROC
- Department of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung 40201, Taiwan, ROC
| | - Jinghua Tsai Chang
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan, ROC
| | - Ya-Chih Huang
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan, ROC
- Department of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung 40201, Taiwan, ROC
| | - Wei-Syuan Lo
- Department of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung 40201, Taiwan, ROC
| | - Chih-Yen Hsiao
- Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, 60002, Taiwan, ROC
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, 71710, Taiwan, ROC
| | - Nu-Man Tsai
- Department of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung 40201, Taiwan, ROC
- Clinical Laboratory, Chung Shan Medical University Hospital, Taichung 40201, Taiwan, ROC
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Biau J, Thivat E, Chautard E, Stefan D, Boone M, Chauffert B, Bourgne C, Richard D, Molnar I, Levesque S, Bellini R, Kwiatkowski F, Karayan-Tapon L, Verrelle P, Godfraind C, Durando X. Phase 1 trial of ralimetinib (LY2228820) with radiotherapy plus concomitant temozolomide in the treatment of newly diagnosed glioblastoma. Radiother Oncol 2020; 154:227-234. [PMID: 32976869 DOI: 10.1016/j.radonc.2020.09.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE This phase 1 trial aimed to determine the maximum tolerated dose (MTD; primary objective) of a p38-MAPK inhibitor, ralimetinib, with radiotherapy (RT) and chemotherapy (TMZ), in the treatment of newly diagnosed glioblastoma (GBM) patients. MATERIALS AND METHODS The study was designed as an open-label dose-escalation study driven by a Tite-CRM design and followed by an expansion cohort. Ralimetinib was administered orally every 12 h, 7 days a week, for 2 cycles of 2 weeks at a dose of 100, 200 or 300 mg/12 h. Patients received ralimetinib added to standard concurrent RT (60 Gy in 30 fractions) with TMZ (75 mg/m2/day) and 6 cycles of adjuvant TMZ (150-200 mg/m2 on days 1-5 every 28 days). RESULTS The MTD of ralimetinib was 100 mg/12 h with chemoradiotherapy. The three patients treated at 200 mg/12 h presented a dose-limiting toxicity: one patient had a grade 3 face edema, and two patients had a grade 3 rash and grade 3 hepatic cytolysis (66%). Of the 18 enrolled patients, 15 received the MTD of ralimetinib. At the MTD, the grade ≥ 3 adverse events during concomitant chemoradiotherapy were hepatic cytolysis (2/15 patients), dermatitis/rash (1/15), lymphopenia (1/15) and nausea/vomiting (1/15). No interaction of TMZ and ralimetinib when administrated concomitantly has been observed. Inhibition of pMAPKAP-K2 (-54%) was observed in peripheral blood mononuclear cells. CONCLUSION This phase 1 trial is the first trial to study the combination of a p38-MAPK inhibitor, ralimetinib, with radiotherapy (RT) and chemotherapy (TMZ), in the treatment of newly diagnosed glioblastoma (GBM) patients. The MTD of ralimetinib was 100 mg/12 h. The most frequent dose-limiting toxicities were hepatic cytolysis and rash.
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Affiliation(s)
- J Biau
- Radiation Department, Centre Jean Perrin, Clermont-Ferrand, France; University of Clermont Auvergne, UFR Médecine, Clermont-Ferrand, France; INSERM U1240 IMoST, University of Clermont Auvergne, Clermont-Ferrand, France; Centre d'Investigation Clinique UMR 501, Clermont-Ferrand, France.
| | - E Thivat
- INSERM U1240 IMoST, University of Clermont Auvergne, Clermont-Ferrand, France; Centre d'Investigation Clinique UMR 501, Clermont-Ferrand, France; Department of Clinical Research, Délégation Recherche Clinique et Innovation, Centre Jean Perrin, Clermont-Ferrand, France
| | - E Chautard
- INSERM U1240 IMoST, University of Clermont Auvergne, Clermont-Ferrand, France; Pathology Department, Centre Jean Perrin, Clermont-Ferrand, France
| | - D Stefan
- Radiation Oncology Department, Centre François Baclesse, Caen, France
| | - M Boone
- Department of Medical oncology, CHU Amiens, France
| | - B Chauffert
- Department of Medical oncology, CHU Amiens, France
| | - C Bourgne
- Department of Biologic hematology, CHU Estaing, Clermont-Ferrand Cedex 1, France
| | - D Richard
- CHU Clermont-Ferrand, University of Clermont-Auvergne, Medical Pharmacology Department, UMR INSERM, Clermont-Ferrand, France
| | - I Molnar
- INSERM U1240 IMoST, University of Clermont Auvergne, Clermont-Ferrand, France; Centre d'Investigation Clinique UMR 501, Clermont-Ferrand, France; Department of Clinical Research, Délégation Recherche Clinique et Innovation, Centre Jean Perrin, Clermont-Ferrand, France
| | - S Levesque
- INSERM U1240 IMoST, University of Clermont Auvergne, Clermont-Ferrand, France; Centre d'Investigation Clinique UMR 501, Clermont-Ferrand, France; Department of Clinical Research, Délégation Recherche Clinique et Innovation, Centre Jean Perrin, Clermont-Ferrand, France
| | - R Bellini
- Radiodiagnostic Department, Centre Jean-Perrin, Clermont-Ferrand, France
| | - F Kwiatkowski
- INSERM U1240 IMoST, University of Clermont Auvergne, Clermont-Ferrand, France; Centre d'Investigation Clinique UMR 501, Clermont-Ferrand, France; Department of Clinical Research, Délégation Recherche Clinique et Innovation, Centre Jean Perrin, Clermont-Ferrand, France
| | - L Karayan-Tapon
- University of Poitiers, INSERMU1084, CHU de Poitiers, Department of Cancer Biology, France
| | - P Verrelle
- Radiation Department, Centre Jean Perrin, Clermont-Ferrand, France; University of Clermont Auvergne, UFR Médecine, Clermont-Ferrand, France; Department of Radiation Oncology, Institut Curie, Paris, France
| | - C Godfraind
- Department of Pathological Anatomy, CHU de Clermont-Ferrand, France
| | - X Durando
- INSERM U1240 IMoST, University of Clermont Auvergne, Clermont-Ferrand, France; Centre d'Investigation Clinique UMR 501, Clermont-Ferrand, France; Department of Clinical Research, Délégation Recherche Clinique et Innovation, Centre Jean Perrin, Clermont-Ferrand, France; Oncology Department, Centre Jean Perrin, Clermont-Ferrand, France; University of Clermont Auvergne, UFR Médecine, Clermont-Ferrand, France
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Grieco A, Tafuri MA, Biolato M, Diletto B, Di Napoli N, Balducci N, Vecchio FM, Miele L. Severe cholestatic hepatitis due to temozolomide: an adverse drug effect to keep in mind. Case report and review of literature. Medicine (Baltimore) 2015; 94:e476. [PMID: 25816026 PMCID: PMC4554001 DOI: 10.1097/md.0000000000000476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Temozolomide is the current standard of therapy for postoperative patients with glioblastoma starting adjuvant radiotherapy. Hematologic adverse events are the most frequent side effects of temozolomide, while liver toxicity has been reported only in the post-marketing period. Here we report a case of severe temozolomide-induced liver injury during concurrent radiotherapy treatment, at a dose level of 75 mg/m2. The aim of this case report is to focus on the problems of temozolomide-induced hepatotoxicity. In conclusion, a close monitoring of liver function tests is recommended during treatment with temozolomide.
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Affiliation(s)
- Antonio Grieco
- From the Institute of Internal Medicine, Catholic University of Rome (AG, MB, LM); Institute of Radiotherapy, Catholic University of Rome (MAT, BD, NDN, NB); and Institute of Pathology, Catholic University of Rome (FMV)
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Chang L, Su J, Jia X, Ren H. Treating malignant glioma in Chinese patients: update on temozolomide. Onco Targets Ther 2014; 7:235-44. [PMID: 24600235 PMCID: PMC3928058 DOI: 10.2147/ott.s41336] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Malignant glioma, ie, anaplastic astrocytoma and glioblastoma, is the most common type of primary malignant brain tumor in the People’s Republic of China, and is particularly aggressive. The median survival of patients with newly diagnosed glioblastoma is only 12–14 months despite advanced therapeutic strategies. Treatment of malignant glioma consists mainly of surgical resection followed by adjuvant radiation and chemotherapy. Temozolomide (TMZ), a second-generation oral alkylating agent, is playing an increasingly important role in the treatment of malignant glioma in Chinese patients. Since the publication of a study by Stupp et al in 2005, which used a protocol of conventional fractionated irradiation with concomitant TMZ followed by standard TMZ for six cycles, many clinical studies in the People’s Republic of China have demonstrated that such a treatment strategy has significantly improved efficacy with limited side effects for newly diagnosed glioblastoma after surgery as compared with strategies that do not contain TMZ. However, as a relatively new agent, the history and development of TMZ for malignant glioma is not well documented in Chinese patients. Multicenter, randomized controlled trials including appropriately sized patient populations investigating multiple aspects of TMZ therapy and related combination therapies are warranted in patients with malignant glioma. This review provides an update on the efficacy, mechanism of action, adverse reactions, and clinical role of TMZ in the treatment of malignant glioma in Chinese patients.
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Affiliation(s)
- Liang Chang
- Department of Neurosurgery, The Tumor Hospital of Harbin Medical University, People's Republic of China
| | - Jun Su
- Department of Neurosurgery, The Tumor Hospital of Harbin Medical University, People's Republic of China
| | - Xiuzhi Jia
- Department of Immunology, Harbin Medical University, People's Republic of China ; Key Lab Infection and Immunity, Heilongjiang Province, Harbin, People's Republic of China
| | - Huan Ren
- Department of Immunology, Harbin Medical University, People's Republic of China ; Key Lab Infection and Immunity, Heilongjiang Province, Harbin, People's Republic of China
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Temozolomide-induced liver damage. A case report. Strahlenther Onkol 2014; 190:408-10. [PMID: 24452817 DOI: 10.1007/s00066-013-0519-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 11/18/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Temozolomide (TMZ) is an alkylating agent used in chemoradiotherapy and adjuvant chemotherapy regimens for treatment of newly diagnosed or recurrent glioblastoma. In Germany alone, 900,000 daily doses of the drug are prescribed each year. Therefore, all severe side effects of TMZ, even those rarely observed, are relevant to radiotherapists. MATERIALS AND METHODS We report a case of severe drug-induced toxic hepatitis that developed during chemoradiotherapy with TMZ in a patient with glioblastoma multiforme. RESULTS Transaminase elevation was observed after 5 weeks of TMZ treatment, followed by severe jaundice symptoms which only subsided 2 months later. These findings were consistent with diagnosis of the mixed hepatic/cholestatic type of drug-induced toxic hepatitis. Due to the early termination of treatment, no life-threatening complications occurred in our patient. However, rare reports of encephalopathy and fatality as complications of TMZ therapy can be found in the literature. CONCLUSION When using TMZ for treatment of glioblastoma, monitoring of liver enzyme levels should be performed twice weekly to prevent fatal toxic hepatitis. In the case of any drug-induced hepatitis, TMZ must be discontinued immediately.
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Temozolomide-related idiosyncratic and other uncommon toxicities: a systematic review. Anticancer Drugs 2013; 23:1099-106. [PMID: 22850321 DOI: 10.1097/cad.0b013e328356f5b0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Temozolomide (TMZ)-related idiosyncratic and other uncommon toxicities have been reported. To better characterize these toxicities and to identify any associated risk factors, we performed a systematic review. We searched the PubMed database, limited to the English language, published between 1999 and December 2011. We selected only those articles in which TMZ was temporally related and was the sole or main contributing chemotherapeutic drug to idiosyncratic drug reactions (IDRs) and other uncommon toxicities. Hematological IDRs are biopsy-proven aplastic anemia or grade V toxicity or grade IV toxicity with slow and incomplete hematological recovery. Seventy-three cases were identified, including 21 hematological IDRs, 31 nonhematological IDRs and uncommon infections, and 21 second primary cancers. With a caveat of publication and reporting bias, the following observations could be made. The hematological IDRs predominantly occurred in female patients (exact binomial two-tailed, P=0.0041) and most patients were receiving TMZ concomitantly with radiotherapy for glioma. The median duration of exposure to TMZ was 30 days and the median cumulative TMZ exposure was 2250 mg/m (range, 500-6900 mg/m). The sex predilection was not evident in nonhematological IDRs and other uncommon toxicities. TMZ-induced pneumonitis and cholestatic hepatitis are emerging as a nonhematological hypersensitive reaction and IDR, respectively. For TMZ-related myelodysplasia or leukemia, the cumulative dose of TMZ ranged from 1400 to 30 000 mg/m. The cumulative dose of TMZ was lower and latency was shorter with a previous exposure to other leukemogenic drugs, suggesting that TMZ may have augmented the leukemogenic potential of other drugs. Early appearance of profound myelosuppression during the course of TMZ and concurrent radiotherapy could be a hematological IDR, which warrants prompt investigations to exclude aplastic anemia. Myelodysplasia or leukemia developed after a median TMZ exposure of 15 g/m.
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Sarganas G, Orzechowski HD, Klimpel A, Thomae M, Kauffmann W, Herbst H, Bronder E, Garbe E. Severe sustained cholestatic hepatitis following temozolomide in a patient with glioblastoma multiforme: case study and review of data from the FDA adverse event reporting system. Neuro Oncol 2012; 14:541-6. [PMID: 22394496 DOI: 10.1093/neuonc/nos056] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Glioblastoma multiforme (GBM) is the most frequent malignant brain tumor in adults. Its established first-line adjuvant treatment is radiotherapy in combination with temozolomide (TZM). Hematotoxicity is listed as a frequent adverse drug reaction in the US prescribing information and hepatotoxicity has been reported infrequently in the postmarketing period. We here present the case of a patient diagnosed with GBM who developed severe sustained cholestatic hepatitis following treatment with TZM. The cholestasis was not reversible after withdrawal of TZM during 6 months before the patient's death. Another 2 published case reports of sustained cholestasis following TZM treatment were identified; however, the sustained nature of cholestasis was not emphasized in these reports. Sixteen cases of cholestatic hepatitis/cholestasis associated with TZM were identified in the FDA spontaneous reporting system between 2007 and 2010. Information on the course of the cholestasis in these cases could not be retrieved. In the literature there are other published reports of hepatotoxicity associated with TZM that have reported reversibility upon withdrawal of the drug. Thus, TZM appears to cause different types of hepatotoxicity. Particular attention should be paid to sustained cholestasis as a very serious type of TZM-associated liver toxicity.
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Affiliation(s)
- Giselle Sarganas
- Clinical Pharmacology and Toxicology, Charité Universitätsmedizin Berlin, Berlin, Germany
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