Tumor blood flow changes induced by chemical modifiers of radiation response

Nitroimidazoles as hypoxic cell radiosensitizers and hypoxia probes: misonidazole, myths and mistakes

Nitroimidazoles have been extensively explored as hypoxic cell radiosensitizers but have had limited clinical success, with efficacy restricted by toxicity. However, they have proven clinically useful as probes for tumour hypoxia. Both applications, and probably much of the dose-limiting toxicities, reflect the dominant chemical property of electron affinity or ease of reduction, associated with the nitro substituent in an aromatic structure. This single dominant property affords unusual, indeed extraordinary flexibility in drug or probe design, suggesting further development is possible in spite of earlier limitations, in particular building on the benefit of hindsight and an appreciation of errors made in earlier studies. The most notable errors were: the delay in viewing cellular thiol depletion as a likely common artefact in testing in vitro; slow recognition of pH-driven concentration gradients when compounds were weak acids and bases; and a failure to explore the possible involvement of pH and ascorbate in influencing hypoxia probe binding. The experience points to the need to involve a wider range of expertise than that historically involved in many laboratories when studying the effects of chemicals on radiation response or using diagnostic probes.

Influence of carboplatin infusion on osteosarcoma blood flow

PURPOSE

Herein we report that carboplatin infusion influenced tumor blood flow signal independent of the mechanical decompression induced by the artificial lymphatics system technology that was being evaluated as part of a randomized veterinary clinical trial, treating spontaneously occurring canine appendicular osteosarcoma, a tumor very similar to its human counterpart.

METHODS

Blood flow within the central region of the tumor was recorded continuously using laser Doppler flowmetry, a real-time measurement technology. Time-averaged flow values were computed from segments taken from the recordings immediately before starting carboplatin infusion, and during infusion.

RESULTS

Carboplatin increased the tumor blood flow signal by an additional 59 +/- 26% (mean +/- SEM; p = 0.06) over the increase induced by the decompression. The increase started within 49 +/- 46 s after the start of infusion, had a response time constant of 19 +/- 21 s and persisted throughout the infusion, ending shortly after infusion ended.

CONCLUSION

The rapidity of the flow signal increase suggests that carboplatin may have an autonomic effect on circulation, either local or systemic. The observations identify a new action of this drug and suggest a possible mechanism to exploit therapeutically.

Chemical radioprotection: a critical review of amifostine as a cytoprotector in radiotherapy

The use of chemical radioprotectors represents an obvious strategy to improve the therapeutic index in radiotherapy. Amofostine (WR-2721) has recently been approved for use in head and neck cancer to protect against radiation-induced xerostomia. Currently, the question has arisen whether amifostine could be used for radioprotection in broader terms. Amifostine may have the potential to enable intensified treatment by ameliorating mucosal reactions that are often a limiting factor in accelerated fractionation or concomitant chemoradiation. However, it has as yet not been clarified whether sufficient amifostine to reduce mucositis can be administered before each radiation fraction without causing unacceptable toxicity. Also, the optimal dosage and schedule of amifostine in chemoradiation combinations have not yet been established. The major concern related to radioprotectiors is the potential hazard of collateral tumor protection. A number of clinical studies have concluded that amifostine does not reduce antitumor efficacy. However, not even the largest study conducted, with over 300 patients, has sufficient statistical power to detect a clinically significant reduction in tumor control rate. To put this issue ultimately to a rest, a clinical trial with a sufficient accrual to definitely rule out a tumor protective effect of amifostine needs to be conducted. Substances reducing radiation-induced toxicity by modulating the biological response to radiation injury may represent an alternative concept in radioprotection. However, such agents are still at a developmental stage.

Has the outlook improved for amifostine as a clinical radioprotector?

Amifostine has recently been approved for clinical radiotherapy as a protector against irradiation-induced xerostomia. It is our aim to review the outlook for using amifostine as a general clinical radioprotector. Protection against X-rays is mainly obtained by the scavenging of free radicals. The degree of protection is therefore highly dependent on oxygen tension, with protection factors ranging from 1 to 3. Maximal protection is observed at physiological levels of oxygenation. A great variability in protection has also been observed between different normal tissues. Some tissue, like brain, is not protected while salivary glands and bone marrow may exhibit a three-fold increase in radiation tolerance. Amifostine is dephosphorylized to its active metabolite by a process involving alkaline phosphatase. Due to lower levels of alkaline phosphatase in tumor vessels, amifostine is marketed as a selective protector of normal tissue and not tumors. However, the preclinical investigations concerning the selectivity of amifostine are controversial and the clinical studies are sparse and do not have the power to evaluate the influence of amifostine on the therapeutic index.

CONCLUSION

based on the present knowledge amifostine should only be used in experimental protocols and not in routine practice.

Change in oxygenation status in intratumour total and quiescent cells following gamma-ray irradiation, tirapazamine administration, cisplatin injection and bleomycin treatment

C3H/He mice bearing SCC VII tumours received 5-bromo-2'-deoxyuridine (BrdU) continuously for 5 days via implanted mini-osmotic pumps to label all proliferating (P) cells. The mice then received gamma-ray irradiation, or administration of tirapazamine (TPZ), cisplatin or bleomycin. At various time points after each treatment, tumour-bearing mice were irradiated with a series of test doses of gamma-rays, while alive or after being killed, to obtain hypoxic fractions (HFs) in the tumours. Immediately after gamma-ray test irradiation, the tumours were excised, minced and trypsinized. Tumour cell suspensions obtained were incubated with cytochalasin-B, a cytokinesis blocker, and the micronucleus (MN) frequency in cells without BrdU labelling (i.e. quiescent (Q) cells) was determined using immunofluorescence staining for BrdU. MN frequency in the total (P + Q) tumour cells was determined from the tumours that were not pre-treated with BrdU. MN frequency of BrdU-unlabelled cells was then used to calculate the surviving fraction of the unlabelled cells from the regression line for the relationship between the MN frequency and the surviving fraction of total tumour cells. TPZ and cisplatin reduced the HF after treatment, especially in Q cells, and this tendency was particularly marked with TPZ. In contrast, bleomycin increased the HF after treatment. Both reoxygenation following gamma-ray irradiation or bleomycin treatment and a subsequent return to pre-treatment levels of HF following TPZ or cisplatin treatment (rehypoxiation) occurred more rapidly in total (P + Q) cells than in Q cells. Based on our previous report that total (P + Q) and Q cells within this tumour have large acutely and chronically HFs, respectively, we conclude that acute hypoxic cells play a major role in reoxygenation and rehypoxiation in SCC VII tumours.

Spatial relationship between hypoxia and the (perfused) vascular network in a human glioma xenograft: a quantitative multi-parameter analysis

PURPOSE

To quantitatively study the spatial distribution of tumor hypoxia in relation to the perfused vasculature.

METHODS AND MATERIALS

Using a human glioma xenograft model, nude mice were administered two different hypoxia markers (NITP or pimonidazole) and the perfusion marker Hoechst 33342. Frozen tumor sections were sequentially scanned for perfusion, hypoxia, and vasculature, respectively, to quantitate perfusion, vasculature, and hypoxia parameters in the same section.

RESULTS

All tumors showed incomplete perfusion. Both NITP and pimonidazole stained the same hypoxic tumor areas. No statistically significant differences between the two markers were observed. The density of the perfused vessels was inversely related to the hypoxic fraction. At critical distances from perfused vessels, hypoxia occurred. These data suggest that predominantly diffusion-limited hypoxia was detected, based on the spatial distribution of nearby vessels. Also, the proportion of hypoxia distributed over arbitrary zones of 50 microm around perfused vessels was calculated. The largest proportion of hypoxia was found at distances beyond 100 microm from perfused vessels.

CONCLUSION

With the multiple staining and functional microscopic imaging technique described here, the spatial relationship between perfused vessels and hypoxia was quantified in whole tumor cross-sections. The usefulness of this histologically-based method to quantitate morphological and physiological aspects of the tumor microenvironment was evaluated.

The relationship between tumour oxygenation determined by oxygen electrode measurements and magnetic resonance spectroscopy of the fluorinated 2-nitroimidazole SR-4554

The relationship between two methods of assessing tumour oxygenation in vivo, namely oxygen electrode measurement and magnetic resonance spectroscopy (MRS) of the fluorinated 2-nitroimidazole SR-4554, was investigated. Using three tumour models (two sites), no linear correlation was observed between 19F retention index and pO2 parameters (r < or = 0.3). Substantial retention of SR-4554 (19F retention index > 0.5) was, however, associated with low tumour pO2 (% pO2 < or = 5 mmHg = 60%). Depending on the pO2 parameters used, SR-4554 administration was shown to produce either a significant or a non-significant increase in tumour oxygenation. We conclude that measurement of SR-4554-related compound(s) by 19F-MRS has the potential to detect clinically relevant levels of tumour hypoxia.

Proliferation and hypoxia in human squamous cell carcinoma of the cervix: first report of combined immunohistochemical assays

PURPOSE

To characterize the distribution of hypoxia and proliferation in human squamous cell carcinoma of the cervix via an immunohistochemical approach prior to initiation of therapy.

METHODS AND MATERIALS

Patients with primary squamous cell carcinoma of the cervix uteri received a single infusion of the 2-nitroimidazole, pimonidazole (0.5 g/m2 i.v.), and 24 h later punch biopsies of the primary tumor were taken. Tissue was formalin fixed, paraffin embedded, and sectioned for immunohistochemistry. Hypoxia was detected by monoclonal antibody binding to adducts of reductively activated pimonidazole in malignant cells. Staining for endogenous MIB-1 and PCNA was detected in tumor cells via commercially available monoclonal antibodies. Point counting was used to quantitate the fraction of tumor cells immunostained for MIB-1, PCNA, and hypoxia marker binding.

RESULTS

Immunostaining for pimonidazole binding was distant from blood vessels. There was no staining in necrotic regions, and only minimal nonspecific staining, mostly in keratin. In general, cells immunostaining for MIB-1 and PCNA did not immunostain for pimonidazole binding. Cells immunostaining for MIB-1 and PCNA showed no obvious geographic predilection such as proximity to vasculature. Quantitative comparison showed an inverse relationship between hypoxia marker binding and proliferation.

CONCLUSIONS

Immunohistochemical staining for pimonidazole binding is consistent with the presence of hypoxic cells in human tumors and may be useful for estimating tumor hypoxia prior to radiation therapy. Immunostaining for pimonidazole binding is an ideal complement to immunohistochemical assays for endogenous proliferation markers allowing for comparisons of tumor hypoxia with other physiological parameters. These parameters might be used to select patients for radiation protocols specifically designed to offset the negative impact of hypoxia and/or proliferation on therapy. The inverse relationship between pimonidazole binding and proliferation markers is a preliminary result requiring verification.

Tumour blood flow influences combined radiation and doxorubicin treatments

BACKGROUND AND PURPOSE

Doxorubicin is usually an effective radiosensitizer in vitro, but in vivo reports have been more variable. We have examined potential explanations for those observations by comprehensively evaluating doxorubicin and radiation treatments in xenografted human tumors, and in conventional mice with syngeneic tumours.

MATERIALS AND METHODS

Nude or SCID mice bearing the SiHa cervical squamous cell carcinoma or WiDr colon adenocarcinoma were studied, as were C3H/HeN animals with SCCVII tumours. Assays included a clonogenic assay in combination with cell sorting, laser Doppler flowmetry, and the dual staining mismatch technique.

RESULTS

Doxorubicin decreased tumour blood flow in all tumour systems, in a dose-dependent fashion with each assay. This resulted in increased tumour hypoxia and decreased response to radiation when inappropriate treatment sequences were employed. However, significant variability from animal to animal was noted.

CONCLUSIONS

To the extent that these results can be extrapolated to human tumour treatments, we conclude that unless compelling evidence suggests that a tumour will be exceedingly sensitive to the drug, the potential effects of doxorubicin on tumour blood flow contraindicate its administration immediately prior to irradiation.

A comparison of the physiological effects of RSU1069 and RB6145 in the SCCVII murine tumour

The physiological and therapeutic effects of the bioreductive agent RSU1069 (80 mg/kg i.p.) and its prodrug RB6145 (240 mg/kg i.p.) were investigated in the SCCVII tumour. Using laser Doppler flowmetry it was found that RSU1069 produced a significant 30% reduction in tumour blood flow 30 min after administration, while RB6145 had no effect. Tumour oxygenation, measured with an Eppendorf oxygen electrode, was unchanged by either agent except for a reduction in values less than 2.5 mmHg at 30 min after injection. Neither agent significantly altered tumour energy metabolism, assessed by 31P magnetic resonance spectroscopy. Both agents significantly increased tumour glucose content by a factor of 1.6-1.7 at 30 min after injection, but had no effect on glucose-6-phosphate or lactate levels. Tumour growth was significantly delayed by heating (42.5 degrees C, 60 min), and although neither RSU1069 nor RB6145 alone had any effect on tumour growth they produced a similar enhancement of the tumour response to heat. The therapeutic effects are consistent with the known conversion in vivo of one third of the pro-drug RB6145 to its active product RSU1069, however the physiological effects of the two agents in the SCCVII tumour are not identical.

The apparent diffusion constant measured by MRI correlates with pO2 in a RIF-1 tumor

As tissue oxygen tension (pO2) is an important variable in cancer therapy, it would be of major clinical benefit to be able to measure pO2 noninvasively. Current methods for determining pO2 in clinical settings are limited to superficial tumors. The authors measured the apparent diffusion constant (ADC) in an implanted murine fibrosarcoma (RIF-1) using magnetic resonance imaging and correlated the ADC with tissue pO2 measured by electron paramagnetic resonance oximetry. The ADC correlates significantly with tissue pO2 in this tumor (r = 0.89; n = 14) and so may provide a noninvasive index of pO2 in tumors.