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Oral vinorelbine and capecitabine as first-line therapy in metastatic breast cancer: a retrospective analysis. Future Sci OA 2021; 7:FSO750. [PMID: 34840807 PMCID: PMC8610004 DOI: 10.2144/fsoa-2020-0095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/16/2021] [Indexed: 12/12/2022] Open
Abstract
A retrospective analysis of 70 patients with triple-negative or hormone-resistant advanced breast carcinoma who had not previously received chemotherapy was carried out. Patients received oral vinorelbine 60 mg/m2 on day 1 and 8, plus capecitabine 1000 mg/m2 bid for 14 consecutive days every 3 weeks. Overall response rate was 53% with a 9% complete response rate. Stable disease was recorded in 27% of the cases. Median progression-free survival was 7.9 months and median overall survival was 29.2 months. Toxicity was generally mild and easily manageable. These data demonstrate that this combination is feasible, safe and active as first-line treatment of triple-negative fully hormone-resistant advanced breast carcinoma patients. The adoption of metronomic chemotherapy in the treatment of breast cancer is an important step forward in the management of this disease. The fluoropyrimidine capecitabine and the vinca alkaloid vinorelbine have been shown to be at least as active. Our data confirm the activity and safety of this all-oral regimen as first-line metronomic therapy being response rate.
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Twelves C, Bartsch R, Ben-Baruch NE, Borstnar S, Dirix L, Tesarova P, Timcheva C, Zhukova L, Pivot X. The Place of Chemotherapy in The Evolving Treatment Landscape for Patients With HR-positive/HER2-negative MBC. Clin Breast Cancer 2021; 22:223-234. [PMID: 34844889 DOI: 10.1016/j.clbc.2021.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/23/2021] [Accepted: 10/19/2021] [Indexed: 11/19/2022]
Abstract
Endocrine therapy (ET) for the treatment of patients with hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR-positive/HER2-negative) metastatic breast cancer (MBC) has changed markedly over recent years with the emergence of new ETs and the use of molecularly targeted agents. Cytotoxic chemotherapy continues, however, to have an important role in these patients and it is important to maximize its efficacy while minimizing toxicity to optimize outcomes. This review examines current HR-positive/HER2-negative MBC clinical guidelines and addresses key questions around the use of chemotherapy in the face of emerging therapeutic options. Specifically, the indications for chemotherapy in patients with HR-positive/HER2-negative MBC and the choice of optimal chemotherapy are discussed.
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Affiliation(s)
- Chris Twelves
- Clinical Cancer Pharmacology and Oncology, Leeds Institute of Medical Research, University of Leeds and Leeds Teaching Hospitals Trust Leeds.
| | - Rupert Bartsch
- Department of Medicine 1, Division of Oncology, Medical University of Vienna, Austria
| | | | - Simona Borstnar
- Division of Medical Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Luc Dirix
- Medical Oncology, Sint-Augustinus Hospital, Antwerp, Belgium
| | - Petra Tesarova
- First Faculty of Medicine and General Teaching Hospital, Charles University, Prague, Czech Republic
| | | | | | - Xavier Pivot
- ICANS - Strasbourg Europe Cancerology Institute, Strasbourg, France
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Xavier JS, Jayabalan K, Ragavendran V, Manoharan MT, Nityananda Shetty A. Virtual and experimental high throughput screening of substituted hydrazones on β-Tubulin polymerization. Bioorg Chem 2021; 114:105094. [PMID: 34167017 DOI: 10.1016/j.bioorg.2021.105094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 10/21/2022]
Abstract
Microtubule targeting agents that disrupt the dynamic functioning of the mitotic spindle are some of the best chemotherapeutic agents. Interruption of microtubule dynamics through polymerization or depolymerization causes cell arrest leading to apoptosis. We report a novel class of aroylhydrazones with anticancer properties. Tubulin inhibition studies were performed using both computational and biological methods. Docking and pharmacophore mapping showed efficient binding between the ligands and the protein. Tubulin inhibition assay showed the aroylhydrazones to be inhibitors of tubulin polymerization. DFT studies explains the geometrical and electronic properties of the compounds. Furthermore, anticancer studies using lung and liver cancer cell lines gave low IC50 values with the methyl substituted hydrazone MH-2 being the most potent. (IC50 of 0.0896 and 0.1040 µM respectively). The methyl group is responsible for the effective binding to the protein. Thus, a new class of tubulin binding agents have been identified as potential agents in cancer therapy.
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Affiliation(s)
- Janet Sabina Xavier
- Department of Chemistry, Sathyabama Institute of Science and Technology, Chennai 600119, India
| | - Karthikeyan Jayabalan
- Department of Chemistry, Sathyabama Institute of Science and Technology, Chennai 600119, India.
| | - V Ragavendran
- Department of Physics, Sri Chandrasekharendra Saraswathi Viswa Mahavidyalaya, Kanchipuram 631561, India
| | - Muthu Tamizh Manoharan
- Department of Chemistry, Siddha Central Research Institute, Central Council for Research in Siddha, Arumbakkam, Chennai 600106, India
| | - A Nityananda Shetty
- Department of Chemistry, National Institute of Technology Karnataka, Mangalore 575025, India
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Hoon SN, Lau PK, White AM, Bulsara MK, Banks PD, Redfern AD. Capecitabine for hormone receptor-positive versus hormone receptor-negative breast cancer. Cochrane Database Syst Rev 2021; 5:CD011220. [PMID: 34037241 PMCID: PMC8150746 DOI: 10.1002/14651858.cd011220.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Retrospective analyses suggest that capecitabine may carry superior activity in hormone receptor-positive relative to hormone receptor-negative metastatic breast cancer. This review examined the veracity of that finding and explored whether this differential activity extends to early breast cancer. OBJECTIVES To assess effects of chemotherapy regimens containing capecitabine compared with regimens not containing capecitabine for women with hormone receptor-positive versus hormone receptor-negative breast cancer across the three major treatment scenarios: neoadjuvant, adjuvant, metastatic. SEARCH METHODS On 4 June 2019, we searched the Cochrane Breast Cancer Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5) in the Cochrane Library; MEDLINE; Embase; the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials looking at chemotherapy regimens containing capecitabine alone or in combination with other agents versus a control or similar regimen without capecitabine for treatment of breast cancer at any stage. The primary outcome measure for metastatic and adjuvant trials was overall survival (OS), and for neoadjuvant studies pathological complete response (pCR). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias and certainty of evidence using the GRADE approach. Hazard ratios (HRs) were derived for time-to-event outcomes, and odds ratios (ORs) for dichotomous outcomes, and meta-analysis was performed using a fixed-effect model. MAIN RESULTS We included 26 studies with outcome data by hormone receptor: 12 metastatic studies (n = 4325), 6 neoadjuvant trials (n = 3152), and 8 adjuvant studies (n = 13,457). Capecitabine treatment was added in several different ways across studies. These could be classified as capecitabine alone compared to another treatment, capecitabine substituted for part of the control chemotherapy, and capecitabine added to control chemotherapy. In the metastatic setting, the effect of capecitabine was heterogenous between hormone receptor-positive and -negative tumours. For OS, no difference between capecitabine-containing and non-capecitabine-containing regimens was observed for all participants taken together (HR 1.01, 95% confidence interval (CI) 0.98 to 1.05; 12 studies, 4325 participants; high-certainty evidence), for those with hormone receptor-positive disease (HR 0.93, 95% CI 0.84 to 1.04; 7 studies, 1834 participants; high-certainty evidence), and for those with hormone receptor-negative disease (HR 1.00, 95% CI 0.88 to 1.13; 8 studies, 1577 participants; high-certainty evidence). For progression-free survival (PFS), a small improvement was seen for all people (HR 0.89, 95% CI 0.82 to 0.96; 12 studies, 4325 participants; moderate-certainty evidence). This was largely accounted for by a moderate improvement in PFS for inclusion of capecitabine in hormone receptor-positive cancers (HR 0.82, 95% CI 0.73 to 0.91; 7 studies, 1594 participants; moderate-certainty evidence) compared to no difference in PFS for hormone receptor-negative cancers (HR 0.96, 95% CI 0.83 to 1.10; 7 studies, 1122 participants; moderate-certainty evidence). Quality of life was assessed in five studies; in general there did not seem to be differences in global health scores between the two treatment groups at around two years' follow-up. Neoadjuvant studies were highly variable in design, having been undertaken to test various experimental regimens using pathological complete response (pCR) as a surrogate for disease-free survival (DFS) and OS. Across all patients, capecitabine-containing regimens resulted in little difference in pCR in comparison to non-capecitabine-containing regimens (odds ratio (OR) 1.12, 95% CI 0.94 to 1.33; 6 studies, 3152 participants; high-certainty evidence). By subtype, no difference in pCR was observed for either hormone receptor-positive (OR 1.22, 95% CI 0.76 to 1.95; 4 studies, 964 participants; moderate-certainty evidence) or hormone receptor-negative tumours (OR 1.28, 95% CI 0.61 to 2.66; 4 studies, 646 participants; moderate-certainty evidence). Four studies with 2460 people reported longer-term outcomes: these investigators detected no difference in either DFS (HR 1.02, 95% CI 0.86 to 1.21; high-certainty evidence) or OS (HR 0.97, 95% CI 0.77 to 1.23; high-certainty evidence). In the adjuvant setting, a modest improvement in OS was observed across all participants (HR 0.89, 95% CI 0.81 to 0.98; 8 studies, 13,547 participants; moderate-certainty evidence), and no difference in OS was seen in hormone receptor-positive cancers (HR 0.86, 95% CI 0.68 to 1.09; 3 studies, 3683 participants), whereas OS improved in hormone receptor-negative cancers (HR 0.72, 95% CI 0.59 to 0.89; 5 studies, 3432 participants). No difference in DFS or relapse-free survival (RFS) was observed across all participants (HR 0.93, 95% CI 0.86 to 1.01; 8 studies, 13,457 participants; moderate-certainty evidence). As was observed for OS, no difference in DFS/RFS was seen in hormone receptor-positive cancers (HR 1.03, 95% CI 0.91 to 1.17; 5 studies, 5604 participants; moderate-certainty evidence), and improvements in DFS/RFS with inclusion of capecitabine were observed for hormone receptor-negative cancers (HR 0.74, 95% CI 0.64 to 0.86; 7 studies, 3307 participants; moderate-certainty evidence). Adverse effects were reported across all three scenarios. When grade 3 or 4 febrile neutropenia was considered, no difference was seen for capecitabine compared to non-capecitabine regimens in neoadjuvant studies (OR 1.31, 95% CI 0.97 to 1.77; 4 studies, 2890 participants; moderate-certainty evidence), and a marked reduction was seen for capecitabine in adjuvant studies (OR 0.55, 95% CI 0.47 to 0.64; 5 studies, 8086 participants; moderate-certainty evidence). There was an increase in diarrhoea and hand-foot syndrome in neoadjuvant (diarrhoea: OR 1.95, 95% CI 1.32 to 2.89; 3 studies, 2686 participants; hand-foot syndrome: OR 6.77, 95% CI 4.89 to 9.38; 5 studies, 3021 participants; both moderate-certainty evidence) and adjuvant trials (diarrhoea: OR 2.46, 95% CI 2.01 to 3.01; hand-foot syndrome: OR 13.60, 95% CI 10.65 to 17.37; 8 studies, 11,207 participants; moderate-certainty evidence for both outcomes). AUTHORS' CONCLUSIONS In summary, a moderate PFS benefit by including capecitabine was seen only in hormone receptor-positive cancers in metastatic studies. No benefit of capecitabine for pCR was noted overall or in hormone receptor subgroups when included in neoadjuvant therapy. In contrast, the addition of capecitabine in the adjuvant setting led to improved outcomes for OS and DFS in hormone receptor-negative cancer. Future studies should stratify by hormone receptor and triple-negative breast cancer (TNBC) status to clarify the differential effects of capecitabine in these subgroups across all treatment scenarios, to optimally guide capecitabine inclusion.
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Affiliation(s)
- Siao-Nge Hoon
- Medical Oncology Department, St John of God Midland, Perth, Australia
- Medical Oncology Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Peter Kh Lau
- Medical Oncology Department, Sir Charles Gairdner Hospital, Perth, Australia
- Medical Oncology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Alison M White
- Murdoch Community Hospice, St John of God Hospital Murdoch, Perth, Australia
- Palliative Care Department, Royal Perth Hospital, Perth, Australia
| | - Max K Bulsara
- Institute for Health Research, University of Notre Dame Australia, Fremantle, Australia
- School of Population and Global Health, The University of Western Australia, Perth, Australia
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Patricia D Banks
- Medical Oncology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
- Medical Oncology Department, University Hospital Geelong, Geelong, Australia
| | - Andrew D Redfern
- School of Medicine, University of Western Australia, Perth, Australia
- Medical Oncology Department, Fiona Stanley Hospital, Perth, Australia
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Chemotherapy Options beyond the First Line in HER-Negative Metastatic Breast Cancer. JOURNAL OF ONCOLOGY 2020; 2020:9645294. [PMID: 33312203 PMCID: PMC7719522 DOI: 10.1155/2020/9645294] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/05/2020] [Accepted: 11/11/2020] [Indexed: 12/24/2022]
Abstract
Despite the recent advances in the biological understanding of breast cancer (BC), chemotherapy still represents a key component in the armamentarium for this disease. Different agents are available as mono-chemotherapy options in patients with locally advanced or metastatic BC (MBC) who progress after a first- and second-line treatment with anthracyclines and taxanes. However, no clear indication exists on what the best option is in some populations, such as heavily pretreated, elderly patients, triple-negative BC (TNBC), and those who do not respond to the first-line therapy. In this article, we summarize available literature evidence on different chemotherapy agents used beyond the first-line, in locally advanced or MBC patients, including rechallenge with anthracyclines and taxanes, antimetabolite and antimicrotubule agents, such as vinorelbine, capecitabine, eribulin, ixabepilone, and the newest developed agents, such as vinflunine, irinotecan, and etirinotecan.
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Péron J, Neven A, Collette L, Launay-Vacher V, Sprangers B, Marreaud S. Impact of acute kidney injury on anticancer treatment dosage and long-term outcomes: a pooled analysis of European Organisation for Research and Treatment of Cancer trials. Nephrol Dial Transplant 2020; 36:gfaa049. [PMID: 32337562 DOI: 10.1093/ndt/gfaa049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The impact of kidney dysfunction on long-term outcomes of patients with advanced cancer remains unclear. METHODS Patients with advanced cancer included in trials conducted by the European Organisation for Research and Treatment of Cancer were eligible for this retrospective analysis. Acute kidney injury (AKI) was identified using serum creatinine levels and using adverse events reported by investigators. The impact of baseline estimated glomerular filtration rates (eGFRs) on progression-free survival (PFS) and overall survival (OS) was investigated. Pooled estimates of the impact of AKI on dose intensity, treatment duration, PFS and OS were obtained following a meta-analytic process. RESULTS Nine trials were included in this study, totalling 2872 metastatic patients with various tumour types and various systemic treatment types. Baseline eGFR had homogeneously no impact on PFS or OS. Most Risk, Injury, Failure, Loss of kidney function and End-stage kidney disease (RIFLE) events occurred early during the course of the treatment. AKI was not associated with an increased rate of treatment discontinuation, while it decreased the study treatment dose intensity. Occurrence of a first RIFLE event significantly and homogeneously reduced PFS (pooled hazard ratio = 1.18, 95% confidence interval 1.07-1.30; P = 0.0012), while its impact on OS was more heterogeneous across trials. CONCLUSION AKI is associated with reduced treatment dose intensity and reduced PFS. Therefore, close monitoring of the kidney function during the first months of treatment should be included in clinical trial protocols and probably also in daily practice to enable early AKI diagnosis and management. Collaboration between oncologists and nephrologists is needed to reduce the risk of undertreatment of patients experiencing AKI.
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Affiliation(s)
- Julien Péron
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
- Oncology Medical Unit, Hospices Civils de Lyon, Université Lyon 1, Lyon, France
| | - Anouk Neven
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Laurence Collette
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | | | - Ben Sprangers
- Department of Microbiology and Immunology, Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Leuven, Belgium
- Division of Nephrology, University Hospitals, UZGasthuisberg, Leuven, Belgium
| | - Sandrine Marreaud
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
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7
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Mierzynska J, Taye M, Pe M, Coens C, Martinelli F, Pogoda K, Velikova G, Bjelic-Radisic V, Cardoso F, Brain E, Ignatiadis M, Piccart M, Van Tienhoven G, Mansel R, Wildiers H, Bottomley A. Reference values for the EORTC QLQ-C30 in early and metastatic breast cancer. Eur J Cancer 2020; 125:69-82. [PMID: 31838407 DOI: 10.1016/j.ejca.2019.10.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Considering the worldwide incidence of breast cancer (BC) and the importance of health-related quality of life (HRQoL) assessment, there is a growing need to have accurate and up-to-date reference values (RVs). RVs are useful for the design of randomised controlled trials (RCTs) and as benchmarks for comparison of cancer RCTs and health care interventions. This study aimed to provide RVs for the QLQ-C30 in early BC (EBC) and metastatic BC (MBC). General patterns of main results from the EORTC dataset (main dataset) were compared with the PDS dataset (comparison dataset) to see whether they would be consistent across pre-defined covariates. METHODS European Organization for Research and Treatment of Cancer (EORTC) (main dataset) and Project Data Sphere (PDS) (comparison dataset) were searched to identify BC RCTs where baseline HRQoL (before treatment) was assessed with the QLQ-C30. RVs were calculated and stratified by disease stage, age, and when available, performance status (PS), comorbidity and region. RVs were reported using descriptive statistics. RESULTS Data from three EORTC (n = 4115) and three PDS RCTs (n = 1406) were included in the analysis. While EBC patients presented better HRQoL with high baseline functioning scores and low prevalence of symptoms, MBC patients reported worse HRQoL with lower functioning scores and more prevalence of symptoms. In MBC, poor PS and presence of comorbidities reflected worse baseline HRQoL. No consistent differences were found for age and countries. CONCLUSION These up-to-date RVs for the EORTC QLQ-C30 in BC show differences in HRQoL scores between stages, PS, and comorbidities. These findings, supported by an independent dataset, will help the clinical interpretation of scores for BCpatients.
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Affiliation(s)
- Justyna Mierzynska
- Department of Quality of Life, European Organization of Research and Treatment for Cancer, Brussels, Belgium
| | - Mekdes Taye
- Department of Quality of Life, European Organization of Research and Treatment for Cancer, Brussels, Belgium
| | - Madeline Pe
- Department of Quality of Life, European Organization of Research and Treatment for Cancer, Brussels, Belgium
| | - Corneel Coens
- Department of Quality of Life, European Organization of Research and Treatment for Cancer, Brussels, Belgium
| | - Francesca Martinelli
- Department of Quality of Life, European Organization of Research and Treatment for Cancer, Brussels, Belgium
| | - Katarzyna Pogoda
- Department of Breast Cancer and Reconstructive Surgery, Maria Sklodowska-Curie Institute - Oncology Center, Warsaw, Poland
| | - Galina Velikova
- Leeds Institute of Medical Research, St James's University of Leeds and Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Vesna Bjelic-Radisic
- Breast Unit, Helios University Clinic Wuppertal & Witten/Herdecke University, Wuppertal & Witten, Germany
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center-Champalimaud Foundation, Lisbon, Portugal
| | - Etienne Brain
- Department of Medical Oncology, Institut Curie, Paris & Saint Cloud, France
| | - Michail Ignatiadis
- Department of Medical Oncology, Jules Bordet Institute, Université Libre de Bruxeles, Brussels, Belgium
| | - Martine Piccart
- Department of Medical Oncology, Jules Bordet Institute, Université Libre de Bruxeles, Brussels, Belgium
| | - Geertjan Van Tienhoven
- Department of Radiation Oncology, Amsterdam UMBC, Location AMC, Amsterdam, the Netherlands
| | - Robert Mansel
- Department of Surgery, Cardiff University, Cardiff, United Kingdom
| | - Hans Wildiers
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Andrew Bottomley
- Department of Quality of Life, European Organization of Research and Treatment for Cancer, Brussels, Belgium.
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Oruç Z, Kaplan MA, Arslan Ç. An update on the currently available and future chemotherapy for treating bone metastases in breast cancer patients. Expert Opin Pharmacother 2018; 19:1305-1316. [PMID: 30129373 DOI: 10.1080/14656566.2018.1504922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Bone metastases in breast cancer patients are a common clinical problem. Many factors influence the treatment decision, including tumor characteristics, previous treatment and tumor burden in the treatment of metastatic breast cancer. AREAS COVERED This present review summarizes the new treatment strategies and the chemotherapeutic agents currently available in the management of metastatic breast cancer with bone metastases. EXPERT OPINION Patients with bone metastases more often have hormone receptor-positive tumours. Although new treatment agents for metastatic breast cancer have been investigated, endocrine therapy is still considered as the treatment of choice for patients with bone metastases although chemotherapy still has an important place. In recent years, new chemotherapeutic agents such as etirinotecan and nab-paclitaxel have been established though there are few studies that have looked at particular types of metastases. In the last decade, therapies for bone metastasis resistant to endocrine therapy have predominantly focused on radiotherapy, surgical resection, chemotherapy, bone-targeting radiopharmaceuticals and targeted therapeutics. New targeted agents include: Src inhibitors, cathepsin K inhibitors, CXCR4 inhibitors, TGF-B blockade and integrin antagonists while drug delivery systems for chemotherapy have also been developed. These new treatment options could be future treatment options for bone metastatic disease if early promising results are confirmed by clinical trials.
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Affiliation(s)
- Zeynep Oruç
- a Department of Medical Oncology , Mersin City Hospital , Mersin , Turkey
| | - Muhammet Ali Kaplan
- b Department of Medical Oncology , Dicle University Faculty of Medicine , Diyarbakır , Turkey
| | - Çağatay Arslan
- c Department of Medical Oncology , Medical Park Hospital , Izmir , Turkey.,d Faculty of Medicine , Bahcesehir University , Istanbul , Turkey
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Single-Agent Oral Vinorelbine as First-Line Chemotherapy for Endocrine-Pretreated Breast Cancer With Bone Metastases and No Visceral Involvement: NORBREAST-228 Phase II Study. Clin Breast Cancer 2017; 18:e41-e47. [PMID: 28666812 DOI: 10.1016/j.clbc.2017.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/25/2017] [Accepted: 05/22/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Single-agent oral chemotherapy is widely used in patients with bone metastases without visceral involvement, especially in hormone receptor-positive metastatic breast cancer (mBC). However, this option has been poorly evaluated in clinical trials. METHODS Eligible patients had mBC with predominantly bone but not visceral metastases, were receiving bisphosphonate therapy, and had previously received endocrine therapy (any setting) but not chemotherapy for mBC. Patients received oral vinorelbine 60 mg/m2 on days 1, 8, 15, and 22 every 4 weeks (escalating to 80 mg/m2 from cycle 2 in the absence of grade 3/4 toxicity) until disease progression or unacceptable toxicity. The primary endpoint was progression-free survival (PFS). Secondary endpoints included clinical benefit rate (complete/partial response or ≥24 weeks' stable disease), overall survival, and safety. RESULTS Seventy patients were treated for a median of 6 cycles (range 1-18). Most (73%) continued treatment until disease progression. After 43 months' median follow-up, median PFS was 8.2 months (95% confidence interval [CI], 5.5-9.8). The clinical benefit rate was 56% (95% CI, 43%-68%). Median overall survival was 35.2 months (95% CI, 26.8-47.1). The most common grade 3/4 adverse event was neutropenia (38% of patients); febrile neutropenia was absent. The most common grade 1/2 adverse events were bone pain, fatigue, and gastrointestinal toxicities. Alopecia was infrequent. CONCLUSIONS In patients with hormone receptor-positive mBC, bone disease, and prior endocrine therapy, first-line oral vinorelbine chemotherapy demonstrated long PFS and good tolerability. In this setting, it could be considered as an active oral alternative to intravenous chemotherapy.
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10
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Biganzoli L, Lichtman S, Michel JP, Papamichael D, Quoix E, Walko C, Aapro M. Oral single-agent chemotherapy in older patients with solid tumours: A position paper from the International Society of Geriatric Oncology (SIOG). Eur J Cancer 2015; 51:2491-500. [DOI: 10.1016/j.ejca.2015.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/09/2015] [Indexed: 10/23/2022]
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11
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Generali D, Venturini S, Rognoni C, Ciani O, Pusztai L, Loi S, Jerusalem G, Bottini A, Tarricone R. A network meta-analysis of everolimus plus exemestane versus chemotherapy in the first- and second-line treatment of estrogen receptor-positive metastatic breast cancer. Breast Cancer Res Treat 2015; 152:95-117. [PMID: 26044370 DOI: 10.1007/s10549-015-3453-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 05/28/2015] [Indexed: 01/09/2023]
Abstract
The goal of this study was to compare the efficacy and toxicity of chemotherapy to exemestane plus everolimus (EXE/EVE) through a network meta-analysis (NMA) of randomized controlled trials. NMA methods extend standard pairwise meta-analysis to allow simultaneous comparison of multiple treatments while maintaining randomization of individual studies. The method enables "direct" evidence (i.e., evidence from studies directly comparing two interventions) and "indirect" evidence (i.e., evidence from studies that do not compare the two interventions directly) to be pooled under the assumption of evidence consistency. We used NMA to evaluate progression-free survival (PFS) and time to progression (TTP) curves in 34 studies, and response rate (RR) and the hazard ratios (HRs) of the PFS/TTP in 36 studies. A number needed to treat (NNT) analysis was also performed as well as descriptive comparison of reported toxicities. The NMA for PFS/TTP curves and for HR shows EXE/EVE is more efficacious than capecitabine plus sunitinib, CMF, megestrol acetate and tamoxifen, with an average of related-PFS/TTP difference ranging from about 10 months for capecitabine plus sunitinib to more than 6 months for tamoxifen. The NMA for overall RR shows that EXE/EVE provides a better RR than bevacizumab plus capecitabine, capecitabine, capecitabine plus sorafenib, capecitabine plus sunitinib, CMF, gemcitabine plus epirubicin plus paclitaxel, EVE plus tamoxifen, EXE, FEC, megestrol acetate, mitoxantrone, and tamoxifen. Finally, the NMA for NNT shows that EXE/EVE is more beneficial as compared to BMF, capecitabine, capecitabine plus sunitinib, CMF, FEC, megestrol acetate, mitoxantrone, and tamoxifen. The combination of EXE/EVE as first- or second-line therapy for ER+ve/HER2-ve metastatic breast cancer is more efficacious than several chemotherapy regimens that were reported in the literature. Toxicities also favored EXE/EVE in most instances.
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Affiliation(s)
- Daniele Generali
- U.O. di Patologia Mammaria-Breast Cancer Unit, U.S. Terapia Molecolare e Farmacogenomica, AO-Istituti Ospitalieri di Cremona, Viale Concordia 1, 26100, Cremona, Italy.
| | - Sergio Venturini
- Centre for Research on Health and Social Care Management (CeRGAS), Bocconi University, Via Roentgen 1, Milan, Italy
| | - Carla Rognoni
- Centre for Research on Health and Social Care Management (CeRGAS), Bocconi University, Via Roentgen 1, Milan, Italy
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management (CeRGAS), Bocconi University, Via Roentgen 1, Milan, Italy
| | - Lajos Pusztai
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, United States
| | - Sherene Loi
- Translational Breast Cancer Genomics and Therapeutics Lab, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Guy Jerusalem
- Centre Hospitalier Universitaire du Sart Tilman Liege and Liege University, Liège, Belgium
| | - Alberto Bottini
- U.O. di Patologia Mammaria-Breast Cancer Unit, U.S. Terapia Molecolare e Farmacogenomica, AO-Istituti Ospitalieri di Cremona, Viale Concordia 1, 26100, Cremona, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CeRGAS), Bocconi University, Via Roentgen 1, Milan, Italy.,Department of Policy Analysis and Public Management, Bocconi University, Via Roentgen 1, Milan, Italy
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12
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Zhu SS, Zhang YS, Sheng XH, Xu M, Wu SS, Shen YM, Huang YJ, Wang Y, Shi YQ. Deacetyl-mycoepoxydiene, isolated from plant endophytic fungi Phomosis sp. demonstrates anti-microtubule activity in MCF-7 cells. Biomed Pharmacother 2015; 69:82-9. [DOI: 10.1016/j.biopha.2014.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/12/2014] [Indexed: 10/24/2022] Open
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13
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Yoo C, Kim SB, Ahn JH, Kim JE, Jung KH, Gong GY, Son BH, Ahn SH, Ahn SD, Kim HH, Shin HJ, Kim WK. A Randomized Phase II Trial of Capecitabine Plus Vinorelbine Followed by Docetaxel Versus Adriamycin Plus Cyclophosphamide Followed by Docetaxel as Neoadjuvant Chemotherapy for Breast Cancer. Cancer Res Treat 2014; 47:406-15. [PMID: 25648092 PMCID: PMC4506113 DOI: 10.4143/crt.2014.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 05/22/2014] [Indexed: 11/21/2022] Open
Abstract
Purpose Given the promising activity of capecitabine and vinorelbine in metastatic breast cancer, this randomized phase II trial evaluated the efficacy and safety of this combination as neoadjuvant chemotherapy in breast cancer. Materials and Methods Patients with operable breast cancer (n=75) were randomly assigned to receive either four cycles of adriamycin 60 mg/m2 plus cyclophosphamide 600 mg/m2 every 3 weeks followed by four cycles of docetaxel 75 mg/m2 every 3 weeks (AC-D) or four cycles of capecitabine 2,000 mg/m2 (day 1-14) plus vinorelbine 25 mg/m2 (days 1 and 8) every 3 weeks followed by four cycles of docetaxel 75 mg/m2 (CV-D). The primary endpoint was pathologic complete response (pCR) in the primary breast (ypT0/is). Results Most patients (84%) had locally advanced (n=41) or inflammatory breast cancer (n=22). pCR rates in the primary breast were 15% (95% confidence interval [CI], 7% to 30%) and 11% (95% CI, 4% to 26%) in the AC-D and CV-D groups, respectively. The overall response rates and 5-year progression-free survival rates in the AC-D and CV-D groups were 62% and 64%, and 51.3% (95% CI, 34.6% to 68.0%) and 30.2% (95% CI, 13.3% to 47.1%), respectively. Although both regimens were well tolerated, CV-D showed less frequent grade 3-4 neutropenia and vomiting than AC-D, whereas manageable diarrhea and hand-foot syndrome were more common in the CV-D group. Conclusion CV-D is a feasible and active non-anthracycline–based neoadjuvant chemotherapy regimen for breast cancer.
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Affiliation(s)
- Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Bae Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Hee Ahn
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyung-Yub Gong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung-Ho Son
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sei-Hyun Ahn
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hak-Hee Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Jung Shin
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Kun Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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14
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Choi BH, Chattopadhaya S, Thanh LN, Feng L, Nguyen QT, Lim CB, Harikishore A, Nanga RPR, Bharatham N, Zhao Y, Liu X, Yoon HS. Suprafenacine, an indazole-hydrazide agent, targets cancer cells through microtubule destabilization. PLoS One 2014; 9:e110955. [PMID: 25354194 PMCID: PMC4212991 DOI: 10.1371/journal.pone.0110955] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 09/26/2014] [Indexed: 12/11/2022] Open
Abstract
Microtubules are a highly validated target in cancer therapy. However, the clinical development of tubulin binding agents (TBA) has been hampered by toxicity and chemoresistance issues and has necessitated the search for new TBAs. Here, we report the identification of a novel cell permeable, tubulin-destabilizing molecule - 4,5,6,7-tetrahydro-1H-indazole-3-carboxylic acid [1p-tolyl-meth-(E)-ylidene]-hydrazide (termed as Suprafenacine, SRF). SRF, identified by in silico screening of annotated chemical libraries, was shown to bind microtubules at the colchicine-binding site and inhibit polymerization. This led to G2/M cell cycle arrest and cell death via a mitochondria-mediated apoptotic pathway. Cell death was preceded by loss of mitochondrial membrane potential, JNK - mediated phosphorylation of Bcl-2 and Bad, and activation of caspase-3. Intriguingly, SRF was found to selectively inhibit cancer cell proliferation and was effective against drug-resistant cancer cells by virtue of its ability to bypass the multidrug resistance transporter P-glycoprotein. Taken together, our results suggest that SRF has potential as a chemotherapeutic agent for cancer treatment and provides an alternate scaffold for the development of improved anti-cancer agents.
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Affiliation(s)
- Bo-Hwa Choi
- Division of Structural Biology and Biochemistry, School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Souvik Chattopadhaya
- Division of Structural Biology and Biochemistry, School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Le Nguyen Thanh
- Division of Chemistry and Biological Chemistry, School of Physical & Mathematical Sciences, Nanyang Technological University, Singapore, Singapore
| | - Lin Feng
- Division of Structural Biology and Biochemistry, School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Quoc Toan Nguyen
- Division of Structural Biology and Biochemistry, School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Chuan Bian Lim
- Division of Structural Biology and Biochemistry, School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Amaravadhi Harikishore
- Division of Structural Biology and Biochemistry, School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Ravi Prakash Reddy Nanga
- Division of Structural Biology and Biochemistry, School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Nagakumar Bharatham
- Division of Structural Biology and Biochemistry, School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Yan Zhao
- Division of Structural Biology and Biochemistry, School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Xuewei Liu
- Division of Chemistry and Biological Chemistry, School of Physical & Mathematical Sciences, Nanyang Technological University, Singapore, Singapore
| | - Ho Sup Yoon
- Division of Structural Biology and Biochemistry, School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
- Department of Genetic Engineering, College of Life Sciences, Kyung Hee University, Yongin-si, Gyeonggi-do, Republic of Korea
- * E-mail:
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15
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Park JS, Jeung HC, Rha SY, Ahn JB, Kang B, Chon HJ, Hong MH, Lim S, Yang WI, Nam CM, Chung HC. Phase II gemcitabine and capecitabine combination therapy in recurrent or metastatic breast cancer patients pretreated with anthracycline and taxane. Cancer Chemother Pharmacol 2014; 74:799-808. [DOI: 10.1007/s00280-014-2551-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 07/25/2014] [Indexed: 11/27/2022]
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16
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Zhu C, Zuo Y, Wang R, Liang B, Yue X, Wen G, Shang N, Huang L, Chen Y, Du J, Bu X. Discovery of Potent Cytotoxic Ortho-Aryl Chalcones as New Scaffold Targeting Tubulin and Mitosis with Affinity-Based Fluorescence. J Med Chem 2014; 57:6364-82. [DOI: 10.1021/jm500024v] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Cuige Zhu
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
| | - Yinglin Zuo
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
| | - Ruimin Wang
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
| | - Baoxia Liang
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
| | - Xin Yue
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
| | - Gesi Wen
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
| | - Nana Shang
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
| | - Lei Huang
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
| | - Yu Chen
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
| | - Jun Du
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
| | - Xianzhang Bu
- School of Pharmaceutical
Sciences, Sun Yat-Sen University, Guangzhou 510006, China
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17
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Martinelli F, Quinten C, Maringwa JT, Coens C, Vercauteren J, Cleeland CS, Flechtner H, Gotay C, Greimel E, King M, Mendoza T, Osoba D, Reeve BB, Ringash J, Koch JSV, Shi Q, Taphoorn MJ, Weis J, Bottomley A. Examining the relationships among health-related quality-of-life indicators in cancer patients participating in clinical trials: a pooled study of baseline EORTC QLQ-C30 data. Expert Rev Pharmacoecon Outcomes Res 2014; 11:587-99. [DOI: 10.1586/erp.11.51] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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18
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Hristodorov D, Nordlohne J, Mladenov R, Huhn M, Fischer R, Thepen T, Barth S. Human microtubule-associated protein tau mediates targeted killing of CD30(+) lymphoma cells in vitro and inhibits tumour growth in vivo. Br J Haematol 2013; 164:251-7. [PMID: 24164493 DOI: 10.1111/bjh.12626] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 09/18/2013] [Indexed: 11/28/2022]
Abstract
Hodgkin lymphoma (HL) and systemic anaplastic large cell lymphoma (sALCL) are rare lymphoproliferative cancer types. Although most HL patients can be cured by chemo- and radio-therapy, 4-50% of patients relapse and have a poor prognosis. The need for improved therapeutic options for patients with relapsed or refractory disease has been addressed by CD30-specific antibody-based immunotherapeutics. However, available CD30-specific monoclonal antibodies (mAbs), antibody drug conjugates (ADCs) or chimeric immunotoxins suffer from the requirement of a functional host immunity, undesirable immune reactions or heterogeneity and instability, respectively. Here, we present a new fusion protein comprised of the CD30-specific antibody single-chain fragment Ki4(scFv) and the human pro-apoptotic effector protein, microtubule-associated protein tau (MAPT). Ki4(scFv)-MAP selectively induced apoptosis in rapidly proliferating L540cy, L428, and Karpas 299 cells in a dose-dependent manner. Tubulin polymerization assays confirmed that Ki4(scFv)-MAP stabilizes microtubules, suggesting a mechanism for its pro-apoptotic action. Dose-finding experiments proved that Ki4(scFv)-MAP is well tolerated in mice compared to the previously reported Ki4(scFv)-ETA'. Ki4(scFv)-MAP significantly inhibited growth of subcutaneous L540cy xenograft tumours in mice. Our data present a novel approach for the treatment of CD30(+) lymphomas, combining the binding specificity of a target-specific antibody fragment with the selective cytotoxicity of MAPT towards proliferating lymphoma cells.
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Affiliation(s)
- Dmitrij Hristodorov
- Department of Experimental Medicine and Immunotherapy, Institute of Applied Medical Engineering, University Hospital RWTH Aachen, Aachen, Germany
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19
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Alotaibi MR, Asnake B, Di X, Beckman MJ, Durrant D, Simoni D, Baruchello R, Lee RM, Schwartz EL, Gewirtz DA. Stilbene 5c, a microtubule poison with vascular disrupting properties that induces multiple modes of growth arrest and cell death. Biochem Pharmacol 2013; 86:1688-98. [PMID: 24144631 DOI: 10.1016/j.bcp.2013.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 10/07/2013] [Accepted: 10/08/2013] [Indexed: 12/19/2022]
Abstract
The stilbene derivative, cis-3,4',5-trimethoxy-3'-aminostilbene (stilbene 5c), is a potentially potent antitumor agent that acts via binding to the colchicine-binding site in tubulin. The current studies were designed to investigate the effectiveness of stilbene 5c against the HCT-116 human colon cancer cell line and B16/F10 melanoma cells as well as human endothelial cell tube formation and tumor perfusion. Stilbene 5c produced a time-dependent decrease in cell viability in both cell lines and the capacity of the cells to proliferate was not restored upon removal of the drug. Treatment with stilbene 5c also promoted both senescence and autophagy in both cell lines. TUNEL and annexin 5 staining indicated that apoptosis also occurs in stilbene 5c-treated HCT-116 cells, but not in B16/F10 melanoma cells. DAPI staining revealed morphological changes in the cell nuclei (binucleated and micronucleated cells) indicative of mitotic catastrophe in HCT-116 cells but not in the B16/F10 melanoma cells. p53-null HCT-116 cells demonstrated a similar growth arrest/cell death response to stilbene as p53-wild type HCT-116 cells. Stilbene 5c also completely inhibited human endothelial cell tube formation on Matrigel, consistent with potential anti-angiogenic actions. Using a new method developed for monitoring the pharmacodynamic effects of stilbene 5c in vivo, we found that a single injection of stilbene 5c reduced tumor perfusion by 65% at 4h, returning to baseline by 24h, while subsequent daily injections of stilbene 5c produced progressively larger reductions and smaller rebounds. This work indicates that stilbene 5c could potentially be effective against melanoma and colon cancer through the promotion of multiple modes of growth arrest and cell death coupled with anti-angiogenic and antivascular actions.
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Affiliation(s)
- M R Alotaibi
- Departments of Pharmacology and Toxicology and Medicine and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298, USA
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Microtubule-associated protein tau facilitates the targeted killing of proliferating cancer cells in vitro and in a xenograft mouse tumour model in vivo. Br J Cancer 2013; 109:1570-8. [PMID: 23942071 PMCID: PMC3776980 DOI: 10.1038/bjc.2013.457] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/18/2013] [Accepted: 07/22/2013] [Indexed: 01/01/2023] Open
Abstract
Background: Antibody drug conjugates (ADCs) and immunotoxins (ITs) are promising anticancer immunotherapeutics. Despite their encouraging performance in clinical trials, both ADCs and ITs often suffer from disadvantages such as stoichiometrically undefined chemical linkage of the cytotoxic payload (ADCs) and the potential immunogenicity of toxins derived from bacteria and plants (ITs). Methods: Human microtubule-associated protein tau (MAP) was cloned in-frame with human EGF, expressed in E. coli and purified by standard chromatographic methods. The in vitro activity was confirmed by flow cytometry, cell viability assays and tubulin polymerisation assay. The in vivo efficacy was demonstrated using noninvasive far-red in vivo imaging. Results: The EGF-MAP selectively induced apoptosis in EGFR-overexpressing proliferating cancer cells through stabilisation of microtubules. Nonproliferating cells were not affected, demonstrating superior selectivity of EGF-MAP for cancer cells. The EGF-MAP was well tolerated at high doses in mice compared with the ETA'-based control. The in vivo efficacy of EGF-MAP was demonstrated in a tumour xenograft mouse model. Conclusion: Our data indicate the general mechanism of action for a new class of human immunotherapeutic reagents suitable for the treatment of cancer. This approach combines the binding specificity of targeting ligands with the selective cytotoxicity of MAP towards proliferating cells.
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21
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Mansour M, Mourad C. Phase II study of single agent oral vinorelbine as first-line treatment in patients with HER-2 negative metastatic breast cancer. Cancer Chemother Pharmacol 2013; 72:429-35. [PMID: 23801283 DOI: 10.1007/s00280-013-2216-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/13/2013] [Indexed: 01/22/2023]
Abstract
PURPOSE Previous studies indicated that oral chemotherapy is convenient and preferred by many patients. We hereby report the efficacy and safety of oral vinorelbine as first-line chemotherapy for metastatic breast cancer (MBC). METHODS Thirty-one patients with HER-2 negative MBC were enrolled between January 2007 and December 2010 in a prospective phase II trial. Patients were treated every 3 weeks with oral vinorelbine 60 mg/m² Days 1 and 8 for the 1st cycle and thereafter 80 mg/m² Days 1 and 8 every 3 weeks. Treatment was administered until disease progression or unexpected adverse event or patient refusal to continue. Primary endpoint was objective response rate (ORR); secondary endpoints were time-to-progression (TTP), overall survival (OS) and safety. Follow-up results until October 2012 are reported. RESULTS Median age was 42 years (range 33-75). 26 (84 %) patients had 2 or more metastatic sites. A median of 6 cycles were administered (range 2-20). ORR was achieved in 9 (29 %) patients including 1 complete and 8 partial responses. 12 (39 %) patients had stable disease, resulting in a disease control rate of 68 %. Median TTP was 5.2 months [95 % CI 2.8-7.5]. Median OS was 16 months [95 % CI 11.3-20.7]. 3 (10 %) patients developed Grade 3-4 neutropenia. No events of febrile neutropenia, cardiac, renal toxicities or alopecia were recorded. Grade 3 thrombocytopenia and nausea-vomiting were reported in 2 (6 %) and 5 (16 %) patients, respectively. CONCLUSION Results show a good efficacy and tolerance profile of oral vinorelbine as first-line chemotherapy for HER-2 negative MBC patients.
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Affiliation(s)
- Maged Mansour
- Clinical Oncology and Nuclear Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
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22
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Xu YC, Wang HX, Tang L, Ma Y, Zhang FC. A systematic review of vinorelbine for the treatment of breast cancer. Breast J 2013; 19:180-8. [PMID: 23320984 DOI: 10.1111/tbj.12071] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to investigate the efficacy and safety profile of vinorelbine-based chemotherapy in different settings for the treatment of breast cancer. We performed a computerized search using combinations of the following keywords: "breast cancer", "breast neoplasms", "trial", "vinorelbine" and "navelbine". A total of 20 trials were included in this analysis, with a total of 5,080 patients accrued. Taxane was associated with enhanced overall survival (OS; p = 0.027) and response rate (RR; p = 0.037) as compared with vinorelbine in monotherapy, but did not show significantly favored progression-free survival (PFS; p = 0.136). Vinorelbine alone was equivalent to fluoropyrimidine treatment in RR (p = 0.79) for the treatment of metastatic breast cancer. For vinorelbine-combined regimens, the analysis showed that the vinorelbine group gave similar results as other regimens for OS (p = 0.849) and PFS (p = 0.143). The RR of vinorelbine-combined regimens was slightly better than that of the other regimens (OR, 1.17), but the difference was not statistically significant. In neoadjuvant setting, vinorelbine treatment was as active as AC (doxorubicin, cyclophosphamide) or DAC (doxorubicin, cyclophosphamide, docetaxel) regimens with respect to RR (p = 0.76) and pathologic complete response (pCR; p = 0.77), but showed lower occurrence of grade 3/4 adverse effects. The analysis also demonstrated that vinorelbine-containing therapy is effective as adjuvant, front-line or salvage therapy of metastatic breast cancer, even for patients who were previously treated with anthracyclines or taxanes.
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Affiliation(s)
- Ying-Chun Xu
- Department of Oncology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, China
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Wang Y, Yang H, Wei JF, Meng L. Efficacy and toxicity of capecitabine-based chemotherapy in patients with metastatic or advanced breast cancer: results from ten randomized trials. Curr Med Res Opin 2012; 28:1911-9. [PMID: 23145857 DOI: 10.1185/03007995.2012.748655] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The efficacy and adverse effects of capecitabine-based chemotherapy versus other regimens reported in previous trials were discordant. The aim of the present study was to determine the efficacy and toxicity profiles of capecitabine-based chemotherapy versus capecitabine-free regimens in patients with metastatic and/or advanced breast cancer. METHODS Randomized trials in which capecitabine-based chemotherapy was compared with capecitabine-free chemotherapy were included by searching the PubMed database. Differences in efficacy and grade 3-4 toxicities between capecitabine-based chemotherapy and other chemotherapy were compared. RESULTS Ten randomized controlled trials were included in our meta-analysis. Compared to patients treated with capecitabine-free chemotherapy, patients treated with capecitabine-based chemotherapy did not have a significantly different complete response (odds ratio (OR): 1.25, 95% confidence interval (CI): 0.87-1.79, p = 0.231), partial response (OR: 1.16, 95% CI: 0.95-1.41, p = 0.147), and overall response (OR: 1.21, 95% CI: 1.00-1.47, p = 0.053). Compared to the capecitabine-free group, less hematological toxicity and more gastrointestinal toxicity occurred in patients treated with capecitabine-based chemotherapy, including neutropenia (OR: 0.34, 95% CI: 0.19-0.59, p <0.001), anemia (OR: 0.41, 95% CI: 0.20-0.85, p = 0.016), leukocytopenia (OR: 0.50, 95% CI: 0.32-0.78, p = 0.002), and diarrhea (OR: 2.35, 95% CI: 1.62-3.42, p < 0.001). Furthermore, patients in the capecitabine group exhibited a significantly higher rate of grade 3 hand-foot syndrome than the capecitabine-free group (OR: 25.16, 95% CI: 12.27-51.58, p < 0.001). CONCLUSIONS The present study suggests that capecitabine-based chemotherapy is as effective as capecitabine-free chemotherapy in patients with metastatic and/or advanced breast cancer with different toxicity profiles. Capecitabine-based chemotherapy may be better tolerated than capecitabine-free chemotherapy. Due to several limitations in our study, future large randomized trials are needed.
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Affiliation(s)
- Yongqing Wang
- Research Division of Clinical Pharmacology, the First Affiliated Hospital, Nanjing Medical University, Nanjing, China
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Structure of the α-tubulin acetyltransferase, αTAT1, and implications for tubulin-specific acetylation. Proc Natl Acad Sci U S A 2012; 109:19655-60. [PMID: 23071314 DOI: 10.1073/pnas.1209357109] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Protein acetylation is an important posttranslational modification with the recent identification of new substrates and enzymes, new links to disease, and modulators of protein acetylation for therapy. α-Tubulin acetyltransferase (αTAT1) is the major α-tubulin lysine-40 (K40) acetyltransferase in mammals, nematodes, and protozoa, and its activity plays a conserved role in several microtubule-based processes. Here, we present the X-ray crystal structure of the human αTAT1/acetyl-CoA complex. Together with structure-based mutagenesis, enzymatic analysis, and functional studies in cells, we elucidate the catalytic mechanism and mode of tubulin-specific acetylation. We find that αTAT1 has an overall fold similar to the Gcn5 histone acetyltransferase but contains a relatively wide substrate binding groove and unique structural elements that play important roles in α-tubulin-specific acetylation. Conserved aspartic acid and cysteine residues play important catalytic roles through a ternary complex mechanism. αTAT1 mutations have analogous effects on tubulin acetylation in vitro and in cells, demonstrating that it is the central determining factor of α-tubulin K40 acetylation levels in vivo. Together, these studies provide general insights into distinguishing features between histone and tubulin acetyltransferases, and they have specific implications for understanding the molecular basis of tubulin acetylation and for developing small molecule modulators of microtubule acetylation for therapy.
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Hsieh YJ, Yang MY, Leu YL, Chen C, Wan CF, Chang MY, Chang CJ. Kalanchoe tubiflora extract inhibits cell proliferation by affecting the mitotic apparatus. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2012; 12:149. [PMID: 22963191 PMCID: PMC3557174 DOI: 10.1186/1472-6882-12-149] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 08/31/2012] [Indexed: 01/15/2023]
Abstract
Background Kalanchoe tubiflora (KT) is a succulent plant native to Madagascar, and is commonly used as a medicinal agent in Southern Brazil. The underlying mechanisms of tumor suppression are largely unexplored. Methods Cell viability and wound-healing were analyzed by MTT assay and scratch assay respectively. Cell cycle profiles were analyzed by FACS. Mitotic defects were analyzed by indirect immunofluoresence images. Results An n-Butanol-soluble fraction of KT (KT-NB) was able to inhibit cell proliferation. After a 48 h treatment with 6.75 μg/ml of KT, the cell viability was less than 50% of controls, and was further reduced to less than 10% at higher concentrations. KT-NB also induced an accumulation of cells in the G2/M phase of the cell cycle as well as an increased level of cells in the subG1 phase. Instead of disrupting the microtubule network of interphase cells, KT-NB reduced cell viability by inducing multipolar spindles and defects in chromosome alignment. KT-NB inhibits cell proliferation and reduces cell viability by two mechanisms that are exclusively involved with cell division: first by inducing multipolarity; second by disrupting chromosome alignment during metaphase. Conclusion KT-NB reduced cell viability by exclusively affecting formation of the proper structure of the mitotic apparatus. This is the main idea of the new generation of anti-mitotic agents. All together, KT-NB has sufficient potential to warrant further investigation as a potential new anticancer agent candidate.
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Aapro M, Finek J. Oral vinorelbine in metastatic breast cancer: A review of current clinical trial results. Cancer Treat Rev 2012; 38:120-6. [DOI: 10.1016/j.ctrv.2011.05.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/12/2011] [Accepted: 05/24/2011] [Indexed: 11/24/2022]
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Intravenous or Oral Vinorelbine Plus Capecitabine As First-Line Treatment in HER2– Metastatic Breast Cancer: Joint Analysis of 2 Consecutive Prospective Phase II Trials. Clin Breast Cancer 2012; 12:30-9. [DOI: 10.1016/j.clbc.2011.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Revised: 11/10/2011] [Accepted: 11/10/2011] [Indexed: 02/08/2023]
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Abstract
Microtubules are dynamic filamentous cytoskeletal proteins that are an important therapeutic target in patients with tumors. Microtubule binding agents have been part of the pharmacopoeia of cancer for decades, and until the advent of targeted therapy microtubules represented the only alternative to DNA as a therapeutic target in cancer. There are currently a variety of available vinca alkaloids and taxanes and other agents, such as ixabepilone and eribulin, have also been approved. Maytansinoids have been used for the production of immunoconjugates, monoclonal antibodies covalently bound to antimitotic molecules. The screening of a variety of botanical species and marine organisms continues to yield promising new antitubulin agents with novel properties. Enhanced tumor specificity, reduced neurotoxicity, and insensitivity to chemoresistance mechanisms are the three main objectives in the current search for novel microtubule binding agents.
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Oostendorp LJM, Stalmeier PFM, Donders ART, van der Graaf WTA, Ottevanger PB. Efficacy and safety of palliative chemotherapy for patients with advanced breast cancer pretreated with anthracyclines and taxanes: a systematic review. Lancet Oncol 2011; 12:1053-61. [PMID: 21621462 DOI: 10.1016/s1470-2045(11)70045-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
No standard monotherapy or combination palliative chemotherapy currently exists for patients with advanced breast cancer pretreated with anthracyclines and taxanes. In this systematic review we assess the current knowledge on the efficacy and safety of palliative single-agent chemotherapy drugs--capecitabine, vinorelbine, gemcitabine, and liposomal doxorubicin--commonly used in daily clinical practice. We identified 22 studies, of which ten investigated capecitabine, nine investigated vinorelbine, three investigated gemcitabine, and one investigated liposomal doxorubicin. The greatest amount of information was available for capecitabine and vinorelbine. These two drugs showed good efficacy. The disease control rate differed significantly between the four drugs, which is relevant in terms of how well tumour symptoms can be improved and whether quality of life can be maintained or even improved. To obtain more evidence of the efficacy and safety of chemotherapeutic agents used in this pretreated population of advanced breast cancer patients, randomised comparisons of the various drugs, as monotherapy and in combination with targeted agents, are needed.
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Affiliation(s)
- Linda J M Oostendorp
- Department of Epidemiology, Biostatistics, HTA, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
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Debled M, Madranges N, Mertens C, Durand M, Brouste V, Brain E, Mauriac L. First-line chemotherapy for metastatic breast cancer in patients ≥75 years: a retrospective single-centre analysis. Crit Rev Oncol Hematol 2010; 80:171-9. [PMID: 21036058 DOI: 10.1016/j.critrevonc.2010.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 09/02/2010] [Accepted: 10/01/2010] [Indexed: 10/18/2022] Open
Abstract
Data on chemotherapy for elderly patients with metastatic breast carcinoma (MBC) are limited. We performed a 7-year retrospective analysis of MBC patients at our institution receiving first-line chemotherapy aged ≥75 years. Of 117 patients, 103 received monotherapy (67 capecitabine, 29 vinorelbine, 5 docetaxel, 2 liposomal doxorubicin) and 14 received polychemotherapy (12 anthracycline-based, 2 vinorelbine-gemcitabine). Chemotherapy demonstrated acceptable tolerability. Median progression-free survival (PFS) and overall survival (OS) from initiation of chemotherapy were 6.2 months and 13.8 months, respectively. At 2 years, 25% of patients were alive; however, 25% died within 3 months of beginning chemotherapy. Independent prognostic factors for longer PFS were good performance status, absence of visceral disease and capecitabine treatment. Good performance status and lack of visceral disease were also significant for OS. These results suggest that palliative chemotherapy should not be systematically excluded in this setting, but should be carefully discussed as it appears to be feasible with apparent benefit in selected patients.
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Affiliation(s)
- Marc Debled
- Institut Bergonié, South-West Comprehensive Cancer Center, Bordeaux, France.
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Abstract
Microtubules are dynamic filamentous cytoskeletal proteins composed of tubulin and are an important therapeutic target in tumour cells. Agents that bind to microtubules have been part of the pharmacopoeia of anticancer therapy for decades and until the advent of targeted therapy, microtubules were the only alternative to DNA as a therapeutic target in cancer. The screening of a range of botanical species and marine organisms has yielded promising new antitubulin agents with novel properties. In the current search for novel microtubule-binding agents, enhanced tumour specificity, reduced neurotoxicity and insensitivity to chemoresistance mechanisms are the three main objectives.
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Affiliation(s)
- Charles Dumontet
- INSERM 590, Faculté Rockefeller, 8 Avenue Rockefeller, 69008 Lyon, France and Université Lyon 1, ISPB, Lyon, F-69003, France.
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Abstract
With more and more breast cancer (BC) patients receiving taxanes and anthracyclines in the adjuvant setting, the number of patients resistant to these drugs is rising. Herein, we review cellular mechanisms (e.g., overexpression of drug efflux pumps) that are associated with clinical anthracycline and/or taxane-resistant BC. We also discuss therapeutic approaches that have received Food and Drug Administration approval in this setting or are in clinical development, including targeted agents that do not employ a cytotoxic mechanism, as well as novel chemotherapeutics such as the epothilones, a class of microtubule stabilizers less susceptible to common cellular resistance mechanisms.
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Affiliation(s)
- Amelia Zelnak
- Department of Hematology and Oncology, Emory University Winship Cancer Institute, Atlanta, Georgia 30322, USA.
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Petrelli F, Barni S. Oral vinorelbine: its role in advanced breast cancer pre-treated with anthracycline and taxane chemotherapies. Oncol Rev 2010. [DOI: 10.1007/s12156-010-0038-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Oliva C, Bergnolo P, Inguì M, Bianco L, Pochettino P, Cutin SC, Boglione A, Dal Canton O, Garetto F, Comandone A. Vinorelbine and fluorouracil plus leucovorin combination (ViFL) in patients with anthracycline and taxane-pretreated metastatic breast cancer: a phase II study. J Cancer Res Clin Oncol 2009; 136:411-7. [PMID: 19727815 DOI: 10.1007/s00432-009-0671-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Accepted: 08/17/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE This phase II study was designed in order to evaluate efficacy and safety of the combination of vinorelbine (VNB), fluorouracil (FU) and leucovorin (LV) in patients with metastatic breast carcinoma (MBC) previously treated with anthracyclines and taxanes. METHODS From 12/2003 to 12/2007, 51 women (median age 59) were treated. Performance status (PS) (ECOG) was 0-2 (median 0). The chemotherapy consisted of VNB 25 mg/sqm on day 1 added to FU and LV (following De Gramont schedule) on day 1 and 2. Treatment was repeated every 14 days. 518 cycles of CT were administered (median 12). Most common sites of metastatic spread were: bone, liver, lymph nodes, lung. RESULTS We recorded three cases of G4 neuthropenia and in one case it was febrile; no others G4 toxicities were seen. G3 toxicities were more common, especially neuthropenia (8 patients) asthenia (4) mucositis (2) and Hand-Foot Syndrome (2). Overall response rate was 27.5% (14 patients had a PR) and disease control rate was 76.5%; 12 patients experienced disease progression. Median time to progression (TTP) was 7.70 months and overall survival (OS) was 18.70 months. CONCLUSIONS Results demonstrate that the ViFL regimen has substantial activity in patients with MBC already treated with anthracyclines and taxanes. The combination may be considered a valid choice for the treatment of MBC. Better survival results were seen in patients with visceral metastases than bone involvement. The low response rate shows that the ViFL regimen is not suitable for the neoadjuvant setting.
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Affiliation(s)
- Cristiano Oliva
- Department of Medical Oncology, Presidio Sanitario Gradenigo, Corso Regina Margherita 8, 10153, Torino, Italy.
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Chan A, Verrill M. Capecitabine and vinorelbine in metastatic breast cancer. Eur J Cancer 2009; 45:2253-65. [DOI: 10.1016/j.ejca.2009.04.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 04/21/2009] [Accepted: 04/24/2009] [Indexed: 10/20/2022]
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A Phase II trial of the combination of vinorelbine and capecitabine as second-line treatment in metastatic breast cancer previously treated with taxanes and/or anthracyclines. J Cancer Res Clin Oncol 2009; 136:115-21. [DOI: 10.1007/s00432-009-0642-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 06/25/2009] [Indexed: 10/20/2022]
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CHOW LWC, IM YH. Current treatment of locally advanced and metastatic breast cancer in the Asia-Pacific region: Challenges and limitations. Asia Pac J Clin Oncol 2008. [DOI: 10.1111/j.1743-7563.2008.00195.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
As therapeutic options have multiplied, chemotherapy for metastatic breast cancer (MBC) has become increasingly complex. Furthermore, advances in the treatment of early-stage breast cancer, in particular the development of taxane-based regimens, have led to increased use of adjuvant chemotherapy. As a result, the decisions regarding the treatment of patients presenting with MBC have become more difficult, because many patients are likely to have received a variety of adjuvant chemotherapy regimens. The primary goal of treatment for MBC is palliation of disease--usually with prolongation of survival--with minimal toxicity. However, there is currently no "gold standard" in this setting, and the literature supports many choices for first- and second-line treatment. Other issues as yet unsettled in these patients are (1) whether to combine >or= 2 drugs or to use each drug alone until disease progression; (2) how to use novel targeted biologic agents; and (3) how to treat patients with HER2-overexpressing tumors after adjuvant treatment with trastuzumab. The role of taxanes, antimetabolites, and targeted agents in patients with MBC will be discussed in this review, particularly in the context of previous adjuvant therapy. The controversy surrounding the use of doublet or sequential therapy will also be discussed. Although considerable advances have been made toward answering these questions, many additional uncertainties have arisen, and further well-designed randomized studies are needed.
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