Experimental and clinical chemoteratogenesis

Comparative Genomics Identifies Putative Interspecies Mechanisms Underlying Crbn-Sall4-Linked Thalidomide Embryopathy

The identification of thalidomide–Cereblon-induced SALL4 degradation has brought new understanding for thalidomide embryopathy (TE) differences across species. Some questions, however, regarding species variability, still remain. The aim of this study was to detect sequence divergences between species, affected or not by TE, and to evaluate the regulated gene co-expression in a murine model. Here, we performed a comparative analysis of proteins experimentally established as affected by thalidomide exposure, evaluating 14 species. The comparative analysis, regarding synteny, neighborhood, and protein conservation, was performed in 42 selected genes. Differential co-expression analysis was performed, using a publicly available assay, GSE61306, which evaluated mouse embryonic stem cells (mESC) exposed to thalidomide. The comparative analyses evidenced 20 genes in the upstream neighborhood of NOS3, which are different between the species who develop, or not, the classic TE phenotype. Considering protein sequence alignments, RECQL4, SALL4, CDH5, KDR, and NOS2 proteins had the biggest number of variants reported in unaffected species. In co-expression analysis, Crbn was a gene identified as a driver of the co-expression of other genes implicated in genetic, non-teratogenic, limb reduction defects (LRD), such as Tbx5, Esco2, Recql4, and Sall4; Crbn and Sall4 were shown to have a moderate co-expression correlation, which is affected after thalidomide exposure. Hence, even though the classic TE phenotype is not identified in mice, a deregulatory Crbn-induced mechanism is suggested in this animal. Functional studies are necessary, especially evaluating the genes responsible for LRD syndromes and their interaction with thalidomide–Cereblon.

Establishment of a molecular embryonic stem cell developmental toxicity assay

The mouse embryonic stem cell test (EST) is a 10-day screen for teratogenic potential developed to reduce animal use for embryotoxicity testing of chemicals (Spielmann, 2005; Spielmann et al., 1997). In this study, we used the cytotoxicity IC(50) values and transcriptional expression changes as primary endpoints in a shorter 4-day version of the EST, the molecular embryonic stem cell assay. Mouse D3 embryonic stem cells were used for cytotoxicity assessment (monolayers) or grown as embryoid bodies in low attachment plates for transcriptional profiling. Sixty-five compounds with known in vivo teratogenicity (33 teratogens and 32 nonteratogens) were evaluated to develop a model for classifying compounds with teratogenic potential. The expression of 12 developmentally regulated gene targets (nanog, fgf5, gsc, cd34, axin2, apln, chst7, lhx1, fgf8, sox17, foxa2, and cxcr4) was measured following exposure of embryoid bodies to a single compound concentration (0.1 × the cytotoxicity IC(20)) for 4 days. In the decision-tree model, compounds with IC(50) values < 22 µM were categorized as teratogens, whereas compounds in the two groups with IC(50) values between 22-200 µM and > 200 µM were categorized as teratogens if ≥ 8 and 12 genes, respectively, were deregulated by at least 10%. Forty-seven of 65 compounds of the training set were correctly identified (72% total concordance). In a test set of 12 additional compounds (5 teratogens, 7 nonteratogens), 10 were correctly classified by this approach (83% concordance). The false positive rate in the training and test sets was 24 and 0%, respectively, indicating that this assay has potential to identify teratogens.

Embryo–fetal toxicity signals for 17α-hydroxyprogesterone caproate in high-risk pregnancies: A review of the non-clinical literature for embryo–fetal toxicity with progestins

OBJECTIVE

A large National Institutes of Health (NIH) study showed that pharmacy-compounded 17alpha-hydroxyprogesterone caproate (17-OHP-C) reduced the incidence of preterm birth. The study results included a signal that 17-OHP-C may be associated with an increase in the rate of miscarriages and stillbirths. The most probable cause of an increased incidence of miscarriage/stillbirths may be the use of 17-OHP-C in high-risk patients. The current search of the non-clinical literature was performed to identify whether there were any signals from studies in animals that might suggest concerns for the safe use of progestins generally, and 17-OHP-C specifically, in the prevention of preterm birth in humans.

METHODS

An extensive literature search was performed for progesterone, 17-hydroxyprogesterone, and 17-OHP-C, using Medline and Toxline databases, textbooks, and then the obtained publications. Because 17-OHP-C does not have a standardized clinical formulation or optimal route of administration identified, all formulations, vehicles, routes and doses were included in the search, as well as treatment during any stage of pregnancy. All publications obtained were reviewed for relevancy; those in German, French, Italian or Russian were translated.

RESULTS

None of the relevant non-clinical studies conducted in mice, rats, rabbits, guinea pigs, horses or non-human primates met current standards for determining reproductive and developmental effects as part of the process of drug development. Most studies focused on the potential of 17-OHP-C for teratogenicity. Many studies used supra-pharmacologic and/or high multiples of human exposure in their study design. Overall, 17-OHP-C was consistently shown to be less potent than progesterone, and neither progesterone nor 17-OHP-C consistently adversely affected maternal weight, embryo-fetal viability or caused malformations. One study in rhesus monkeys raises concerns because resorption/abortion occurred at the human equivalent dose of 17-OHP-C, 10 mg/kg; this finding did not occur in cynomolgus monkeys. The absence of information regarding the serum levels of both progesterone and 17-OHP-C in the animal studies and in humans, as well as presumed inter-species metabolic differences, make it difficult to conclude that the findings with 17-OHP-C in rhesus monkeys and the signal in the NIH trial are related. A few studies in rats raised questions regarding potential effects on postnatal development, but in the absence of better study designs, the relevancy of these findings to human risk are also questionable at best.

CONCLUSION

There is a signal for embryo-fetal toxicity associated with 17-OHP-C in the two largest clinical trials conducted to date; there is also a signal for embryo-fetal toxicity with 17-OHP-C in rhesus monkeys and possibly one in rodent species. The relationship between these signals is unclear given the absence of state-of-the-art reproductive toxicology studies and human pharmacokinetic studies.

Conflicting priorities in surgical intervention for cancer in pregnancy

Cancer in pregnancy is uncommon, with an incidence of about one to two cases in every 1000 pregnancies. There are no randomised trials on any aspect of the management of cancer in pregnancy. Stage for stage cancer outcomes are similar in women who are pregnant compared with those who are not. Misdiagnosis and delayed diagnosis are common where the index of suspicion by the mother and health carers is low. Surgical interventions pose some risk to the fetus, especially laparotomy for abdominal tumours and procedures undertaken during the first trimester. Chemotherapy is teratogenic in the early stages, but seems to be safe in later pregnancy, and radiotherapy can be used for localised tumours remote from the uterus, such as head and neck or limb neoplasms. Suspicious symptoms should be appropriately investigated during pregnancy, and recent advances in non-ionising-radiation staging techniques, such as MRI and ultrasound, are especially helpful. Surgical interventions can be safely undertaken with minimum risk, although there is almost always some element of maternal-fetal conflict.

Maternal antiepileptic drug use and effects on fetal development

Many pregnant women take antiepileptic medications, and concern has arisen about the risks this poses to the fetus. It has been debated whether the causative agent is the medication or the underlying maternal disorder. Review of the recent literature indicates that the effects seem to be from the medications themselves. The frequency of malformations is about two to three-fold above the background rate and is dose-related for some of the medications. There seem to be effects on birth weight, length, and head circumference caused by at least some of the medications. The risks are greater when more than one medication is used. Cognitive effects from the medications have been shown, although these effects are of lower magnitude than previously reported. More investigation needs to be done to determine the exact risks of each individual medication, especially the newer ones. Studies on underlying mechanisms indicate potential genetic susceptibility and altered developmental gene expression patterns.

Thalidomide induced alteration in secondary structure of rat embryonic DNA in vivo

Teratogenicity of thalidomide was demonstrated in Wistar rats following a single maternal intravenous injection during the embryonic organogenetic period. When compared to day 13 embryonic DNA isolated from untreated control mothers, differences were observed in the mean wet weights of day 13 embryos from rats treated with thalidomide during days 10 or 11 of gestation, and significantly less amounts of embryonic DNA were recovered from mothers similarly treated on days 10 or 12 of their respective gestation periods. Rat embryonic DNA may be separated into two fractions by stepwise elution from benzoylated DEAE-cellulose (BD-cellulose) columns with 1.0 M NaCl (SE-DNA) and 1.8% (w/v) caffeine (CE-DNA) solutions, respectively. Other studies using bacterial, yeast, and rat liver DNA suggested that the first fraction contains native DNA, whereas the second may exhibit some degree of single-stranded character. Similar reproducible chromatographic profiles were obtained using a novel "batch method" developed for general application. Rat embryonic DNA was monitored by labelling in vivo with an i.p. injection of [methyl-3H]-thymidine (3H-TdR) during days 5, 6, and 7 of the gestation period. All samples were analysed on day 13 of gestation. A simple increase in percentage of caffeine-eluted DNA was not detected in thalidomide treated samples; however, diversity of percent (%) CE-DNA within litter was noted. Briefly, the percent CE-DNA values for embryos in one litter were ranked and arbitrarily grouped in classes with limits of mean +/- 1 SD, mean +/- 2 SD, and so on to generate a characteristic profile of percent CE-DNA distribution. The number of embryos within the range of each SD unit was expressed as a percentage of each litter. A plot of the ranges of percent CE-DNA versus percentage of each litter was used to illustrate the distribution profile of the particular litter and to be used for comparison between samples from untreated control and thalidomide and/or dimethylformamide (DMF) treated DNA. Treatment of day 12 mothers with thalidomide produced a majority of embryos having percent CE-DNA values similar to those of untreated controls with the exception of the inclusion of a second population of embryos with much higher percent CE-DNA values than those of the untreated controls. Similar treatment of day 11 animals produced a majority of embryos still having percent CE-DNA values similar to those of untreated controls and also having a second group of embryos with a lower percent CE-DNA values than those of untreated controls.(ABSTRACT TRUNCATED AT 400 WORDS)

Teratology: principles and practice

Gross anomalies of structure and/or function affect 2 to 4 per cent of all human newborns and are the leading cause of perinatal mortality in this country. Despite their significance, the etiology of most such defects remains unclear. A majority are unassociated with any identifiable cause; a small but significant percentage are attributed to heritable disorders of either a Mendelian (single gene) or chromosomal nature. Drugs and environmental exposures are currently implicated in only a small percentage of affected pregnancies. Nevertheless, an awareness of the principles of teratogenesis, an appreciation for the role--though imprecise--of placental transfer and fetal drug disposition, and avoidance of known teratogens currently offers our best hope for the study and prevention of birth defects.

The relative teratogenic index and teratogenic potency: proposed components of developmental toxicity risk assessment

Teratogenicity tests should provide answers to three questions: (1) Can the agent induce developmental defects? ("teratogenic potential"); (2) What are the effective doses? ("teratogenic potency"); and (3) Are effective doses below adult toxic doses? ("teratogenic hazard"). The answers to (2) and (3) should be quantitative in nature, but there are no accepted parameters to express these properties. In this paper we propose parameters for the description of teratogenic potency and hazard in quantitative terms. Derivation and calculation of the parameters are illustrated by the analysis of adult lethality and teratogenicity data of eight structurally related anhydrides and imides, following testing in the CD-1 mouse. Teratogenicity was evaluated following treatment on Days 8-10 of gestation, using an average of four dose groups per compound and at least 10 dams per group. Adult lethality was estimated following a similar 3-day dosage schedule with an average of 6 dose groups per compound and at least 8 animals per group. Dose-response relationships of teratogenicity were fitted to a probit model from which tD50 (median effective dose), and other effective doses were computed. It is proposed that tD05, as a minimum teratogenic dose, best represents teratogenic potency. In this study, potency ranged from 0.17 mmol/kg/day for phenytoin to 5.2 mmol/kg/day for ethosuximide. In order to measure teratogenic hazard a ratio between adult toxic (lethality was chosen as the most appropriate measure) and teratogenic responses was made. Since the dose-response slopes of lethality and teratogenicity were different, a simple ratio between median effective doses could not be used. It is shown that a ratio of LD01 to tD05 provides a "Relative Teratogenic Index" (RTI) which reflects the teratogenic hazard of a test agent. The following RTI values (LD01/tD05) were computed in this study: phthalic anhydride, 0.9; phensuximide, 1.0; succinic anhydride, 1.0; ethosuximide, 1.2; phenytoin, 1.6; phenacemide, 3.3; trimethadione, 4.0; and sodium valproate, 4.1. For these data, tD05 and RTI clearly represent the differing teratogenic potencies and hazards of the tested compounds. it is suggested that these parameters may be useful in comparative teratogenicity studies and may be valuable components of developmental toxicity risk assessment.

Animal virus screens for potential teratogens. I. Poxvirus morphogenesis

The growth of poxvirions in cell culture is considered a teratogen screening test, since this virus has a rapid, simple morphogenetic pathway that is dependent upon cell proliferation. Vaccinia WR-infected BSC 40 monolayers were exposed to 42 known teratogens and 9 nonteratogens at dosages from 1 microM to 100 mM. After 24 h of infection, the number of functional virions was determined by plaque assay. Thirty-three of the 42 teratogens inhibited the virus, 3 teratogens stimulated the virus, and 6 teratogens were false-negatives. Eight of the 9 nonteratogens had no effect on virus proliferation at dosages as high as 600 times the lowest reported teratogenic dosage. The number of new virions could be directly related to the concentration of the teratogen in vitro, thus allowing each compound to be characterized by an RD50. The RD50 dosage in milligrams per liter was 98% correlated with the lowest reported teratogenic dose in vivo in milligrams per kilogram. In sum, vaccinia-infected cells have an easily identifiable endpoint, plaque-forming units, which may be an accurate prognosticator of teratogenesis.

Are female sex hormones teratogenic?

An analysis of available epidemiologic data leads the present reviewers to conclude that the use of exogenous hormones during human pregnancy has not been proved to cause developmental abnormality in nongenital organs and tissues. This conclusion is further supported by the animal laboratory data. The preponderance of evidence at this writing indicates a lack of causal association between hormonal use during pregnancy and nongenital malformation of the offspring. The quality of the epidemiologic data does not, at this time, permit a definitive conclusion that sex hormones during pregnancy may not, under as yet to be defined conditions, have some adverse effect on human prenatal development. If there are increased risks of nongenital malformations associated with the administration of certain sex steroids, the risks are very small, may not be causal, and are substantially below the spontaneous risk of malformations. In spite of the present degree of uncertainty, the clinical, epidemiologic, and laboratory data do permit the formulation of a rational approach to handling problems related to sex steroid usage and exposure in pregnant women.

Congenital abnormalities and hormones during pregnancy: a clinical review

A review of the extensive literature on the subject indicates that sex hormones have been associated with a wide variety of adverse clinical conditions following usage during pregnancy. About 230 cases of female pseudohermaphroditism have been reported following use of hormones with androgenic potency, but masculinization observed with estrogens in a few females may represent only adrenal-stimulated pseudohermaphroditism. Feminization of males, mostly by progestogens in some 45 cases, is unproven at present. Realizing the limitations of the published studies when all present data are considered, there seems no justification for undue concern over the induction of nongenital congenital malformations through hormone use in pregnancy. The available data on the association to cardiac, limb, and CNS defects, and to several malformative syndromes, are not convincing: the effects appear to be remarkably nonspecific, the studies are contradicted by a large number of negative reports, and an increased incidence of defects with increased usage has not materialized. A possible exception are the CNS malformations associated with the use of the antifertility agent clomiphene, and careful surveillance is warranted at present. While a reasonable interpretation from this review would be that hormones present no major teratogenic hazard, elimination of hormonal exposure whenever possible during pregnancy is suggested.

The evolution of teratological testing

The beginnings of mammalian experimental teratology in this century are briefly reviewed and it is noted that prior to 1960 a degree of sophistication in concept and technology had already been achieved. Thus, contrary to claims that teratology had its beginning with the thalidomide catastrophe, a modest but expanding activity and body of knowledge already existed before this unfortunate event. This activity and this knowledge, however, were largely confined to academic and research institute laboratories and made little impact on the agencies in medicine, government and industry which oversaw public health and safety and set policies intended to preserve them. No individual, group, or agency can rightly be blamed for not having sooner brought together the concepts and methodology needed for meaningful animal testing and the regulatory insignt and experience needed intelligently to apply test data to human safety evaluation and experience needed intelligently to apply test data to human safety evaluation. To accomplish this liaison seems to have required the largest toxicological catastrophe yet recorded in human history. The major events leading to formulation of the first standardized guidelines are reviewed, but it is emphasized that even today the best animal testing can only provide a limited statement of probability regarding human risk vis-à-vis safety.

Non-confirmation of thalidomide induced teratogenesis in rats and mice

It has been reported that thalidomide, dissolved in a 1:3 mixture of Tween 20 and physiological saline and administered intraperitoneally to pregnant mice and rats induces a variety of malformations, including limb deformaties, characteristic of the primate syndrome. The studies reported herein attempted to confirm these findings without success although the rodent strains used were not the same. A low level of non-specific malformations was observed in the fetuses of both species at dose levels reported to cause a 47 percent and 92 percent rate of malformation in mice and rats respectively. One possible source of difference was Tween 20 which was toxic to the point of lethality in these studies at dose levels reported to be non-toxic in the earlier studies.

Study of closure of the embryonic rat palate in vitro with the effects of certain chemicals

In organ cultures of rat-palatal processes from 15-day-old embryos, addition of vitamin A or vitamin A with cortisone to the culture medium caused nonfusion and epithelial disruption. Cortisone alone did not show a teratogenic effect; nor did it exaggerate the effect of vitamin A.