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Gajski G, Kašuba V, Milić M, Gerić M, Matković K, Delić L, Nikolić M, Pavičić M, Rozgaj R, Garaj-Vrhovac V, Kopjar N. Exploring cytokinesis block micronucleus assay in Croatia: A journey through the past, present, and future in biomonitoring of the general population. MUTATION RESEARCH. GENETIC TOXICOLOGY AND ENVIRONMENTAL MUTAGENESIS 2024; 895:503749. [PMID: 38575251 DOI: 10.1016/j.mrgentox.2024.503749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/06/2024] [Accepted: 03/12/2024] [Indexed: 04/06/2024]
Abstract
In this study, we used the cytokinesis-block micronucleus (CBMN) assay to evaluate the background frequency of cytogenetic damage in peripheral blood lymphocytes of the general population concerning different anthropometric data and lifestyle factors. The background frequency of CBMN assay parameters was analysed in 850 healthy, occupationally non-exposed male and female subjects (average age, 38±11 years) gathered from the general Croatian population from 2000 to 2023. The mean background values for micronuclei (MNi) in the whole population were 5.3±4.3 per 1000 binucleated cells, while the mean frequency of nucleoplasmic bridges (NPBs) was 0.7±1.3 and of nuclear buds (NBUDs) 3.1±3.2. The cut-off value, which corresponds to the 95th percentile of the distribution of 850 individual values, was 14 MNi, 3 NPBs, and 9 NBUDs. Results from our database also showed an association of the tested genomic instability parameters with age and sex but also with other lifestyle factors. These findings underscore the importance of considering several anthropometric and lifestyle factors when conducting biomonitoring studies. Overall, the normal and cut-off values attained here present normal values for the general population that can later serve as baseline values for further human biomonitoring studies either in Croatia or worldwide.
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Affiliation(s)
- Goran Gajski
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia.
| | - Vilena Kašuba
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia
| | - Mirta Milić
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia
| | - Marko Gerić
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia
| | - Katarina Matković
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia
| | - Luka Delić
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia
| | - Maja Nikolić
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia
| | - Martina Pavičić
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia
| | - Ružica Rozgaj
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia
| | - Vera Garaj-Vrhovac
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia
| | - Nevenka Kopjar
- Institute for Medical Research and Occupational Health, Division of Toxicology, Mutagenesis Unit, 10000 Zagreb, Croatia
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Vanneste D, Verscheure E, Srinivasan AN, Godderis L, Ghosh M. Systematic review of genotoxicity induced by occupational exposure to antineoplastic drugs. Arch Toxicol 2023; 97:1453-1517. [PMID: 37099053 DOI: 10.1007/s00204-023-03481-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/02/2023] [Indexed: 04/27/2023]
Abstract
With increasing numbers of cancer cases, the use of antineoplastic agents is expected to rise. This will be accompanied by an increase in occupational exposure, which can cause unwanted health effects in workers. Our aim was to give an overview of genotoxic and epigenetic effects after occupational exposure to antineoplastic agents and to assess the concentration-effect relation. Four databases were searched for papers investigating genotoxic and/or epigenetic effects of occupational exposure to antineoplastic agents. Out of the 245 retrieved papers, 62 were included in this review. In this systematic literature review, we confirmed that exposure of healthcare workers to antineoplastic agents can lead to genotoxic damage. However, we observed a lack of data on exposure as well as genotoxic and epigenetic effects in workers other than healthcare workers. Furthermore, gaps in the current knowledge regarding the potential epigenetic effects caused by antineoplastic drug exposure and regarding the link between internal antineoplastic drug concentration and genotoxic and epigenetic effects after occupational exposure to antineoplastic agents were identified, offering a first step for future research.
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Affiliation(s)
- Dorian Vanneste
- Environment and Health, Department of Public Health and Primary Care, KU Leuven, ON5 Herestraat 49, Box 952, 3000, Leuven, Belgium
| | - Eline Verscheure
- Environment and Health, Department of Public Health and Primary Care, KU Leuven, ON5 Herestraat 49, Box 952, 3000, Leuven, Belgium
| | - Adhithya Narayanan Srinivasan
- Environment and Health, Department of Public Health and Primary Care, KU Leuven, ON5 Herestraat 49, Box 952, 3000, Leuven, Belgium
| | - Lode Godderis
- Environment and Health, Department of Public Health and Primary Care, KU Leuven, ON5 Herestraat 49, Box 952, 3000, Leuven, Belgium
| | - Manosij Ghosh
- Environment and Health, Department of Public Health and Primary Care, KU Leuven, ON5 Herestraat 49, Box 952, 3000, Leuven, Belgium.
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Huang H, Gu Y, Liu S, Hu S, Zhong X, Huang Y, Peng J, Huang X. The meta-analysis of cytogenetic biomarkers as an assessment of occupational risk for healthcare workers exposed to antineoplastic drugs. Int Arch Occup Environ Health 2023:10.1007/s00420-023-01969-6. [PMID: 37079056 DOI: 10.1007/s00420-023-01969-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/07/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Antineoplastic drugs (ADs) are widely used in clinical practice and have been demonstrated to be effective in treating malignant tumors. However, they carry a risk of cytogenotoxicity for healthcare workers. Studies have reported that genotoxic biomarkers can be applied to assess the occupational health status of healthcare workers at an early stage, but results of different studies are variable. The objectives of the review were examine the association between long-term exposure to ADs and cytogenetic damage to healthcare workers. METHODS We systematically reviewed studies between 2005 and 2021 using PubMed, Embase and Web of Science databases that used cytogenetic biomarkers to assess occupational exposure to ADs in healthcare workers. We used RevMan5.4 to analyze the tail length parameters of the DNA, frequency of the chromosomal aberrations, sister chromatid exchanges and micronuclei. A total of 16 studies were included in our study. The studies evaluate the quality of the literature through the Agency for Healthcare Research and Quality. RESULTS The results revealed that under the random-effects model, the estimated standard deviation was 2.37 (95% confidence interval [CI] 0.92-3.81, P = 0.001) for the tail length parameters of the DNA, 1.48 (95% CI 0.71-2.25, P = 0.0002) for the frequency of chromosomal aberrations, 1.74 (95% CI 0.49-2.99, P = 0.006) for the frequency of sister chromatid exchanges and 1.64 (95% CI 0.83-2.45, P < 0.0001) for the frequency of micronuclei. CONCLUSIONS The results indicate that there is a significant association between occupational exposure to ADs and cytogenetic damage, to which healthcare workers should be alerted.
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Affiliation(s)
- Hong Huang
- Shenzhen Clinical Medical College, Guangzhou University of Chinese Medicine, No.6082 Longgang Avenue, Shenzhen, 518116, China
| | - Yeqing Gu
- Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Shuhan Liu
- Shenzhen Clinical Medical College, Guangzhou University of Chinese Medicine, No.6082 Longgang Avenue, Shenzhen, 518116, China
| | - Song Hu
- Longgang District Central Hospital of Shenzhen, Shenzhen, 518116, Guangdong, China
| | - Xiao Zhong
- Longgang District Central Hospital of Shenzhen, Shenzhen, 518116, Guangdong, China
| | - Yanshan Huang
- Longgang District Central Hospital of Shenzhen, Shenzhen, 518116, Guangdong, China
- Shantou University Medical College, Shantou, 515041, Guangdong, China
| | - Ji Peng
- Longgang District Central Hospital of Shenzhen, Shenzhen, 518116, Guangdong, China
| | - Xiaohong Huang
- Department of Nursing, Longgang District Central Hospital of Shenzhen, Shenzhen, Guangdong, China.
- Shenzhen Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China.
- Longgang District Central Hospital of Shenzhen, No.6082 Longgang Avenue, Longgang District, Shenzhen, Guangdong, China.
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Ahmad A, Jan BL, Raish M, Rachamalla HKR, Banerjee R, Mukhopadhyay D, Alkharfy KM. Evaluation of the in vivo genotoxicity of liposomal formulation for delivering anticancer estrogenic derivative (ESC8) in a mouse model. Saudi Pharm J 2019; 27:637-642. [PMID: 31297017 PMCID: PMC6598449 DOI: 10.1016/j.jsps.2019.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/09/2019] [Indexed: 12/03/2022] Open
Abstract
The genotoxic potential of glucocorticoid receptor (GR)-targeted liposomal formulations of the anticancer drug molecule ESC8 was studied in vivo. A methodical literature review discovered no previous studies on the genotoxicity of ESC8. Genotoxicity was assessed in both male and female mice by various assay systems, such as comet assay, chromosomal aberrations and micronuclei assay, which detect different abnormalities. Eleven groups of male mice and eleven groups of female mice, containing six animals per group, were used in the present study: group I served as vehicle control; group II received the positive control (cyclophosphamide 40 mg/kg; CYP); and animals in group III to XI received free drug (ESC8), DX liposome and drug-associated DX liposomal formulation (DXE), respectively, dissolved in 5% solution of glucose at a drug-dose of 1.83, 3.67 and 7.34 mg/kg, respectively. Same drug treatments were followed for the female mice groups. The obtained data revealed the safety of DXE, which did not show substantial genotoxic effects at different dose levels. In contrast, the positive control, CYP, exhibited highly substantial irregular cytogenetic variations in comparison with the control group in different assays.
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Affiliation(s)
- Ajaz Ahmad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
| | - Basit Latief Jan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
| | - Mohammad Raish
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
| | | | - Rajkumar Banerjee
- Department of Applied Biology, CSIR-Indian Institute of Chemical Technology, Hyderabad 500007, India
| | | | - Khalid M. Alkharfy
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
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Smith AN, Klahn S, Phillips B, Parshley L, Bennett P, Flory A, Calderon R. ACVIM small animal consensus statement on safe use of cytotoxic chemotherapeutics in veterinary practice. J Vet Intern Med 2018; 32:904-913. [PMID: 29603372 PMCID: PMC5980460 DOI: 10.1111/jvim.15077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 01/22/2018] [Accepted: 01/22/2018] [Indexed: 11/28/2022] Open
Abstract
The purpose of this report is to offer a consensus opinion of ACVIM oncology diplomates and technicians on the safe use of cytotoxic chemotherapeutics in veterinary practice. The focus is on minimizing harm to the personnel exposed to the drugs: veterinary practitioners, veterinary technicians, veterinary staff, and pet owners. The safety of the patient receiving these drugs is also of paramount importance, but is not addressed in this statement. Much of the information presented is based on national recommendations by Occupational Safety and Health Administration, National Institute for Occupational Safety and Health, United States Pharmacopeia, and other published regulations. These directives reflect an abundance of caution to minimize exposure to medical personnel, but large-scale studies about the consequences of long-term occupational exposure are not available in veterinary medicine. Challenges in the delivery of optimal treatment safely and economically to veterinary patients in general practice without access to a veterinary oncologist or other specialist, because of costs or proximity, remain.
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Affiliation(s)
- Annette N. Smith
- Department of Clinical SciencesAuburn University College of Veterinary MedicineAuburnAlabama
| | - Shawna Klahn
- Department of Small Animal Clinical SciencesVirginia–Maryland Regional College of Veterinary Medicine, Virginia TechBlacksburgVirginia
| | - Brenda Phillips
- Oncology Veterinary Specialty Hospital of San DiegoSan DiegoCalifornia
| | - Lisa Parshley
- Oncology Olympia Veterinary Cancer CenterOlympiaWashington
| | - Peter Bennett
- Oncology University Veterinary Teaching Hospital Sydney, University of SydneySydneyAustralia
| | - Andi Flory
- Oncology Veterinary Specialty Hospital of San DiegoSan DiegoCalifornia
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Lepage N, Canal-Raffin M, Villa A. Propositions pour la mise en œuvre d’une surveillance biologique de l’exposition professionnelle aux médicaments anticancéreux. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2017. [DOI: 10.1016/j.toxac.2017.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lamberti M, Porto S, Marra M, Zappavigna S, Grimaldi A, Feola D, Pesce D, Naviglio S, Spina A, Sannolo N, Caraglia M. 5-Fluorouracil induces apoptosis in rat cardiocytes through intracellular oxidative stress. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2012; 31:60. [PMID: 22812382 PMCID: PMC3461434 DOI: 10.1186/1756-9966-31-60] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 07/19/2012] [Indexed: 01/05/2023]
Abstract
Background Cardiotoxicity is a major complication of anticancer drugs, including anthracyclines and 5-fluorouracil(5-FU) and it can have detrimental effects both in patients and workers involved in the preparation of chemotherapy. Methods Specifically, we have assessed the effects of increasing concentrations of 5-FU and doxorubicin (DOXO) on proliferation of H9c2 rat cardiocytes and HT-29 human colon adenocarcinoma cells by MTT assay. Cells were treated for 24, 48 and 72 h with different concentrations of the two drugs alone or with 5-FU in combination with 10-4 M of levofolene (LF). Results 5-FU induced a time- and dose-dependent growth inhibition in both cell lines. The 50% growth inhibition (IC:50) was reached at 72 h with concentrations of 4 μM and 400 μM on HT-29 and H9c2, respectively. The addition of LF to 5-FU enhanced this effect. On the other hand, the IC:50 of DOXO was reached at 72 h with concentrations of 0.118 μM on H9c2 and of 0.31 μM for HT-29. We have evaluated the cell death mechanism induced by 50% growth inhibitory concentrations of 5-FU or DOXO in cardiocytes and colon cancer cells. We have found that the treatment with 400 μM 5-FU induced apoptosis in 32% of H9c2 cells. This effect was increased by the addition of LF to 5-FU (38% of apoptotic cells). Apoptosis occurred in only about 10% of HT-29 cells treated with either 5-FU or 5-FU and LF in combination. DOXO induced poor effects on apoptosis of both H9c2 and HT-29 cells (5–7% apoptotic cells, respectively). The apoptosis induced by 5-FU and LF in cardiocytes was paralleled by the activation of caspases 3, 9 and 7 and by the intracellular increase of O2− levels. Conclusions These results suggest that cardiotoxic mechanism of chemotherapy agents are different and this disclose a new scenario for prevention of this complication.
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Affiliation(s)
- Monica Lamberti
- Occupational Medicine, Hygiene and Industrial Toxicology Section, Department of Experimental Medicine, Second University of Naples, Naples, Italy
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Tekcan A, Elbistan M, Ulusoy AN. Sister chromatid exchanges in breast cancer patients who underwent chemotherapy. J Toxicol Sci 2012; 37:235-43. [DOI: 10.2131/jts.37.235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Akin Tekcan
- Department of Medical Biology and Genetics, Faculty of Medicine, Ondokuz Mayis University, Turkey
| | - Mehmet Elbistan
- Department of Medical Biology and Genetics, Faculty of Medicine, Ondokuz Mayis University, Turkey
| | - Ali Naki Ulusoy
- Department of General Surgery, Faculty of Medicine, Ondokuz Mayis University, Turkey
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Suspiro A, Prista J. Biomarkers of occupational exposure do anticancer agents: a minireview. Toxicol Lett 2011; 207:42-52. [PMID: 21911042 DOI: 10.1016/j.toxlet.2011.08.022] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Revised: 08/27/2011] [Accepted: 08/29/2011] [Indexed: 11/29/2022]
Abstract
The majority of anticancer agents has in common DNA-damaging properties and affects not only target-cells but also non-tumour cells. Its genotoxicity has been demonstrated in experimental models and in cancer patients treated with chemotherapy. Health care personnel involved in the preparation and administration of chemotherapy is therefore at risk for adverse health effects, since most environmental sampling studies demonstrated that there is widespread contamination of work surfaces and equipments with anticancer drugs. Adherence to safety guidelines and proper use of personal protective equipment are insufficient to prevent significant absorption, as evidenced by the presence of detectable amounts of drugs in urine samples and increased frequency of genotoxicity biomarkers. In this minireview, a critical appraisal of the most important biomarkers used for the evaluation of occupational exposure to anticancer agents as well as a summary of the key findings from several studies published in this field is performed.
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Affiliation(s)
- A Suspiro
- ENSP-UNL, Escola Nacional de Saúde Pública Universidade Nova de Lisboa, UNL, Avenida Padre Cruz, 1600-560 Lisboa, Portugal.
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Villarini M, Dominici L, Piccinini R, Fatigoni C, Ambrogi M, Curti G, Morucci P, Muzi G, Monarca S, Moretti M. Assessment of primary, oxidative and excision repaired DNA damage in hospital personnel handling antineoplastic drugs. Mutagenesis 2010; 26:359-69. [PMID: 21112930 DOI: 10.1093/mutage/geq102] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The International Agency for Research on Cancer has classified several antineoplastic drugs in Group 1 (human carcinogens), among which chlorambucil, cyclophosphamide (CP) and tamoxifen, Group 2A (probable human carcinogens), among which cisplatin, etoposide, N-ethyl- and N-methyl-N-nitrosourea, and Group 2B (possible human carcinogens), among which bleomycins, merphalan and mitomycin C. The widespread use of these mutagenic/carcinogenic drugs in the treatment of cancer has led to anxiety about possible genotoxic hazards to medical personnel handling these drugs. The aim of the present study was to evaluate work environment contamination by antineoplastic drugs in a hospital in Central Italy and to assess the genotoxic risks associated with antineoplastic drug handling. The study group comprised 52 exposed subjects and 52 controls. Environmental contamination was assessed by taking wipe samples from different surfaces in preparation and administration rooms and nonwoven swabs were used as pads for the surrogate evaluation of dermal exposure, 5-fluorouracil and cytarabine were chosen as markers of exposure to antineoplastic drugs in the working environment. The actual exposure to antineoplastic drugs was evaluated by determining the urinary excretion of CP. The extent of primary, oxidative and excision repaired DNA damage was measured in peripheral blood leukocytes with the alkaline comet assay. To evaluate the role, if any, of genetic variants in the extent of genotoxic effects related to antineoplastic drug occupational exposure, the study subjects were genotyped for GSTM1, GSTT1, GSTP1 and TP53 polymorphisms. Primary DNA damage significantly increased in leukocytes of exposed nurses compared to controls. The use of personal protective equipment (i.e. gloves and/mask) was associated with a decrease in the extent of primary DNA damage.
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Affiliation(s)
- Milena Villarini
- Department of Medical-Surgical Specialties and Public Health University of Perugia, Via del Giochetto, 06122 Perugia, Italy
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Antineoplastic Drugs as a Potential Risk Factor in Occupational Settings: Mechanisms of Action at the Cell Level, Genotoxic Effects, and Their Detection Using Different Biomarkers. Arh Hig Rada Toksikol 2010; 61:121-46. [DOI: 10.2478/10004-1254-61-2010-2025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Antineoplastični Lijekovi Kao Čimbenik Rizika u Radnom Okolišu: Mehanizmi Djelovanja na Razini Stanice i Pregled Metoda za Otkrivanje Njihovih Genotoksičnih UčinakaU članku je prikazana osnovna podjela antineoplastičnih lijekova prema mehanizmima djelovanja na razini stanice. Objašnjeni su mehanizmi genotoksičnosti najvažnijih vrsta lijekova koji se primjenjuju u okviru uobičajenih protokola za liječenje zloćudnih novotvorina. Navedena je važeća klasifikacija antineoplastika prema kancerogenom potencijalu, podaci o mutagenom potencijalu te je prikazana njihova podjela u skladu s anatomsko-terapijsko-kemijskim sustavom klasifikacije. Sustavno su prikazani najvažniji rezultati svjetskih i hrvatskih istraživanja na populacijama radnika izloženih antineoplasticima, provedenih u razdoblju 1980.-2009. s pomoću četiri najčešće primjenjivane metode: analize izmjena sestrinskih kromatida, analize kromosomskih aberacija, mikronukleus-testa i komet-testa. Objašnjena su osnovna načela navedenih metoda te raspravljene njihove prednosti i nedostaci. Biološki pokazatelji daju važne podatke o individualnoj osjetljivosti profesionalno izloženih ispitanika koji mogu poslužiti unaprjeđenju postojećih uvjeta rada i upravljanju rizicima pri izloženosti genotoksičnim agensima. Na osnovi prednosti i nedostataka citogenetičkih metoda zaključeno je da je mikronukleus-test, koji podjednako uspješno dokazuje klastogene i aneugene učinke, jedna od najboljih metoda dostupnih za otkrivanje štetnih djelovanja antineoplastičnih lijekova koji su u aktivnoj primjeni.
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