Myocardial Injury Induced by a Single Dose of Adriamycin: An Electron Microscopic Study

Ultrastructural Alterations of Atrial Myocardium Induced by Adriamycin in Chronically Treated Animals

The clinical use of adriamycin (AM) is limited by a possible dose-dependent myocardiopathy. Severe lesions of ventricular myocardium widely described by electron microscopy have been correlated to irreversible congestive heart failure. On the other hand, the atrial contractile elements which differ from the ventricular ones because of the presence of the so-called specific granules have rarely been considered. In the work described in this paper, adriamycin was injected into rabbits and mice according to schedules of chronic toxicity. At the end of the treatment the atrial myocells presented diffuse ultrastructural lesions of mitochondria, sarcoplasmic reticulum and myofibrillar bundles. These alterations might be caused by the ribonucleoprotein synthesis inhibition, by a direct drug toxicity or by an energetic crisis due to early mitochondrial lesions. Besides, adriamycin produces a decrease of the specific atrial granules that play a hypothetic role in the metabolism of myocardial cells. However, lack of information about the contents and the exact function of atrial granules does not allow us to conclude that their decrease in treated animals has a pathogenetic significance in myocardiopathy induced by adriamycin.

Early Diagnosis and Prediction of Anticancer Drug-induced Cardiotoxicity: From Cardiac Imaging to "Omics" Technologies

Heart failure due to antineoplastic therapy remains a major cause of morbidity and mortality in oncological patients. These patients often have no prior manifestation of disease. There is therefore a need for accurate identification of individuals at risk of such events before the appearance of clinical manifestations. The present article aims to provide an overview of cardiac imaging as well as new "-omics" technologies, especially with regard to genomics and proteomics as promising tools for the early detection and prediction of cardiotoxicity and individual responses to antineoplastic drugs.

Coenzyme Q10 for Prevention of Anthracycline-Induced Cardiotoxicity

Preclinical and clinical studies suggest that anthracycline-induced cardiotoxicity can be prevented by administering coenzyme Q10 during cancer chemotherapy that includes drugs such as doxorubicin and daunorubicin. Studies further suggest that coenzyme Q10 does not interfere with the antineoplastic action of anthracyclines and might even enhance their anticancer effects. Preventing cardiotoxicity might allow for escalation of the anthracycline dose, which would further enhance the anticancer effects. Based on clinical investigation, although limited, a cumulative dose of doxorubicin of up to 900 mg/m2, and possibly higher, can be administered safely during chemotherapy as long as coenzyme Q10 is administered concurrently. The etiology of the dose-limiting cardiomyopathy that is induced by anthracyclines can be explained by irreversible damage to heart cell mitochondria, which differ from mitochondria of other cells in that they possess a unique enzyme on the inner mitochondrial membrane. This enzyme reduces anthracyclines to their semiquinones, resulting in severe oxidative stress, disruption of mitochondrial energetics, and irreversible damage to mitochondrial DNA. Damage to mitochondrial DNA blocks the regenerative capability of the organelle and ultimately leads to apoptosis or necrosis of myocytes. Coenzyme Q10, an essential component of the electron transport system and a potent intracellular antioxidant, appears to prevent damage to the mitochondria of the heart, thus preventing the development of anthracycline-induced cardiomyopathy.

Oxidative Damage Precedes Nitrative Damage in Adriamycin-Induced Cardiac Mitochondrial Injury

The purpose of the present study was to determine if elevated reactive oxygen (ROS)/nitrogen species (RNS) reported to be present in adriamycin (ADR)-induced cardiotoxicity actually resulted in cardiomyocyte oxidative/nitrative damage, and to quantitatively determine the time course and subcellular localization of these postulated damage products using an in vivo approach. B6C3 mice were treated with a single dose of 20 mg/kg ADR. Ultrastructural damage and levels of 4-hydroxy-2-nonenal (4HNE)-protein adducts and 3-nitrotyrosine (3NT) were analyzed. Quantitative ultrastructural damage using computerized image techniques showed cardiomyocyte injury as early as 3 hours, with mitochondria being the most extensively and progressively injured subcellular organelle. Analysis of 4HNE protein adducts by immunogold electron microscopy showed appearance of 4HNE protein adducts in mitochondria as early as 3 hours, with a peak at 6 hours and subsequent decline at 24 hours. 3NT levels were significantly increased in all subcellular compartments at 6 hours and subsequently declined at 24 hours. Our data showed ADR induced 4HNE-protein adducts in mitochondria at the same time point as when mitochondrial injury initially appeared. These results document for the first time in vivo that mitochondrial oxidative damage precedes nitrative damage. The progressive nature of mitochondrial injury suggests that mitochondria, not other subcellular organelles, are the major site of intracellular injury.

Cardiac side effects of anticancer treatments: new mechanistic insights

Damage to heart cells leading to heart failure is a known complication of well-established cancer therapies including anthracycline antibiotics and radiation therapy, and the cardiovascular complications of these therapies has been controlled in large part through dose limitations and modifications of delivery methods. Recent research into the cellular and molecular mechanisms for the cardiovascular effects of these therapies may lead to other cardioprotective strategies that improve effectiveness of cancer treatments. Newer cancer therapies that have been developed based upon specifically targeting oncogene signaling also have been associated with heart failure. Rapid development of a detailed understanding of how these agents cause cardiac dysfunction promises to improve outcomes in cancer patients, as well as stimulate concepts of cardiovascular homeostasis that will likely accelerate development of cardiovascular therapies.

A novel purification method of murine embryonic stem cell- and human-induced pluripotent stem cell-derived cardiomyocytes by simple manual dissociation

Cardiomyocytes derived from embryonic stem cells (ES-CMs) and induced pluripotent stem cells (iPS-CMs) are useful for toxicity and pharmacology screening. In the present study, we found that cardiomyocyte-rich beating cell clusters (CCs) emerged from murine embryonic stem cell (mESC)-derived beating EBs and from human-induced pluripotent stem cell (hiPSC)-derived beating EBs dissociated by gentle pipetting with a thin glass pipette. The percentage of cardiac troponin T (cTnT)-positive cells in the beating CCs obtained from mESC-derived and hiPSC-derived beating EBs was higher (81.5% and 91.6%, respectively) than in beating-undissociated EBs (13.7% and 67.1%, respectively). For mESCs, the yield of cTnT-positive cells from beating CCs was estimated to be 1.6 times higher than that of beating EBs. The bromodeoxyuridine labeling index of mouse ES-CMs and human iPS-CMs in beating CCs was 1.5- and 3.2-fold, respectively, greater than those in beating EBs. To investigate the utility of the cells in toxicity assessment, we showed that doxorubicin, a cardiotoxic drug, induced myofilament disruption in cardiomyocytes isolated by this method. This simple method enables preparation of mouse ES-CMs and human iPS-CMs with better proliferative activity than beating EBs not dissociated by pipetting, and the cardiomyocytes are useful for drug-induced myocardial toxicity testing.

Effects of doxorubicin on myocardial expression of apolipoprotein-B

OBJECTIVE

Doxorubicin (DOX) is an effective antitumour agent against a variety of human malignancies but is associated with deleterious side effects, including myocardial damage and heart failure. Myocardial apoB-containing lipoprotein (apoB) is upregulated post myocardial infarction and has been shown to be cardioprotective in this setting by unloading excessive lipid. The aim of this study was to investigate whether apoB expression is increased also in DOX-induced heart failure and whether apoB overexpression protects the heart in DOX-induced myocardial injury.

DESIGN

Cardiac function and energy metabolism was studied in mice and rats 24 hours after intraperitoneally administered DOX.

RESULTS

We found that the content of apoB was decreased in rat myocardium 24 hours after DOX injection. In contrast, apoB content was increased in the infarcted myocardium of rats 24 hours post ischemia-reperfusion. Moreover, transgenic mice overexpressing apoB had better cardiac function and lower intracellular lipid accumulation compared to wild type mice 24 hours post DOX.

CONCLUSIONS

Our findings indicate that depression of the myocardial apoB system may contribute to DOX-induced cardiac injury and that overexpression of apoB is protective, not only in ischemically damaged myocardium, but also in DOX-induced heart failure.

Glutathione peroxidase 1-deficient mice are more susceptible to doxorubicin-induced cardiotoxicity

Doxorubicin (DOX)-induced cardiotoxicity is thought to be mediated by the generation of superoxide anion radicals (superoxide) from redox cycling of DOX in cardiomyocyte mitochondria. Reduction of superoxide generates H(2)O(2), which diffuses throughout the cell and potentially contributes to oxidant-mediated cardiac injury. The mitochondrial and cytosolic glutathione peroxidase 1 (Gpx1) primarily functions to eradicate H(2)O(2). In this study, we hypothesize that Gpx1 plays a pivotal role in the clearance of H(2)O(2) generated by DOX. To test this hypothesis, we compared DOX-induced cardiac dysfunction, mitochondrial injury, protein nitration, and apoptosis in Gpx1-deficient and wild type mouse hearts. The Gpx1-deficient hearts showed increased susceptibility to DOX-induced acute functional derangements than wild type hearts, including impaired contractility and diastolic properties, decreased coronary flow rate, and reduced heart rate. In addition, DOX treatment impaired the mitochondrial function of Gpx1-deficient hearts. Specifically, Gpx1-deficient hearts treated with DOX demonstrated an increased rate of NAD-linked state 4 respiration and a decline in the P/O ratio relative to wild type hearts, suggesting that DOX uncouples the electron transfer chain and oxidative phosphorylation in Gpx1-deficient hearts. Finally, apoptosis and protein nitration were significantly increased in Gpx1-deficient mouse hearts compared to wild type hearts. These studies suggest that Gpx1 plays significant roles in protecting DOX-induced mitochondrial impairment and cardiac dysfunction in the acute phase.

3D-MEDNEs: an alternative "in silico" technique for chemical research in toxicology. 2. quantitative proteome-toxicity relationships (QPTR) based on mass spectrum spiral entropy

Low range mass spectra (MS) characterization of serum proteome offers the best chance of discovering proteome-(early drug-induced cardiac toxicity) relationships, called here Pro-EDICToRs. However, due to the thousands of proteins involved, finding the single disease-related protein could be a hard task. The search for a model based on general MS patterns becomes a more realistic choice. In our previous work ( González-Díaz, H. , et al. Chem. Res. Toxicol. 2003, 16, 1318- 1327 ), we introduced the molecular structure information indices called 3D-Markovian electronic delocalization entropies (3D-MEDNEs). In this previous work, quantitative structure-toxicity relationship (QSTR) techniques allowed us to link 3D-MEDNEs with blood toxicological properties of drugs. In this second part, we extend 3D-MEDNEs to numerically encode biologically relevant information present in MS of the serum proteome for the first time. Using the same idea behind QSTR techniques, we can seek now by analogy a quantitative proteome-toxicity relationship (QPTR). The new QPTR models link MS 3D-MEDNEs with drug-induced toxicological properties from blood proteome information. We first generalized Randic's spiral graph and lattice networks of protein sequences to represent the MS of 62 serum proteome samples with more than 370 100 intensity ( I i ) signals with m/ z bandwidth above 700-12000 each. Next, we calculated the 3D-MEDNEs for each MS using the software MARCH-INSIDE. After that, we developed several QPTR models using different machine learning and MS representation algorithms to classify samples as control or positive Pro-EDICToRs samples. The best QPTR proposed showed accuracy values ranging from 83.8% to 87.1% and leave-one-out (LOO) predictive ability of 77.4-85.5%. This work demonstrated that the idea behind classic drug QSTR models may be extended to construct QPTRs with proteome MS data.

Toxicoproteomics: serum proteomic pattern diagnostics for early detection of drug induced cardiac toxicities and cardioprotection

Proteomics is more than just generating lists of proteins that increase or decrease in expression as a cause or consequence of pathology. The goal should be to characterize the information flow through the intercellular protein circuitry which communicates with the extracellular microenvironment and then ultimately to the serum/plasma macroenvironment. The nature of this information can be a cause, or a consequence, of disease and toxicity based processes as cascades of reinforcing information percolate through the system and become reflected in changing proteomic information content of the circulation. Serum Proteomic Pattern Diagnostics is a new type of proteomic platform in which patterns of proteomic signatures from high dimensional mass spectrometry data are used as a diagnostic classifier. While this approach has shown tremendous promise in early detection of cancers, detection of drug-induced toxicity may also be possible with this same technology. Analysis of serum from rat models of anthracycline and anthracenedione induced cardiotoxicity indicate the potential clinical utility of diagnostic proteomic patterns where low molecular weight peptides and protein fragments may have higher accuracy than traditional biomarkers of cardiotoxicity such as troponins. These fragments may one day be harvested by circulating nanoparticles designed to absorb, enrich and amplify the diagnostic biomarker repertoire generated even at the critical initial stages of toxicity.

Pifithrin-alpha protects against doxorubicin-induced apoptosis and acute cardiotoxicity in mice

The present experiments were designed to evaluate the effects of pifithrin-alpha (PFT-alpha), which is a p53 inhibitor, on doxorubicin (DOX)-induced apoptosis and cardiac injury. Administration of DOX (22.5 mg/kg ip) in mice upregulated the mRNA levels of Bax and MDM2, whereas PFT-alpha attenuated those levels when administered at a total dose of 4.4 mg/kg at 30 min before and 3 h after DOX challenge. DOX treatment led to an upregulation of p53 protein levels, which was preceded by elevated levels of phosphorylated p53 at Ser15. PFT-alpha had no effect on the level of p53 or its phosphorylated form. The protein levels of Bax and MDM2 were elevated by DOX and attenuated by PFT-alpha. DOX gave rise to increased apoptosis-positive nuclei in cardiac cells, elevated serum creatine phosphokinase, ultrastructural alterations, and cardiac dysfunction. PFT-alpha offered protection against all of the aforementioned changes. Finally, PFT-alpha did not interfere with the antitumor potency of DOX. This study demonstrates that PFT-alpha effectively inhibits DOX-induced cardiomyocyte apoptosis, which suggests that PFT-alpha has the potential to protect cancer patients against DOX-induced cardiac injury.

Doxorubicin directly binds to the cardiac-type ryanodine receptor

The clinical use of doxorubicin, an antineoplasmic agent, is limited by its extensive cardiotoxicity which is mediated by the mobilization of intracellular Ca2+ from SR. In order to elucidate the mechanism of Ca2+ release, we analyzed the binding sites of doxorubicin on rabbit cardiac SR (sarcoplasmic reticulum). One of the binding sites was identified as cardiac-type ryanodine receptor (RyR2) which was purified by immunoprecipitation from solubilized cardiac SR in the presence of DTT. Ligand blot analysis revealed the direct binding of doxorubicin to RyR2. The binding of doxorubicin to RyR2 was specific and displaced by caffeine. Both doxorubicin and caffeine enhanced [3H]-ryanodine binding to RyR2 in a Ca2+ dependent manner. These results suggest that there is a doxorubicin binding site on RyR2.

Modulation of anthracycline-induced myofibrillar disarray in rat ventricular myocytes by neuregulin-1beta and anti-erbB2: potential mechanism for trastuzumab-induced cardiotoxicity

BACKGROUND

There is an increased incidence of heart failure in patients treated concurrently with anthracyclines and the chemotherapeutic anti-erbB2 agent trastuzumab (Herceptin). On the basis of our previous studies with recombinant neuregulin-1beta (NRG-1beta), a ligand for the erbB2 receptor tyrosine kinase, we hypothesized that activation of erbB2 by anti-erbB2 versus NRG-1 would cause differential effects on myocyte intracellular signaling as well as anthracycline-induced myofibrillar injury and might potentially account for the clinical toxicity of trastuzumab in the setting of concurrent anthracycline therapy.

METHODS AND RESULTS

We tested this hypothesis using adult rat ventricular myocytes (ARVMs) in culture, assessing myofibrillar structure by immunostaining for myomesin and filamentous actin. Activation of erbB2, extracellular signal-regulated kinase 1/2 (Erk1/2), and Akt was assessed by use of antibodies to phosphorylated activated receptor or kinase detected by immunoblot. ARVMs treated with doxorubicin (0.1 to 0.5 micromol/L) showed a concentration-dependent increase in myofilament disarray. NRG-1beta (10 ng/mL) activated erbB2, Erk1/2, and Akt in ARVMs and significantly reduced anthracycline-induced disarray. In contrast to NRG-1beta, anti-erbB2 (1 microg/mL) caused rapid phosphorylation of erbB2 but not Erk1/2 or Akt, with downregulation of erbB2 by 24 hours. Concomitant treatment of myocytes with anti-erbB2 and doxorubicin caused a significant increase in myofibrillar disarray versus doxorubicin alone.

CONCLUSIONS

NRG-1beta/erbB signaling regulates anthracycline-induced myofilament injury. The increased susceptibility of myofilaments to doxorubicin in the presence of antibody to erbB2 may explain the contractile dysfunction seen in patients receiving concurrent trastuzumab and anthracyclines.

Interference with calcium-dependent mitochondrial bioenergetics in cardiac myocytes isolated from doxorubicin-treated rats

In previous studies we showed that doxorubicin (DOX) interferes with mitochondrial calcium homeostasis and that cardiac mitochondria from DOX-treated rats express a dose-dependent, cumulative, and irreversible decrease in calcium-loading capacity. Associated with this is an increased sensitivity to calcium-induced cell killing of cardiac myocytes from DOX-treated rats. Because mitochondria play an important role in cytosolic calcium regulation, we questioned whether cardiac myocytes isolated from DOX-treated rats express an exaggerated response to interventions that increase cytosolic calcium. Adult male Sprague-Dawley rats received six weekly (sc) injections of either 2 mg/kg of doxorubicin or an equivalent volume of saline and were killed the following week. Cardiac myocytes were isolated and exposed in vitro to 25 microM of A23187, 20 mM of caffeine, or 500 microM of ouabain. A23187 and ouabain caused a dose-dependent increase in intracellular calcium, as measured fluorometrically with Fura-2AM. In the case of ouabain, the increase in cytosolic calcium was greater for myocytes from DOX-treated rats than for cells from control rats. With caffeine, however, the increase in intracellular calcium was not evident unless the mitochondria were depolarized. A23187 also caused depolarization of mitochondria, the extent of which was greater for cardiac myocytes from DOX-treated rats. All three agents caused depletion of cardiac myocyte ATP and cell killing, both of which were more profound in cells from DOX-treated rats than in controls. We suggest that by interfering with mitochondrial calcium regulation, long-term treatment with DOX renders myocytes susceptible to agents that increase cytosolic calcium, presumably by increasing the calcium-dependent disruption of mitochondrial function, leading to depletion of ATP and eventually cell death. This interference with mitochondrial calcium regulation may underlie the pathogenesis of DOX-induced cardiomyopathy.

Cardiac resistance to adriamycin in transgenic mice expressing a rat alpha-cardiac myosin heavy chain/human multiple drug resistance 1 fusion gene

Cardiac toxicity is a major factor that limits the use of anthracyclines in cancer chemotherapy. Heart failure frequently develops in patients treated with doxorubicin (Adriamycin), when they receive a cumulative dose greater than 500 mg/m2. To make a mouse model for gene therapy designed to prevent this toxic effect, we have produced transgenic mice overexpressing the human cDNA for the multiple drug resistance (h-mdr1) gene driven by 2.12 kb of the 5' flanking region of the rat alpha-cardiac myosin (aCM) heavy chain gene. Two lines of transgenic mice expressed the transgene at a high level in heart muscle. Transgenic and control animals were treated with Adriamycin intravenously at either a single dose of 10 mg/kg or a cumulative dose of 30 mg/kg in three injections. Subsequent light and electron microscopic examination of heart tissue demonstrated degenerative changes in control mice that were absent in transgenic animals at both doses. These results show that expression of the alphaCM/h-mdr1 transgene in heart confers protection from the toxic effect of Adriamycin and suggest that such constructs, if employed effectively in cardiac gene therapy protocols, could allow a more aggressive use of anthracyclines in the treatment of cancer.

Lipid peroxidation of rat myocardial tissue following daunomycin administration

Daunomycin-induced cardiotoxicity has been regarded to be the result of oxygen-mediated lipid peroxidation of cell membranes. The aim of the present work was to evaluate the extent of lipid peroxidation in rat heart after administration of this anticancer drug and, further, to examine possible activation of some endogenous antioxidant defense systems. Myocardial tissue from both control and drug-treated rats was tested for lipid peroxidation using a selective third-order derivative method that is based on the analysis of the free malondialdehyde produced. Determination of reduced/oxidized glutathione levels and measurement of the activity of DT-diaphorase, glutathione-S-transferase, glutathione reductase, glucose-6-phosphate dehydrogenase and NADPH-cytochrome P-450 reductase were also carried out using literature methods. Significant increase of malondialdehyde content, and DT-diaphorase and glutathione-S-transferase activities were found in myocardial tissue from daunomycin-treated rats. On the other hand, reduced and oxidized glutathione levels were significantly decreased while the activity of glutathione reductase, glucose-6-phosphate dehydrogenase and NADPH-cytochrome P-450 reductase remained unchanged after daunomycin administration. The results of the present study give further evidence that daunomycin can induce lipid peroxidation in heart. However, additional experimentation is needed in order to delineate the molecular details of this process as well as of the mechanisms evolved to limit it.

Dexrazoxane in the prevention of doxorubicin-induced cardiotoxicity

OBJECTIVE

To review doxorubicin-induced cardiotoxicity and to evaluate the use of dexrazoxane in its prevention.

DATA SOURCES

All animal and human reports involving doxorubicin-induced cardiac adverse effects were searched using MEDLINE combined with a fan search of relevant papers.

DATA EXTRACTION

Animal, in vitro cellular, and human data are thoroughly reviewed with particular emphasis on doxorubicin-induced cardiotoxicity, including clinical manifestations, risk factors, and mechanisms of toxicity. The role of dexrazoxane in the prevention of doxorubicin-induced cardiotoxicity is reviewed, including mechanism of effect, animal data, and human trials.

DATA SYNTHESIS

Anthracyclines are associated with a cumulative, dose-dependent, irreversible cardiomyopathy that can lead to congestive heart failure and death. The incidence of cardiotoxicity rises sharply at a total lifetime dose of more than 550 mg/m2. Through its semiquinone metabolite, doxorubicin appears to generate superoxide anion and superhydroxide free radicals with iron as a cofactor. Because of poor myocardial concentrations of superoxide dismutase, catalase, and glutathione peroxidase, these free radicals cause extensive lipid peroxidation and mitochondrial destruction.

CONCLUSIONS

Dexrazoxane is hydrolyzed to its active form intracellularly and binds iron to prevent the formation of superhydroxide radicals, thus preventing mitochondrial destruction. The effect of dexrazoxane on the prevention of doxorubicin-induced cardiotoxicity is impressive in both animal and human studies. Further research is needed to clearly demonstrate the effect dexrazoxane has on the antitumor effects of combination chemotherapy while defining optimal dosing strategies to minimize myelosuppression and maximize cardioprotection.

Effects of Adriamycin on heart mitochondrial function in rested and exercised rats

The effect of Adriamycin (ADM) administration on heart mitochondria was investigated in rats at rest and after an acute bout of maximal exercise. ADM was given intravenously at a dosage of 8 mg/kg body weight 24 and 1 hr before rats were decapitated. Respiratory functions of the isolated heart mitochondria were measured polarographically with both site 1 (pyruvate-malate and 2-oxoglutarate) and site 2 (succinate) substrates. State 4 (basal) respiration was increased using all substrates in ADM-treated rat hearts compared with non-drug control hearts. The mitochondrial respiratory control index was decreased with ADM, but the reduction was due to an increase in state 4 rather than a decrease of state 3 (ADP-stimulated) respiration. ADM administration abolished an exercise-induced elevation of state 3 respiration using all substrates. There was no significant myocardial oxidative damage of dysfunction as evaluated by lipid peroxidation and antioxidant enzyme activity. Addition of exogenous free radicals to the respiratory medium using hypoxanthine and xanthine oxidase resulted in significant deterioration of mitochondrial function in all parameters measured, but no drug- or exercise-specific patterns of damage were revealed. It is concluded that the current dose of ADM (20% of the established cumulative toxic dose) administered within 24 hr can interfere with normal heart mitochondrial function both at rest and during heavy exercise, but does not elicit overwhelming oxidative damage to the myocardium.

Heart and liver membrane phospholipid homeostasis during acute administration of various antitumoral drugs to the rat

The purpose of this study was to investigate in the rat heart and liver the effects of an acute administration of three anthracyclines, doxorubicin, epirubicin and pirarubicin, and an anthracenedione, mitoxantrone, on the membrane peroxidative status, which was estimated by the composition of polyunsaturated fatty acids (PUFA), and on the activities of the enzymes involved in membrane repair processes and lipid hydroperoxide detoxification. Rats were injected for four consecutive days with the drugs or saline (control) and killed 24 hr after the last injection. All the drugs induced an increase in plasma thiobarbituric reactive substances and alpha-tocopherol concentrations, both expressed per milligram of plasma lipids. Plasma vitamin A was decreased by about a factor of two by all the drugs. The fatty acid profile in the heart lipids showed that the polyunsaturated species (20:4 n-6, 22:6 n-3) remained at the same or even higher levels after anthracycline treatment. This can be explained by the fact that the activities of the enzymes involved in either the recycling of membrane phospholipids, such as phospholipases A1 and A2 (EC 3.1.1.4 and EC 3.1.1.32), lysophospholipases (EC 3.1.1.5) and acylCoA:lysophosphatidylcholine acyltransferases (EC 2.3.1.23), or hydroperoxide detoxification, such as selenium-dependent glutathione peroxidase (GSH-PX, EC 1.11.1.9) and glutathione S-transferases (GSH-T, EC 2.1.5.18), were maintained at the same level of activity after the antitumoral treatment. In liver, membrane phospholipid levels of PUFA were maintained as well as the activities of phospholipid-metabolizing enzymes. GSH-PX activity was not affected whereas that of GSH-T was slightly lowered by the drugs. These results suggest that during acute antitumoral-induced lipid peroxidation of membranes, the multi-enzymatic complex of the immediate processes of repair and detoxification is fully operational, allowing the membrane to rapidly recover its functional status. The results are discussed in the context of the equivocal relationships between antitumoral-induced lipid peroxidation and cardiac disturbances.

Etiology of sarcoplasmic reticulum calcium release channel lesions in doxorubicin-induced cardiomyopathy

Alterations in the native function of the ryanodine-sensitive Ca2+ release channel complex of sarcoplasmic reticulum (SR) isolated from rat cardiac ventricles during acute and chronic exposure to doxorubicin are examined. Compared to control SR, actively loaded SR from animals exposed to a single intravenous dose of doxorubicin exhibit faster rates of doxorubicin-induced Ca2+ release and the occupancy of [3H]ryanodine is significantly enhanced with subsequent exposure of SR membranes to doxorubicin in vitro. One week after acute exposure to doxorubicin in vitro, the EC50 for activation of the binding of [3H]ryanodine by Ca2+ is not significantly different from control SR. However, the persistence of doxorubicin-sensitized SR channels appears to be latent since repeated exposure to doxorubicin in vitro significantly enhances receptor occupancy in SR obtained from the treated rats compared to control SR. Ryanodine receptors from rats chronically exposed to doxorubicin consistently exhibit a higher sensitivity to activation Ca2+ which persists at least 4 weeks following the last injection of drug. Chronic exposure produces a concomitant reduction in the capacity of [3H]ryanodine binding sites. The marked decrease in receptor density observed with SR from doxorubicin-treated rats coincides with significant reduction in body weight, suggesting a possible influence of nutrition. However, sodium dodecyl sulfate polyacrylamide electrophoresis indicates no significant loss of the high molecular weight subunit of the ryanodine receptor, suggesting that loss of [3H]ryanodine-binding capacity may be the result of progressive and permanent channel desensitization. Consistent with desensitized receptors, membrane vesicles prepared from rats chronically exposed to doxorubicin take up significantly more Ca2+ and exhibit significantly reduced rates of doxorubicin or Ca2+/ryanodine induced Ca2+ release. The data demonstrates (i) doxorubicin inflicts cumulative SR channel lesions in vivo, (ii) a persistent sensitization of the SR channel to activation by Ca2+ and (iii) a significant and apparently irreversible reduction in the number of functional channel complexes.

Nucleolar organizer regions in cardiac lesions induced by doxorubicin

The use of the argyrophilic (Ag) staining technique for nucleolar organizer regions (NORs) revealed nuclear changes in myocytes of the left atrium of 10 rats treated twice a week for 6 weeks with doxorubicin (1 mg/kg body weight) iv and sacrificed after 6 weeks without treatment. The changes were easily detected qualitatively and further assessed by quantification. Cardiac myocytes of doxorubicin-treated rats had larger nuclei and/or a larger quantity of AgNORs that were either dispersed in a number of small dots or clustered in rounded, rod-shaped, or tortuous large structures. AgNOR alterations may reflect a defect of nucleolar association leading to an impairment of protein synthesis that could be involved in doxorubicin cardiotoxicity.

Cardiotoxic effects and the influence on the beta-adrenoceptor function of doxorubicin (Adriamycin) in the rat

The possible relationship between the effect of the anthracycline-cytostatic doxorubicin (Dox) on the cardiac beta-adrenoceptor function in vitro and the development of delayed cardiotoxicity in vivo has been investigated in the rat. Dox (10(-5)-10(-4) M) blocked the chronotropic effect of isoprenaline on isolated atria in a competitive manner. Treatment with a single dose of Dox 5 mg/kg intravenously caused marked ECG changes manifested by progressive prologations of the Q alpha T and S alpha T-intervals, which amounted to 37% and 58% respectivity 5 weeks after the medication. At this time no beta-blocking action was detectable when tested on the isolated atria in the same rats. The results indicate that the delayed cardiotoxicity induced by Dox is not mediated by an interference with the cardiac beta-adrenoceptor function.

Inhibition of flavin metabolism by adriamycin in skeletal muscle

Adriamycin (ADR), a potent antineoplastic agent, has been shown to interact with flavin derivatives and to compete with flavin coenzymes for their respective binding sites on flavin-containing enzymes. The present investigation determined that ADR administration inhibited flavin adenine dinucleotide (FAD) biosynthesis from riboflavin in rat skeletal muscle in a dose-related manner compared to results in pair-fed controls. Five groups of adult Holtzman rats of both sexes were given twice daily intraperitoneal injections of ADR for 3 days, representing cumulative doses of 6, 12, 18, 24, and 30 mg/kg body weight. At the cumulative dose of 6 mg/kg, there was no significant effect, but at 12, 18, 24, and 30 mg/kg levels significant increases in [14C]FAD formation from [14C]riboflavin occurred. ADR-induced myopathy may be due, at least in part, to inhibition of FAD formation, ultimately leading to changes in energy metabolism and oxidative capacity.

Early and late sarcoplasmic reticulum changes in doxorubicin cardiomyopathy. An ultrastructural investigation with the zinc iodide-osmium tetroxide (ZIO) technique

The sequence of myocardial changes in the mouse induced by doxorubicin (Dx) treatment (10 mg/kg i.v.) has been investigated by electron microscopy with the help of the zinc iodide-osmium tetroxide (ZIO) technique. Accumulation of ZIO-reactive material, possibly oxidized glutathione and other disulfides, in the sarcoplasmic reticulum (S.R.) is among the earliest (1 h after Dx injection), more prominent and persistent findings (up to 100 days). It may have a pathogenic relationship with a number of functional and morphologic changes occurring in myocardial cells, including impairment of calcium transport and contractility, S.R. dilation up to extensive vacuolization, as well as inhibition of DNA, RNA and protein synthesis leading to atrophy and disruption of sarcomeres. The latter finding, first appearing in a few cells 4 to 7 days after Dx and progressively increasing in severity and extension during the next 3 months, may represent a key factor in the evolution of chronic cardiomyopathy to cardiac insufficiency. In most cells, only a minority of mitochondria showed obvious ultrastructural lesions, which were first observed 24 h after treatment and disappeared by the end of the first month, when no more mitochondrial damage was found outside degenerating cells. The myocardium of mice receiving multiple Dx injections (4 mg/Kg, 10 times, or 9 mg/Kg, 5 times) showed the same changes observed in animals treated with a single dose, though they were more severe and extensive.

Doxorubicin induced alterations in lipid metabolism of cultured myocardial cells

Doxorubicin (DX) was found to inhibit the incorporation of [1-14C]linoleic acid and [1(3)-3H]glycerol into the major membrane phosphoglycerides, phosphatidylcholine and phosphatidylethanolamine of cultured myocardial cells in a dose-dependent manner (0.16-16 microM). It is suggested that DX affects de novo biosynthesis of these lipids. In contrast, DX-treatment of the cells stimulated incorporation of [1-14C]linoleic acid into triacylglycerol. The effects of DX on lipid metabolism were only demonstrable 20-24 hr after a 1 hr exposure of the cells to the drug indicating that DX exerts little or no direct effect on the enzymes participating in lipid synthesis and that the alterations in lipid metabolism induced by DX probably are secondary to inhibition of protein synthesis and progressive cell injury. Extensive peroxidative decomposition of membrane lipids appeared not to take place in the DX-treated cells as judged from fatty acid analysis of total membrane phosphoglyceride.

Acute effects of doxorubicin (adriamycin) on left ventricular function in dogs

Although chronic doxorubicin (adriamycin) cardiotoxicity often is attributed to repeated episodes of acute myocardial injury, the acute effects of doxorubicin on in vivo left ventricular performance have not been studied in a carefully controlled setting. Accordingly, we recorded high-fidelity left ventricular pressures and segmental dimensions before and after either intravenous or intracoronary doxorubicin in twelve open-chest dogs. Propranolol was administered to prevent reflex sympathetic stimulation, and heart rate was held constant by atrial pacing. Intravenous doxorubicin (1.5 mg/kg) (n = 6) caused significant decreases in all measured indices of myocardial contractility, in association with a large decrease in left ventricular systolic pressure (125 +/- 28 and 81 +/- 23 mm Hg before and 5 min after doxorubicin, respectively, P less than 0.01). Intracoronary doxorubicin (0.075 to 0.3 mg/kg) (n = 6) caused similar decreases in percent segment shortening (from 19 +/- 7 to 16 +/- 8, P less than 0.05), mean normalized shortening rate (from 0.87 +/- 0.34 to 0.71 +/- 0.37 segment lengths/sec, P less than 0.05), and peak positive left ventricular dP/dt (by 10 +/- 11%, P less than 0.07), although left ventricular systolic pressure was only modestly decreased (126 +/- 20 and 113 +/- 17 mm Hg before and after doxorubicin, respectively, P less than 0.01). Intracoronary doxorubicin also slowed the rate of left ventricular relaxation, as evidenced by an increase in the time constant for isovolumic pressure fall from 32.0 +/- 9.0 to 36.9 +/- 7.5 msec, and significantly altered the relationship between left ventricular pressure and dimension at end-diastole.

Acute anthracycline cardiotoxicity. Comparative morphologic study of three analogues

Chemotherapeutic use of anthracycline antibiotics is limited by their cardiotoxic effects. A potential solution to this problem is the development of anthracycline analogues retaining antitumor efficacy but without cardiac toxicity. An isolated perfused rabbit heart model was used to compare the nature and extent of early ultrastructural effects on the myocyte of three anthracycline analogues purported to have lesser cardiotoxicity than Adriamycin (doxorubicin). Seventeen rabbit hearts were perfused with oxygenated Krebs-Ringer bicarbonate buffer at 39 degrees C containing either Adriamycin (4 mg/L), daunomycin (10.6 mg/L), aclacinomycin (8 mg/L), or rubidazone (17.6 mg/L). For comparison, three hearts each were exposed to phosphoramide mustard (14.7 mg or 25 mg/L) or 4-hydroperoxy cyclophosphamide (24 mg or 17 mg/L), two active congeners of cyclophosphamide, an agent interacting with DNA differently than the anthracyclines and which is known to be cardiotoxic in high dose. Two hearts were exposed to dactinomycin (0.1 mg or 0.2 mg/L) which intercalates with DNA in a manner similar to the anthracyclines but which is not cardiotoxic. Ten control hearts were perfused with oxygenated buffer solution only. Light microscopic study disclosed no differences between treated and control hearts. Electron microscopic examination showed a striking and distinctive clumping of nuclear chromatin with clearing of chromatin from the nuclear membrane in all anthracycline treated hearts but in no hearts treated with 4-hydroperoxy cyclophosphamide, phosphoramide Mustard, dactinomycin, or control hearts. The nuclear effects of the four anthracycline analogues were indistinguishable. Thus, all anthracycline analogues studied produced acute nuclear alterations which were distinctive from the changes produced by other DNA interactive chemotherapeutic agents. The relationship of the distinctive anthracycline nuclear changes to the late cardiomyopathy requires further definition.

Effects of feed-pairing and different doses of doxorubicin on mortality and electrolyte changes in the mouse heart

Various electrolyte changes have been documented in the hearts of different species of laboratory animals intoxicated with doxorubicin. However, it has not been determined what role the drug-induced relative nutritional lack plays in the electrolyte imbalance of this antineoplastic drug, nor to what extent the electrolyte imbalance is dose-related. A feed-pairing study performed after a single 20 mg/kg i.p. dose of doxorubicin demonstrated that relative heart weight was significantly increased in responding drug treated mice over ad libitum controls. The heart weights of feed-paired animals were also elevated to the same extent. Nutrition did not appear to have any effect on the drug-induced elevation of total ventricular calcium levels in responding animals. Although heart sodium concentrations were increased over ad libitum controls by feed restriction, they were still significantly lower than the doxorubicin-treated animals. Cardiac levels of magnesium and potassium were significantly decreased over both ad libitum and feed-paired controls. Calcium and sodium levels were increased significantly at 32 mg/kg but not at 50 or 80 mg/kg doxorubicin, while potassium and magnesium were depressed at these doses. Both the median time of death and total weight loss were inversely related to dose. It is concluded that the electrolyte disturbances are not due to the nutrition-related weight loss, and may be a proximal cause of doxorubicin-induced cardiotoxicity.

Effects of adriamycin on calcium concentration and morphology of mouse salivary glands

A large single dose (15 mg/kg body wt, ip) of the antitumor agent adriamycin (ADR) caused a marked increase in calcium concentration of submaxillary gland of female mice, and a smaller increase in the parotid gland within 2 days of injection. A small dose (2.5 mg/kg body wt) had no effect. The histological appearance of the glands was also changed and included an increase in size of granules and acinar cells of the submaxillary glands and a decrease in size of acinar cells of the parotid. At the EM level, there was evidence of mitochondrial alteration in the parotid but not in the submaxillary glands. Rough endoplasmic reticulum (RER) was markedly disorganized in the parotid, and abnormal whorls of RER were evident. Submaxillary glands showed no change in RER. Water content of either gland was unchanged from that of controls. Heart ventricles, unexpectedly, showed no change in calcium concentration from that of control tissues, at 3 h, 1, 2 or 4 days after ADR administration. The [Ca] changes induced by ADR in the submaxillary glands are not mediated via beta-adrenoceptor activation since propranolol did not alter the ADR-induced changes. The marked difference in response of the glands (and heart) to ADR, suggests that the mechanisms involved in calcium homeostasis in these organs are very different.

Early changes in human myocardial nuclei after doxorubicin

Ten nuclei from the endomyocardial biopsies for each of the following 32 patients were examined by electron microscopy: seven patients before and then four and 24 hours after treatment with first-dose doxorubicin; seven patients before and four and 24 hours after treatment with first-dose doxorubicin plus N-acetyl cysteine; nine patients with doxorubicin induced cardiomyopathy; and nine patients with idiopathic congestive cardiomyopathy. Five criteria were used to semiquantitatively compare nuclei and nucleoli from each group. The most dramatic changes in nuclear and nucleolar morphology were seen four hours after doxorubicin administration. Nucleoli were smaller, contracted or segregated and contained fewer fibrillar centers and a collapsed or fragmented nucleolonema. The addition of N-acetylcysteine to treatment did not alter these results. By 24 hours, nuclei had returned to the pre-treatment status. Long-term doxorubicin therapy produced increased chromatin clumping and slightly contracted nucleoli. The idiopathic congestive cardiomyopathic nuclei differed significantly from these doxorubicin cardiomyopathic nuclei in the decreased amount of chromatin clumping and the increase in fibrillar centers and nucleonema pattern. It is concluded from this study that: (1) doxorubicin markedly alters the morphology of the human myocardial nucleus and nucleolus four hours after treatment, but these changes diminish by 24 hours; (2) N-acetylcysteine treatment fails to prevent these changes; and (3) the nuclei and nucleoli of chronic doxorubicin-induced cardiomyopathy differ significantly from other congestive cardiomyopathies, but do resemble changes seen four hours after the first dose of doxorubicin.

Cytotoxic effects of adriamycin on mouse hypoglossal neurons following retrograde axonal transport from the tongue

We reported recently that the fluorescent, cytostatic drug, adriamycin (Doxorubicin) may reach the hypoglossal neurons by retrograde axonal transport from the nerve terminals of the tongue. The present investigation was undertaken to ascertain whether morphological changes occur in the hypoglossal neurons due to retrograde transport of adriamycin. Neuronal degeneration was observed in the hypoglossal nucleus 14 days after i.m. injection of adriamycin into the tongue. Early neuronal changes, such as rarefaction of the nuclear chromatin and segregation and fragmentation of the nucleolar components, were succeeded by cytoplasmic vacuolation, disappearance of ribosomes and other degenerative features. These observations are important from a neurotoxicologic viewpoint since they demonstrate that retrograde axonal transport may provide a route for the entry of adriamycin into the nervous system. Thus far, adriamycin appears to be the only known substance which can be traced directly in the neurons and cause their degeneration. An experimental method of damaging the motor neurons of the CNS has been introduced. A new toxic model for the investigation of experimental motor neuron disease is therefore available by the use of adriamycin.

Anthracycline cardiotoxicity: clinical and pathologic outcomes assessed by radionuclide ejection fraction

A clinical syndrome of severe cardiomyopathy often accompanies administration of high doses of anthracycline agents. We studied 36 patients serially with radionuclide angiography. At three weeks following drug administration, 8 of 36 patients showed depression of ejection fraction (EF). All had received at least 280 mg/m2 of the drug and 7 had received more than 380 mg/M2. Definite clinical syndromes of congestive cardiomyopathy developed only in patients showing EF depression and in some patients, EF depression developed without signs of congestive heart failure. Ejection fraction studies at 5 minutes, 1 hour, 4 hours, 24 hours, 72 hours, and one week following drug administration showed no changes when compared to immediate preg-drug EF. Seven patients who died during the study underwent histologic examination. Only the single patient with a depressed EF showed histologic evidence of athracycline cardiotoxicity, although all but 1 of these patients had received at least 400 mg/M2. We conclude that serial radionuclide EF just prior to anthracycline administration is a potentially useful predictor of cardiac toxicity, and that EF depression and/or preservation of a normal EF should be weighed in the decision for administering a drug of this type at high dosage levels.

A study of drug-induced kinetic perturbations in the marrow of a patient with neuroblastoma

The kinetic perturbations induced by vincristine, cyclophosphamide, and adriamycin were studied in the bone marrow of a patient with neuroblastoma. Serial marrow samples were studied by dual parameter (Coulter volume and DNA content), flow cytometry, and radioautography, and findings were correlated with cytomorphologic changes. Multiparameter studies were useful in sorting out the various sequences of drug-induced kinetic changes. Distinctive effects of vincristine were observed at 2 and 24 hours after drug administration. An early drug-induced proliferative response was observed between 2 and 48 hours after initiation of therapy. Cell damage was apparent on day 4, with recovery in cell proliferative rate observed on days 6 through 9. The kinetics of perturbation may be useful in identifying temporal windows for optimum scheduling of chemotherapeutic agents in man.

Selective Mitochondrial Alterations Induced by a Single Dose of Daunorubicin or 4-Demethoxydaunorubicin in Mouse Ventricular Myocardium

The ventricular myocardium of CD1 mice given a single high dose (LD50) of daunorubicin (DNR) or its derivative, 4-demethoxydaunorubicin (4DD), was studied under the electron microscope. Severe degenerative alterations were observed, but only in the mitochondria in myocardial tissue samples taken 3 and 7 days after treatment. This suggests that mitochondrial lesions might play an important role in the pathogenesis of anthracycline myocardiopathy. Furthermore, the nucleolar segregation phenomenon, already described in experimental doxorubicin myocardiopathy, was not observed in the myocardial samples taken 1 and 3 h after DNR or 4DD injection: this fact may be interpreted, without excluding a possible DNA-mediated toxic mechanism, as the result of different kinetic behaviour of DNR and 4DD compared to doxorubicin.