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Malik JR, Podany AT, Khan P, Shaffer CL, Siddiqui JA, Baranowska‐Kortylewicz J, Le J, Fletcher CV, Ether SA, Avedissian SN. Chemotherapy in pediatric brain tumor and the challenge of the blood-brain barrier. Cancer Med 2023; 12:21075-21096. [PMID: 37997517 PMCID: PMC10726873 DOI: 10.1002/cam4.6647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/18/2023] [Accepted: 10/12/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Pediatric brain tumors (PBT) stand as the leading cause of cancer-related deaths in children. Chemoradiation protocols have improved survival rates, even for non-resectable tumors. Nonetheless, radiation therapy carries the risk of numerous adverse effects that can have long-lasting, detrimental effects on the quality of life for survivors. The pursuit of chemotherapeutics that could obviate the need for radiotherapy remains ongoing. Several anti-tumor agents, including sunitinib, valproic acid, carboplatin, and panobinostat, have shown effectiveness in various malignancies but have not proven effective in treating PBT. The presence of the blood-brain barrier (BBB) plays a pivotal role in maintaining suboptimal concentrations of anti-cancer drugs in the central nervous system (CNS). Ongoing research aims to modulate the integrity of the BBB to attain clinically effective drug concentrations in the CNS. However, current findings on the interaction of exogenous chemical agents with the BBB remain limited and do not provide a comprehensive explanation for the ineffectiveness of established anti-cancer drugs in PBT. METHODS We conducted our search for chemotherapeutic agents associated with the blood-brain barrier (BBB) using the following keywords: Chemotherapy in Cancer, Chemotherapy in Brain Cancer, Chemotherapy in PBT, BBB Inhibition of Drugs into CNS, Suboptimal Concentration of CNS Drugs, PBT Drugs and BBB, and Potential PBT Drugs. We reviewed each relevant article before compiling the information in our manuscript. For the generation of figures, we utilized BioRender software. FOCUS We focused our article search on chemical agents for PBT and subsequently investigated the role of the BBB in this context. Our search criteria included clinical trials, both randomized and non-randomized studies, preclinical research, review articles, and research papers. FINDING Our research suggests that, despite the availability of potent chemotherapeutic agents for several types of cancer, the effectiveness of these chemical agents in treating PBT has not been comprehensively explored. Additionally, there is a scarcity of studies examining the role of the BBB in the suboptimal outcomes of PBT treatment, despite the effectiveness of these drugs for other types of tumors.
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Affiliation(s)
- Johid Reza Malik
- Antiviral Pharmacology LaboratoryCollege of Pharmacy, University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Anthony T. Podany
- Antiviral Pharmacology LaboratoryCollege of Pharmacy, University of Nebraska Medical CenterOmahaNebraskaUSA
- Pediatric Clinical Pharmacology ProgramChild Health Research Institute, University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Parvez Khan
- Department of Biochemistry and Molecular BiologyUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Christopher L. Shaffer
- Pediatric Clinical Pharmacology ProgramChild Health Research Institute, University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Jawed A. Siddiqui
- Department of Biochemistry and Molecular BiologyUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | | | - Jennifer Le
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical SciencesSan DiegoCaliforniaUSA
| | - Courtney V. Fletcher
- Antiviral Pharmacology LaboratoryCollege of Pharmacy, University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Sadia Afruz Ether
- Antiviral Pharmacology LaboratoryCollege of Pharmacy, University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Sean N. Avedissian
- Antiviral Pharmacology LaboratoryCollege of Pharmacy, University of Nebraska Medical CenterOmahaNebraskaUSA
- Pediatric Clinical Pharmacology ProgramChild Health Research Institute, University of Nebraska Medical CenterOmahaNebraskaUSA
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Sutedja EK, Arianto TR, Lesmana R, Suwarsa O, Setiabudiawan B. The Chemoprotective Role of Vitamin D in Skin Cancer: A Systematic Review. Cancer Manag Res 2022; 14:3551-3565. [PMID: 36583029 PMCID: PMC9793722 DOI: 10.2147/cmar.s389591] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Research in mice showed that vitamin D receptor deficiency was correlated with an increased rate of non-melanoma skin cancer. Therapeutic supplemental vitamin D has also been reported to reduce cell growth in both melanoma and non-melanoma skin cancer. This paper aims to describe the existing research studies that discuss the potential and role of vitamin D in the management of skin cancer. Methods Articles were searched from three databases (PubMed, ScienceDirect, Scopus) and manual search. 18 articles were included. These were further divided into in vivo and in vitro studies. The literature search was based on the following Patients, Intervention, Control, and Outcome (PICO) criteria: Patients with any types of skin cancer; Vitamin D and their derivates as the intervention; placebo or standard regimen as control, and survival rate or response rate as primary outcome. Results From the three databases, we obtained 802 studies. Prior to screening of the literature obtained, several studies were excluded. In the eligibility assessment, seven studies were excluded due to their outcomes being not eligible for analysis, and two studies were excluded due to inaccessible full texts. The remaining 18 studies were included. Five studies had a clinical research design (randomized controlled trial or interventional study), which use vitamin D3 as vitamin D derivatives and the results showed that the administration of vitamin D3 reduces the proliferation of skin cancer cells. Similar results were also reported in studies with pre-clinical research designs, either in vivo or in vitro, where six were in vivo studies and nine studies were in vitro studies. Conclusion Our literature review revealed that that vitamin D derivatives, such as 1,25(OH)2D3 or 20(OH)D3 can effectively reduce the proliferation of skin cancer cells by contributing in the inhibition of cell growth and development, highlighting vitamin D's role as good prognostic factor.
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Affiliation(s)
- Eva Krishna Sutedja
- Department of Dermatology and Venereology, Faculty of Medicine Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, West Java, Indonesia,Correspondence: Eva Krishna Sutedja, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin General Hospital, Jl. Pasteur No. 38, Bandung, West Java, 40161, Indonesia, Tel +62222032426 ext. 3449, Fax +62222032426, Email
| | - Tiara Rachmaputeri Arianto
- Department of Dermatology and Venereology, Faculty of Medicine Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, West Java, Indonesia
| | - Ronny Lesmana
- Department of Physiology, Faculty of Medicine Universitas Padjadjaran – Dr. Hasan Sadikin Hospital Bandung, Bandung, West Java, Indonesia
| | - Oki Suwarsa
- Department of Dermatology and Venereology, Faculty of Medicine Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, West Java, Indonesia
| | - Budi Setiabudiawan
- Department of Child Health, Faculty of Medicine Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, West Java, Indonesia
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Vitamin D and Vitamin D Analogs as Adjuncts to Field Therapy Treatments for Actinic Keratoses: Current Research and Future Approaches. J Skin Cancer 2021; 2021:9920558. [PMID: 34306760 PMCID: PMC8249223 DOI: 10.1155/2021/9920558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/11/2021] [Indexed: 11/22/2022] Open
Abstract
Actinic keratoses (AK), also known as solar keratoses, are precancerous hyperkeratotic papules caused by long-term exposure to ultraviolet radiation. Management of AK prior to progression to cutaneous malignancy represents an important window of intervention. This is important on a population level, given the high incidence, morbidity, financial costs, and the low but measurable risk of mortality from cutaneous neoplasia. Treatments for AK have been refined for many years with significant progress over the past decade. Those recent advancements lead to questions about current treatment paradigms and the role of harnessing the immune system in field therapies. Recent studies suggest a key interplay between vitamin D and cancer immunity; in particular, the systemic and/or topical vitamin D analogs can augment field therapies used for severe actinic damage. In this review, we will examine the literature supporting the use of vitamin D-directed therapies to improve field therapy approaches. An enhanced understanding of these recent concepts with a focus on mechanisms is important in the optimized management of AK. These mechanisms will be critical in guiding whether selected populations, including those with immunosuppression, heritable cancer syndromes, and other risk factors for skin cancer, can benefit from these new concepts with vitamin D analogs and whether the approaches will be as effective in these populations as in immunocompetent patients.
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Krishnan V, Peng K, Sarode A, Prakash S, Zhao Z, Filippov SK, Todorova K, Sell BR, Lujano O, Bakre S, Pusuluri A, Vogus D, Tsai KY, Mandinova A, Mitragotri S. Hyaluronic acid conjugates for topical treatment of skin cancer lesions. SCIENCE ADVANCES 2021; 7:7/24/eabe6627. [PMID: 34117055 PMCID: PMC8195472 DOI: 10.1126/sciadv.abe6627] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 04/23/2021] [Indexed: 05/31/2023]
Abstract
Skin cancer is one of the most common types of cancer in the United States and worldwide. Topical products are effective for treating cancerous skin lesions when surgery is not feasible. However, current topical products induce severe irritation, light-sensitivity, burning, scaling, and inflammation. Using hyaluronic acid (HA), we engineered clinically translatable polymer-drug conjugates of doxorubicin and camptothecin termed, DOxorubicin and Camptothecin Tailored at Optimal Ratios (DOCTOR) for topical treatment of skin cancers. When compared to the clinical standard, Efudex, DOCTOR exhibited high cancer-cell killing specificity with superior safety to healthy skin cells. In vivo studies confirmed its efficacy in treating cancerous lesions without irritation or systemic absorption. When tested on patient-derived primary cells and live-skin explants, DOCTOR killed the cancer with a selectivity as high as 21-fold over healthy skin tissue from the same donor. Collectively, DOCTOR provides a safe and potent option for treating skin cancer in the clinic.
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Affiliation(s)
- Vinu Krishnan
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA 02115, USA
| | - Kevin Peng
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA 02115, USA
| | - Apoorva Sarode
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA 02115, USA
| | - Supriya Prakash
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA 02115, USA
| | - Zongmin Zhao
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA 02115, USA
| | - Sergey K Filippov
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
| | - Kristina Todorova
- Cutaneous Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Building 149 13th Street, Charlestown, MA 02129, USA
| | - Brittney R Sell
- Departments of Anatomic Pathology and Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Omar Lujano
- Department of Molecular, Cellular, and Developmental Biology (MCDB), University of California, Santa Barbara, Santa Barbara, CA 93117, USA
| | - Shirin Bakre
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
| | - Anusha Pusuluri
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA 02115, USA
| | - Douglas Vogus
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA 02115, USA
| | - Kenneth Y Tsai
- Departments of Anatomic Pathology and Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Anna Mandinova
- Cutaneous Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Building 149 13th Street, Charlestown, MA 02129, USA
- Broad Institute of Harvard and MIT, 7 Cambridge Center, MA 02142, USA
- Harvard Stem Cell Institute, 7 Divinity Avenue, Cambridge, MA 02138, USA
| | - Samir Mitragotri
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA.
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA 02115, USA
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Khan A, Gamble LD, Upton DH, Ung C, Yu DMT, Ehteda A, Pandher R, Mayoh C, Hébert S, Jabado N, Kleinman CL, Burns MR, Norris MD, Haber M, Tsoli M, Ziegler DS. Dual targeting of polyamine synthesis and uptake in diffuse intrinsic pontine gliomas. Nat Commun 2021; 12:971. [PMID: 33579942 PMCID: PMC7881014 DOI: 10.1038/s41467-021-20896-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/18/2020] [Indexed: 02/07/2023] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is an incurable malignant childhood brain tumor, with no active systemic therapies and a 5-year survival of less than 1%. Polyamines are small organic polycations that are essential for DNA replication, translation and cell proliferation. Ornithine decarboxylase 1 (ODC1), the rate-limiting enzyme in polyamine synthesis, is irreversibly inhibited by difluoromethylornithine (DFMO). Herein we show that polyamine synthesis is upregulated in DIPG, leading to sensitivity to DFMO. DIPG cells compensate for ODC1 inhibition by upregulation of the polyamine transporter SLC3A2. Treatment with the polyamine transporter inhibitor AMXT 1501 reduces uptake of polyamines in DIPG cells, and co-administration of AMXT 1501 and DFMO leads to potent in vitro activity, and significant extension of survival in three aggressive DIPG orthotopic animal models. Collectively, these results demonstrate the potential of dual targeting of polyamine synthesis and uptake as a therapeutic strategy for incurable DIPG.
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Affiliation(s)
- Aaminah Khan
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia
| | - Laura D. Gamble
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia
| | - Dannielle H. Upton
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia
| | - Caitlin Ung
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia
| | - Denise M. T. Yu
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia
| | - Anahid Ehteda
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia
| | - Ruby Pandher
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia
| | - Chelsea Mayoh
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia
| | - Steven Hébert
- grid.14709.3b0000 0004 1936 8649Lady Davis Institute for Medical Research, Jewish General Hospital, Department of Human Genetics, McGill University, 3999 Côte Ste-Catherine Road, Montreal, QC H4A 3J1 Canada
| | - Nada Jabado
- grid.63984.300000 0000 9064 4811Department of Pediatrics, McGill University Health Center, 1001 Decarie Boulevard, Montreal, QC H4A 3J1 Canada
| | - Claudia L. Kleinman
- grid.14709.3b0000 0004 1936 8649Lady Davis Institute for Medical Research, Jewish General Hospital, Department of Human Genetics, McGill University, 3999 Côte Ste-Catherine Road, Montreal, QC H4A 3J1 Canada
| | - Mark R. Burns
- Aminex Therapeutics Inc., Suite #364, 6947 Coal Creek Parkway SE, Newcastle, WA 98059 USA
| | - Murray D. Norris
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia ,grid.1005.40000 0004 4902 0432Centre for Childhood Cancer Research, UNSW Sydney, Kensington, NSW 2052 Australia
| | - Michelle Haber
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia ,grid.1005.40000 0004 4902 0432Centre for Childhood Cancer Research, UNSW Sydney, Kensington, NSW 2052 Australia
| | - Maria Tsoli
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia
| | - David S. Ziegler
- grid.1005.40000 0004 4902 0432Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW 2052 Australia ,grid.414009.80000 0001 1282 788XKids Cancer Centre, Sydney Children’s Hospital, High St, Randwick, 2031 Australia
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Huang XF, Gao HW, Lee SC, Chang KF, Tang LT, Tsai NM. Juniperus indica Bertol. extract synergized with cisplatin against melanoma cells via the suppression of AKT/mTOR and MAPK signaling and induction of cell apoptosis. Int J Med Sci 2021; 18:157-168. [PMID: 33390784 PMCID: PMC7738970 DOI: 10.7150/ijms.49423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/15/2020] [Indexed: 01/05/2023] Open
Abstract
Juniperus indica Bertol. is an herbal plant that belongs to the genus Juniperus, which is commonly used in traditional medicine to refresh the mind and for diuretic use. However, few studies have reported the function of J. indica Bertol. Hence, this study aimed to investigate the anti-tumor and synergistic potential of J. indica Bertol. extract (JIB extract) for melanoma cells. Our results indicated the anti-melanoma activity of JIB extract. JIB extract induced cell cycle arrest at the G0/G1 phase and decreased cyclin and cdk protein expressions. In addition, AKT/mTOR signaling and MAPK signaling were inhibited by JIB extract to suppress melanoma cell growth and proliferation. Additionally, JIB extract induced B16/F10 cell apoptosis via the caspase cascade. According to the JIB extract's anti-melanoma capacity, to assess the synergistic effects of cisplatin and JIB extract. The results demonstrated that JIB extract combined with cisplatin enhanced the inhibition of cell growth, proliferation, and survival through the obstruction of cell cycle progression and AKT/mTOR and MAPK signaling as well as the induction of cell apoptosis. Collectively, our results indicate that JIB extract showed anti-tumor effects and synergized with cisplatin against B16/F10 cells, indicating the possibility of JIB extract to be developed as adjuvant therapy for melanoma.
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Affiliation(s)
- Xiao-Fan Huang
- Institute of Medicine, Chung Shan Medical University, Taichung, 40201, Taiwan, ROC.,Department of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung, 40201, Taiwan, ROC
| | - Hong-Wei Gao
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, 11490, Taiwan, ROC
| | - Shan-Chih Lee
- Department of Medical Imaging and Radiological Sciences, Chung Shan Medical University, Taichung, 40201, Taiwan, ROC.,Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung, 40201, Taiwan, ROC
| | - Kai-Fu Chang
- Institute of Medicine, Chung Shan Medical University, Taichung, 40201, Taiwan, ROC.,Department of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung, 40201, Taiwan, ROC
| | - Li-Ting Tang
- Department of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung, 40201, Taiwan, ROC
| | - Nu-Man Tsai
- Department of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung, 40201, Taiwan, ROC.,Clinical Laboratory, Chung Shan Medical University Hospital, Taichung, 40201, Taiwan, ROC
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Alexiou GA, Lianos GD, Ragos V, Galani V, Kyritsis AP. Difluoromethylornithine in cancer: new advances. Future Oncol 2017; 13:809-819. [PMID: 28125906 DOI: 10.2217/fon-2016-0266] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Difluoromethylornithine (DFMO; eflornithine) is an irreversible suicide inhibitor of the enzyme ornithine decarboxylase which is involved in polyamine synthesis. Polyamines are important for cell survival, thus DFMO was studied as an anticancer agent and as a chemoprevention agent. DFMO exhibited mainly cytostatic activity and had single agent efficacy as well as activity in combination with other chemotherapeutic drugs for some cancers and leukemias. Herewith, we summarize the current knowledge of the anticancer and chemopreventive properties of DFMO and assess the status of clinical trials.
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Affiliation(s)
- George A Alexiou
- Neurosurgical Institute, Ioannina University School of Medicine, Ioannina, GR 451 10, Greece
| | - Georgios D Lianos
- Neurosurgical Institute, Ioannina University School of Medicine, Ioannina, GR 451 10, Greece
| | - Vassileios Ragos
- Neurosurgical Institute, Ioannina University School of Medicine, Ioannina, GR 451 10, Greece
| | - Vasiliki Galani
- Department of Anatomy-Histology-Embryology, Medical School, University of Ioannina, 45110 Ioannina, Greece
| | - Athanassios P Kyritsis
- Neurosurgical Institute, Ioannina University School of Medicine, Ioannina, GR 451 10, Greece
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