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Kolokotroni E, Abler D, Ghosh A, Tzamali E, Grogan J, Georgiadi E, Büchler P, Radhakrishnan R, Byrne H, Sakkalis V, Nikiforaki K, Karatzanis I, McFarlane NJB, Kaba D, Dong F, Bohle RM, Meese E, Graf N, Stamatakos G. A Multidisciplinary Hyper-Modeling Scheme in Personalized In Silico Oncology: Coupling Cell Kinetics with Metabolism, Signaling Networks, and Biomechanics as Plug-In Component Models of a Cancer Digital Twin. J Pers Med 2024; 14:475. [PMID: 38793058 PMCID: PMC11122096 DOI: 10.3390/jpm14050475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 05/26/2024] Open
Abstract
The massive amount of human biological, imaging, and clinical data produced by multiple and diverse sources necessitates integrative modeling approaches able to summarize all this information into answers to specific clinical questions. In this paper, we present a hypermodeling scheme able to combine models of diverse cancer aspects regardless of their underlying method or scale. Describing tissue-scale cancer cell proliferation, biomechanical tumor growth, nutrient transport, genomic-scale aberrant cancer cell metabolism, and cell-signaling pathways that regulate the cellular response to therapy, the hypermodel integrates mutation, miRNA expression, imaging, and clinical data. The constituting hypomodels, as well as their orchestration and links, are described. Two specific cancer types, Wilms tumor (nephroblastoma) and non-small cell lung cancer, are addressed as proof-of-concept study cases. Personalized simulations of the actual anatomy of a patient have been conducted. The hypermodel has also been applied to predict tumor control after radiotherapy and the relationship between tumor proliferative activity and response to neoadjuvant chemotherapy. Our innovative hypermodel holds promise as a digital twin-based clinical decision support system and as the core of future in silico trial platforms, although additional retrospective adaptation and validation are necessary.
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Affiliation(s)
- Eleni Kolokotroni
- In Silico Oncology and In Silico Medicine Group, Institute of Communication and Computer Systems, School of Electrical and Computer Engineering, National Technical University of Athens, 157 80 Zografos, Greece;
| | - Daniel Abler
- Department of Oncology, Geneva University Hospitals and University of Geneva, 1205 Geneva, Switzerland;
- Department of Oncology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Alokendra Ghosh
- Department of Chemical and Biomolecular Engineering, Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA; (A.G.); (R.R.)
| | - Eleftheria Tzamali
- Institute of Computer Science, Foundation for Research and Technology—Hellas, 70013 Heraklion, Greece; (E.T.); (V.S.); (K.N.); (I.K.)
| | - James Grogan
- Irish Centre for High End Computing, University of Galway, H91 TK33 Galway, Ireland;
| | - Eleni Georgiadi
- In Silico Oncology and In Silico Medicine Group, Institute of Communication and Computer Systems, School of Electrical and Computer Engineering, National Technical University of Athens, 157 80 Zografos, Greece;
- Biomedical Engineering Department, University of West Attica, 12243 Egaleo, Greece
| | | | - Ravi Radhakrishnan
- Department of Chemical and Biomolecular Engineering, Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA; (A.G.); (R.R.)
| | - Helen Byrne
- Mathematical Institute, University of Oxford, Oxford OX1 2JD, UK;
| | - Vangelis Sakkalis
- Institute of Computer Science, Foundation for Research and Technology—Hellas, 70013 Heraklion, Greece; (E.T.); (V.S.); (K.N.); (I.K.)
| | - Katerina Nikiforaki
- Institute of Computer Science, Foundation for Research and Technology—Hellas, 70013 Heraklion, Greece; (E.T.); (V.S.); (K.N.); (I.K.)
| | - Ioannis Karatzanis
- Institute of Computer Science, Foundation for Research and Technology—Hellas, 70013 Heraklion, Greece; (E.T.); (V.S.); (K.N.); (I.K.)
| | | | - Djibril Kaba
- Department of Computer Science and Technology, University of Bedfordshire, Luton LU1 3JU, UK;
| | - Feng Dong
- Department of Computer & Information Sciences, University of Strathclyde, Glasgow G1 1XH, UK;
| | - Rainer M. Bohle
- Department of Pathology, Saarland University, 66421 Homburg, Germany;
| | - Eckart Meese
- Department of Human Genetics, Saarland University, 66421 Homburg, Germany;
| | - Norbert Graf
- Department of Paediatric Oncology and Haematology, Saarland University, 66421 Homburg, Germany;
| | - Georgios Stamatakos
- In Silico Oncology and In Silico Medicine Group, Institute of Communication and Computer Systems, School of Electrical and Computer Engineering, National Technical University of Athens, 157 80 Zografos, Greece;
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Picher EA, Wahajuddin M, Barth S, Chisholm J, Shipley J, Pors K. The Capacity of Drug-Metabolising Enzymes in Modulating the Therapeutic Efficacy of Drugs to Treat Rhabdomyosarcoma. Cancers (Basel) 2024; 16:1012. [PMID: 38473371 DOI: 10.3390/cancers16051012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
Rhabdomyosarcoma (RMS) is a rare soft tissue sarcoma (STS) that predominantly affects children and teenagers. It is the most common STS in children (40%) and accounts for 5-8% of total childhood malignancies. Apart from surgery and radiotherapy in eligible patients, standard chemotherapy is the only therapeutic option clinically available for RMS patients. While survival rates for this childhood cancer have considerably improved over the last few decades for low-risk and intermediate-risk cases, the mortality rate remains exceptionally high in high-risk RMS patients with recurrent and/or metastatic disease. The intensification of chemotherapeutic protocols in advanced-stage RMS has historically induced aggravated toxicity with only very modest therapeutic gain. In this review, we critically analyse what has been achieved so far in RMS therapy and provide insight into how a diverse group of drug-metabolising enzymes (DMEs) possess the capacity to modify the clinical efficacy of chemotherapy. We provide suggestions for new therapeutic strategies that exploit the presence of DMEs for prodrug activation, targeted chemotherapy that does not rely on DMEs, and RMS-molecular-subtype-targeted therapies that have the potential to enter clinical evaluation.
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Affiliation(s)
- Enric Arasanz Picher
- Institute of Cancer Therapeutics, Faculty of Life Sciences, University of Bradford, Bradford BD7 1DP, UK
| | - Muhammad Wahajuddin
- Institute of Cancer Therapeutics, Faculty of Life Sciences, University of Bradford, Bradford BD7 1DP, UK
| | - Stefan Barth
- Medical Biotechnology and Immunotherapy Research Unit, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa
| | - Julia Chisholm
- Children and Young People's Unit, Royal Marsden Hospital, Institute of Cancer Research, Sutton SM2 5PR, UK
| | - Janet Shipley
- Sarcoma Molecular Pathology Group, Division of Molecular Pathology, The Institute of Cancer Research, Sutton SM2 5NG, UK
| | - Klaus Pors
- Institute of Cancer Therapeutics, Faculty of Life Sciences, University of Bradford, Bradford BD7 1DP, UK
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3
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Centanni M, van de Velde ME, Uittenboogaard A, Kaspers GJL, Karlsson MO, Friberg LE. Model-Informed Precision Dosing to Reduce Vincristine-Induced Peripheral Neuropathy in Pediatric Patients: A Pharmacokinetic and Pharmacodynamic Modeling and Simulation Analysis. Clin Pharmacokinet 2024; 63:197-209. [PMID: 38141094 PMCID: PMC10847206 DOI: 10.1007/s40262-023-01336-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Vincristine-induced peripheral neuropathy (VIPN) is a common adverse effect of vincristine, a drug often used in pediatric oncology. Previous studies demonstrated large inter- and intrapatient variability in vincristine pharmacokinetics (PK). Model-informed precision dosing (MIPD) can be applied to calculate patient exposure and individualize dosing using therapeutic drug monitoring (TDM) measurements. This study set out to investigate the PK/pharmacodynamic (PKPD) relationship of VIPN and determine the utility of MIPD to support clinical decisions regarding dose selection and individualization. METHODS Data from 35 pediatric patients were utilized to quantify the relationship between vincristine dose, exposure and the development of VIPN. Measurements of vincristine exposure and VIPN (Common Terminology Criteria for Adverse Events [CTCAE]) were available at baseline and for each subsequent dosing occasions (1-5). A PK and PKPD analysis was performed to assess the inter- and intraindividual variability in vincristine exposure and VIPN over time. In silico trials were performed to portray the utility of vincristine MIPD in pediatric subpopulations with a certain age, weight and cytochrome P450 (CYP) 3A5 genotype distribution. RESULTS A two-compartmental model with linear PK provided a good description of the vincristine exposure data. Clearance and distribution parameters were related to bodyweight through allometric scaling. A proportional odds model with Markovian elements described the incidence of Grades 0, 1 and ≥ 2 VIPN overdosing occasions. Vincristine area under the curve (AUC) was the most significant exposure metric related to the development of VIPN, where an AUC of 50 ng⋅h/mL was estimated to be related to an average VIPN probability of 40% over five dosing occasions. The incidence of Grade ≥ 2 VIPN reduced from 62.1 to 53.9% for MIPD-based dosing compared with body surface area (BSA)-based dosing in patients. Dose decreases occurred in 81.4% of patients with MIPD (vs. 86.4% for standard dosing) and dose increments were performed in 33.4% of patients (no dose increments allowed for standard dosing). CONCLUSIONS The PK and PKPD analysis supports the use of MIPD to guide clinical dose decisions and reduce the incidence of VIPN. The current work can be used to support decisions with respect to dose selection and dose individualization in children receiving vincristine.
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Affiliation(s)
- Maddalena Centanni
- Department of Pharmacy, Uppsala University, Box 580, 751 23, Uppsala, Sweden
| | - Mirjam E van de Velde
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Aniek Uittenboogaard
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gertjan J L Kaspers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mats O Karlsson
- Department of Pharmacy, Uppsala University, Box 580, 751 23, Uppsala, Sweden
| | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Box 580, 751 23, Uppsala, Sweden.
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Yuan Y, Chen C, You G, Yao R, Zhu X, Wu X, Wu J, Zhao W, Li Z, Zhang S. Simultaneous quantification and pharmacokinetics of vincristine and its major metabolite M1 in Chinese pediatric ALL patients by LC-MS/MS. J Pharm Biomed Anal 2023; 234:115578. [PMID: 37459833 DOI: 10.1016/j.jpba.2023.115578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 08/26/2023]
Abstract
Vincristine (VCR) is a vital component in numerous treatment regimens for pediatric blood cancer. VCR-induced peripheral neuropathy (VIPN) represents a type of VCR toxicity influenced by multiple factors, including age, race, genetic traits, dosage, interactions, and administration regimen. However, the dose-response relationship of VIPN remains elusive. VCR is primarily metabolized by cytochrome P450 (CYP) 3 A to generate the major metabolite M1. To date, there is a lack of literature documenting the pharmacokinetics (PK) characteristics of VCR and M1 in Chinese children within a 96 h timeframe. To address the gap, a developed LC-MS/MS method was successfully employed in the PK study of VCR and M1 in Chinese pediatric acute lymphoblastic leukemia (ALL) patients. M1 was obtained through in vitro metabolism experiments, and mixed plasma samples of M1 and VCR were prepared. Plasma samples were pre-processed using the solid-phase extraction (SPE) technique. Samples were loaded into ProElut C18 Cartridges, washed with 5% methanol aqueous solution, and eluted with methanol. The eluent was concentrated and reconstituted for liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis. The standard calibration curves for VCR and M1 were 0.1-50 ng/mL and 0.05-5 ng/mL, respectively, with linear coefficients exceeding 0.99. Accuracy and precision of quality control (QC) samples fell within 115%. The analytical approach satisfied the quantitative demands for VCR and M1 in plasma samples within 96 h. VCR was metabolized to M1 at a relatively constant proportion (5.37%-18.06%) of VCR in vivo. No significant differences were observed in PK parameters of VCR in Chinese children compared to other countries and races. Further investigation is required to identify the key factors influencing VIPN in Chinese children.
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Affiliation(s)
- Yawen Yuan
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Changcheng Chen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guoling You
- Department of Laboratory Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruen Yao
- Department of Medical Genetics, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao Zhu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Xiaoyu Wu
- Institute of Pediatric Translational Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong School of Medicine, Shanghai, China
| | - Juan Wu
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Wei Zhao
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Zhiling Li
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China.
| | - Shunguo Zhang
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China.
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Italia M, Wertheim KY, Taschner-Mandl S, Walker D, Dercole F. Mathematical Model of Clonal Evolution Proposes a Personalised Multi-Modal Therapy for High-Risk Neuroblastoma. Cancers (Basel) 2023; 15:cancers15071986. [PMID: 37046647 PMCID: PMC10093626 DOI: 10.3390/cancers15071986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/15/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Neuroblastoma is the most common extra-cranial solid tumour in children. Despite multi-modal therapy, over half of the high-risk patients will succumb. One contributing factor is the one-size-fits-all nature of multi-modal therapy. For example, during the first step (induction chemotherapy), the standard regimen (rapid COJEC) administers fixed doses of chemotherapeutic agents in eight two-week cycles. Perhaps because of differences in resistance, this standard regimen results in highly heterogeneous outcomes in different tumours. In this study, we formulated a mathematical model comprising ordinary differential equations. The equations describe the clonal evolution within a neuroblastoma tumour being treated with vincristine and cyclophosphamide, which are used in the rapid COJEC regimen, including genetically conferred and phenotypic drug resistance. The equations also describe the agents’ pharmacokinetics. We devised an optimisation algorithm to find the best chemotherapy schedules for tumours with different pre-treatment clonal compositions. The optimised chemotherapy schedules exploit the cytotoxic difference between the two drugs and intra-tumoural clonal competition to shrink the tumours as much as possible during induction chemotherapy and before surgical removal. They indicate that induction chemotherapy can be improved by finding and using personalised schedules. More broadly, we propose that the overall multi-modal therapy can be enhanced by employing targeted therapies against the mutations and oncogenic pathways enriched and activated by the chemotherapeutic agents. To translate the proposed personalised multi-modal therapy into clinical use, patient-specific model calibration and treatment optimisation are necessary. This entails a decision support system informed by emerging medical technologies such as multi-region sequencing and liquid biopsies. The results and tools presented in this paper could be the foundation of this decision support system.
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Affiliation(s)
- Matteo Italia
- Department of Electronic, Information, and Bioengineering, Politecnico di Milano, 20133 Milano, Italy
- Correspondence:
| | - Kenneth Y. Wertheim
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield S10 2TN, UK
- Department of Computer Science, University of Sheffield, Sheffield S10 2TN, UK
- Centre of Excellence for Data Science, Artificial Intelligence, and Modelling, University of Hull, Kingston upon Hull HU6 7RX, UK
- School of Computer Science, University of Hull, Kingston upon Hull HU6 7RX, UK
| | | | - Dawn Walker
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield S10 2TN, UK
- Department of Computer Science, University of Sheffield, Sheffield S10 2TN, UK
| | - Fabio Dercole
- Department of Electronic, Information, and Bioengineering, Politecnico di Milano, 20133 Milano, Italy
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6
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van der Heijden LT, Uittenboogaard A, Nijstad AL, Gebretensae A, Kaspers GJL, Beijnen JH, Huitema ADR, Rosing H. A sensitive liquid chromatographic-mass spectrometry method for the quantification of vincristine in whole blood collected with volumetric absorptive microsampling. J Pharm Biomed Anal 2023; 225:115232. [PMID: 36608428 DOI: 10.1016/j.jpba.2023.115232] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/23/2022] [Accepted: 01/01/2023] [Indexed: 01/04/2023]
Abstract
Vincristine is a well-established cytotoxic drug. In paediatric populations blood collection via venipuncture is not always feasible. Volumetric absorptive microsampling (VAMS) is a less invasive method for blood collection. Furthermore, VAMS lacks the haematocrit effect on the recovery known with dried blood spots. Therefore, a liquid chromatography tandem-mass spectrometry method was developed and validated for the quantification of vincristine in whole blood collected with VAMS devices. Sample preparation consisted of solid-liquid extraction with 0.2% formic acid in water and acetonitrile. The final extract was injected on a C18 column (2.0 ×50 mm, 5 µm). Gradient elution was used and quantification was accomplished with a triple quadruple mass spectrometer operating in the positive mode. The validated concentration range was from 1 to 50 ng/mL with an intra- and inter-accuracy and precision of ± 10.3% and ≤ 7.3%, respectively. This method was able to successfully quantify vincristine concentrations in whole blood collected with VAMS from paediatric oncology patients. Vincristine concentrations in whole blood were non-linearly associated with plasma concentrations, which could be described with a saturable binding equilibrium model.
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Affiliation(s)
- Lisa T van der Heijden
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Aniek Uittenboogaard
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam Paediatric Oncology, 1081 HV Amsterdam, the Netherlands; Department of Pharmacology, Princess Maxima Center for Paediatric Oncology, Utrecht, the Netherlands
| | - A Laura Nijstad
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Pharmacology, Princess Maxima Center for Paediatric Oncology, Utrecht, the Netherlands
| | - Abadi Gebretensae
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Gertjan J L Kaspers
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam Paediatric Oncology, 1081 HV Amsterdam, the Netherlands; Dutch Childhood Oncology Group, Utrecht, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Pharmaco-epidemiology and Clinical Pharmacology, Faculty of Science, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Pharmacology, Princess Maxima Center for Paediatric Oncology, Utrecht, the Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands
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7
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Wu CY, Li GT, Chu CC, Guo HL, Fang WR, Li T, Wang YR, Xu J, Hu YH, Zhou L, Chen F. Proactive therapeutic drug monitoring of vincristine in pediatric and adult cancer patients: current supporting evidence and future efforts. Arch Toxicol 2023; 97:377-392. [PMID: 36418572 DOI: 10.1007/s00204-022-03418-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022]
Abstract
Vincristine (VCR), an effective antitumor drug, has been utilized in several polytherapy regimens for acute lymphoblastic leukemia, neuroblastoma and rhabdomyosarcoma. However, clinical evidence shows that the metabolism of VCR varies greatly among patients. The traditional based body surface area (BSA) administration method is prone to insufficient exposure to VCR or severe VCR-induced peripheral neurotoxicity (VIPN). Therefore, reliable strategies are urgently needed to improve efficacy and reduce VIPN. Due to the unpredictable pharmacokinetic changes of VCR, therapeutic drug monitoring (TDM) may help to ensure its efficacy and to manage VIPN. At present, there is a lot of supporting evidence for the suitability of applying TDM to VCR therapy. Based on the consensus guidelines drafted by the International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT), this review aimed to summarize various available data to evaluate the potential utility of VCR TDM for cancer patients. Of note, valuable evidence has accumulated on pharmacokinetics variability, pharmacodynamics, drug exposure-clinical response relationship, biomarkers for VIPN prediction, and assays for VCR monitoring. However, there are still many relevant clinical pharmacological questions that cannot yet be answered merely based on insufficient evidence. Currently, we cannot recommend a therapeutic exposure range and cannot yet provide a dose-adaptation strategy for clinicians and patients. In areas where the evidence is not yet sufficient, more research is needed in the future. The precision medicine of VCR cannot rely on TDM alone and needs to consider the clinical, environmental, genetic background and patient-specific factors as a whole.
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Affiliation(s)
- Chun-Ying Wu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Guan-Ting Li
- The First School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Chen-Chao Chu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Hong-Li Guo
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Wei-Rong Fang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Tao Li
- Department of Solid Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yong-Ren Wang
- Department of Hematology /Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Xu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Ya-Hui Hu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China.
| | - Li Zhou
- Department of Hematology /Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Feng Chen
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China.
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8
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Nijstad AL, Chu WY, de Vos-Kerkhof E, Enters-Weijnen CF, van de Velde ME, Kaspers GJL, Barnett S, Veal GJ, Lalmohamed A, Zwaan CM, Huitema ADR. A Population Pharmacokinetic Modelling Approach to Unravel the Complex Pharmacokinetics of Vincristine in Children. Pharm Res 2022; 39:2487-2495. [PMID: 35986122 PMCID: PMC9556337 DOI: 10.1007/s11095-022-03364-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022]
Abstract
Abstract
Background
Vincristine, a chemotherapeutic agent that extensively binds to β-tubulin, is commonly dosed at 1.4–2.0 mg/m2 capped at 2 mg. For infants, doses vary from 0.025–0.05 mg/kg or 50–80% of the mg/m2 dose. However, evidence for lower doses in infants compared to older children is lacking. This study was conducted to unravel the complex pharmacokinetics of vincristine, including the effects of age, to assist optimal dosing in this population.
Methods
206 patients (0.04–33.9 years; 25 patients < 1 years), receiving vincristine, with 1297 plasma concentrations were included. Semi-mechanistic population pharmacokinetic analyses were performed using non-linear mixed effects modelling.
Results
A three-compartment model, with one saturable compartment resembling saturable binding to β-tubulin and thus, saturable distribution, best described vincristine pharmacokinetics. Body weight and age were covariates significantly influencing the maximal binding capacity to β-tubulin, which increased with increasing body weight and decreased with increasing age. Vincristine clearance (CL) was estimated as 30.6 L/h (95% confidence interval (CI) 27.6–33.0), intercompartmental CL (Q) as 63.2 L/h (95%CI 57.2–70.1), volume of distribution of the central compartment as 5.39 L (95%CI 4.23–6.46) and of the peripheral compartment as 400 L (95%CI 357–463) (all parameters correspond to a patient of 70 kg). The maximal binding capacity was 0.525 mg (95%CI 0.479–0.602) (for an 18 year old patient of 70 kg), with a high association rate constant, fixed at 1300 /h and a dissociation constant of 11.5 /h.
Interpretation
A decrease of vincristine β-tubulin binding capacity with increasing age suggests that young children tolerate higher doses of vincristine.
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Affiliation(s)
- A Laura Nijstad
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands.
- Department of Clinical Pharmacy, University Medical Center Utrecht, Internal postal D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands.
| | - Wan-Yu Chu
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Evelien de Vos-Kerkhof
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - Catherine F Enters-Weijnen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mirjam E van de Velde
- Emma Children's Hospital, Pediatric Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, 1105 AZ, Amsterdam, The Netherlands
| | - Gertjan J L Kaspers
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
- Emma Children's Hospital, Pediatric Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, 1105 AZ, Amsterdam, The Netherlands
| | - Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, the Netherlands
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
- Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
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Rashidbaghan A, Mostafaie A, Yazdani Y, Mansouri K. More Related Gene Pathways to Vincristine-Induced Death Events in a Human T-Acute Lymphoblastic Leukemia Cell Line. Rep Biochem Mol Biol 2022; 10:554-564. [PMID: 35291614 PMCID: PMC8903353 DOI: 10.52547/rbmb.10.4.554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/25/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Acute lymphoblastic leukemia (ALL) is common in children but rare in adults. Vincristine (VCR) is one of the drugs used at the beginning of treatment. Some genes are resistant to VCR in B-ALL. METHODS Here, we examined the effect of VCR on gene expression changes in a T-ALL cell line, Jurkat. The MTT method was used to determine the IC50 in Jurkat cells treated with different concentrations of VCR for 48 and 72 hours. Total RNA was isolated from the cells and cDNA was prepared. The Human Cancer Drug Target PCR Array kit was used to evaluate the 84 gene expression changes in Jurkat cells. Protein-protein interaction was analyzed by STRING software. RESULTS We identified 66 differentially expressed genes as comparison to untreated cells. The response to VCR-induced apoptotic events was remarkable in the pathways of heat shock protein, topoisomerases, protein kinases, cathepsins and cell cycle. In other pathways, there were resistant genes as well as sensitive genes to VCR treatment. Some proteins like HSP90AA1 and ESR1 had determining associations with other proteins. CONCLUSION The results suggest VCR target genes in T-ALL cells may be beneficial biomarkers for ALL treatment and can be used to select appropriate synergistic drugs for VCR.
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Affiliation(s)
- Azam Rashidbaghan
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Ali Mostafaie
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Yaghoub Yazdani
- Stem Cell Research Center, Golestan University of Medical Sciences, Gorgan, Iran.
| | - Kamran Mansouri
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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10
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Rapid quantification of vincristine in mouse plasma using ESI-LC-MS/MS: Application to pharmacokinetic studies. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1168:122591. [PMID: 33684722 DOI: 10.1016/j.jchromb.2021.122591] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/30/2021] [Accepted: 02/09/2021] [Indexed: 11/20/2022]
Abstract
A simple, rapid, and sensitive LC-MS/MS method for determining concentrations of the anticancer alkaloid vincristine in micro volumes of mouse plasma was developed and validated in positive ion mode. Separation of vincristine and the internal standard [2H3]-vincristine was achieved on an Accucore aQ column with a gradient mobile phase delivered at a flow rate of 0.4 mL/min and a run time of 2.2 min. Calibration curves were linear (r2 > 0.99, n = 8) up to 250 ng/mL, with a lower limit of quantitation of 2.5 ng/mL. The matrix effect and extraction recovery for vincristine were ranging 108-110% and 88.4-107%, respectively. The intra-day and inter-day precision of quality controls tested at 3 different concentrations were always less than 15%, and accuracy ranged from 91.7 to 107%. The method was successfully applied to evaluate the pharmacokinetic profile of vincristine in wild-type and CYP3A-deficient mice in support of a project to provide mechanistic insight into drug-drug interactions and to identify sources of inter-individual pharmacokinetic variability associated with vincristine-induced peripheral neuropathy.
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11
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Population pharmacokinetic model development and exposure-response analysis of vincristine in patients with malignant lymphoma. Cancer Chemother Pharmacol 2021; 87:501-511. [PMID: 33416909 DOI: 10.1007/s00280-020-04220-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/25/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Vincristine (VCR) is a key drug for treating various malignancies. However, few data are available on the pharmacokinetics of VCR, especially in adult patients. The objective of this study was to clarify the population pharmacokinetics and exposure-response relationships of VCR in adult malignant lymphoma patients. METHODS Blood samples were collected from patients who were administered R-CHOP-like regimens, and the VCR plasma concentration was determined using liquid chromatography-mass spectrometry. Using NONMEM software, population pharmacokinetic parameters were estimated, and covariates were evaluated. The relationships between the individual parameters and adverse events or therapeutic effects were also investigated. RESULTS Plasma concentrations were measured in 30 patients. In the final population pharmacokinetics model, body surface area and age were incorporated into clearance as significant covariates. The inter-individual variations in clearance and volume of distribution in the central and third compartments were 17.0, 26.6, and 66.3%, respectively, and the residual variability in the plasma concentration was 23.8%. Although the variability observed in the volume of distribution was large, good predictability was obtained in the individual estimation. The severity of anemia and peripheral neuropathy was correlated with clearance and peak concentration, respectively (adjusted P = 0.040 and 0.024, respectively). In diffuse large B cell lymphoma patients, those with higher area under the curve and dose experienced longer progression-free survival (P = 0.023 and 0.013, respectively). CONCLUSION The population pharmacokinetics of VCR were evaluated in adult malignant lymphoma patients. VCR pharmacokinetic data could explain in part the adverse events and prognosis of these patients.
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Jiang N, Wang L, Xiang X, Li Z, Chiew EKH, Koo YM, Lee HS, Lin HP, Tan AM, Quah TC, Kham SKY, Goh BC, Ariffin H, Yeoh AEJ. Intracellular vincristine levels in lymphoblasts affect treatment outcome in childhood B-lymphoblastic leukaemia: Ma-Spore ALL 2010 study. Br J Clin Pharmacol 2020; 87:1990-1999. [PMID: 33037681 DOI: 10.1111/bcp.14596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/19/2020] [Accepted: 09/27/2020] [Indexed: 11/27/2022] Open
Abstract
AIMS Vincristine (VCR) is a key drug in the successful multidrug chemotherapy for childhood acute lymphoblastic leukaemia (ALL). However, it remains unclear how VCR pharmacokinetics affects its antileukaemic efficacy. The objective of this study is to explore the VCR pharmacokinetic parameters and intracellular VCR levels in an up-front window of Ma-Spore ALL 2010 (MS2010) study. METHODS We randomised 429 children with newly diagnosed ALL to 15-minute vs 3-hour infusion for the first dose of VCR to study if prolonging the first dose of VCR infusion improved response. In a subgroup of 115 B-ALL and 20 T-ALL patients, we performed VCR plasma (n = 135 patients) and intracellular (n = 66 patients) pharmacokinetic studies. The correlations between pharmacokinetic parameters and intracellular VCR levels with early treatment response, final outcome and ABCB1 genotypes were analysed. RESULTS There was no significant difference between 15-minute and 3-hour infusion schedules in median Day 8 peripheral or bone marrow blast response. Plasma VCR pharmacokinetic parameters did not predict outcome. However, in B-ALL, Day 33 minimal residual disease (MRD) negative patients and patients in continuous complete remission had significantly higher median intracellular VCR24h levels (P = .03 and P = .04, respectively). The median VCR24h intracellular levels were similar among the common genetic subtypes of ALL (P = .4). Patients homozygous for wild-type ABCB1 2677GG had significantly higher median intracellular VCR24h (P = .04) than 2677TT. CONCLUSION We showed that in childhood B-ALL, the intracellular VCR24h levels in lymphoblasts affected treatment outcomes. The intracellular VCR24h level was independent of leukaemia subtype but dependent on host ABCB1 G2677T genotype.
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Affiliation(s)
- Nan Jiang
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lingzhi Wang
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Xiaoqiang Xiang
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai, China
| | - Zhenhua Li
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Edwynn Kean Hui Chiew
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yok Moi Koo
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - How Sung Lee
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hai Peng Lin
- Sime Darby Medical Centre, Subang Jaya, Malaysia
| | - Ah Moy Tan
- Department of Paediatrics, KK Women's & Cheildren's Hospital, Singapore, Singapore
| | - Thuan Chong Quah
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
| | - Shirley Kow Yin Kham
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Boon Cher Goh
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Hany Ariffin
- University of Malaya Cancer Research Institute, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Allen Eng-Juh Yeoh
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore.,Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
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Orgel E, Sea JL, Mittelman SD. Mechanisms by Which Obesity Impacts Survival from Acute Lymphoblastic Leukemia. J Natl Cancer Inst Monogr 2020; 2019:152-156. [PMID: 31532535 DOI: 10.1093/jncimonographs/lgz020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/22/2019] [Accepted: 07/01/2019] [Indexed: 01/29/2023] Open
Abstract
The prevalence of obesity has steadily risen over the past decades, even doubling in more than 70 countries. High levels of body fat (adiposity) and obesity are associated with endocrine and hormonal dysregulation, cardiovascular compromise, hepatic dysfunction, pancreatitis, changes in drug metabolism and clearance, inflammation, and metabolic stress. It is thus unsurprising that obesity can affect the development of and survival from a wide variety of malignancies. This review focuses on acute lymphoblastic leukemia, the most common malignancy in children, to explore the multiple mechanisms connecting acute lymphoblastic leukemia, obesity, and adipocytes, and the implications for leukemia therapy.
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Affiliation(s)
- Etan Orgel
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA Department of Pediatrics, Keck School of Medicine, University of Southern California
| | - Jessica L Sea
- Division of Pediatric Endocrinology, UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine UCLA, Los Angeles, CA
| | - Steven D Mittelman
- Division of Pediatric Endocrinology, UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine UCLA, Los Angeles, CA
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14
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Population Pharmacokinetics of Vincristine Related to Infusion Duration and Peripheral Neuropathy in Pediatric Oncology Patients. Cancers (Basel) 2020; 12:cancers12071789. [PMID: 32635465 PMCID: PMC7407622 DOI: 10.3390/cancers12071789] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 11/17/2022] Open
Abstract
Vincristine (VCR) is frequently used in pediatric oncology and can be administered intravenously through push injections or 1 h infusions. The effects of administration duration on population pharmacokinetics (PK) are unknown. We described PK differences related to administration duration and the relation between PK and VCR-induced peripheral neuropathy (VIPN). PK was assessed in 1-5 occasions (1-8 samples in 24 h per occasion). Samples were analyzed using high-performance liquid chromatography/tandem mass spectrometry. Population PK of VCR and its relationship with administration duration was determined using a non-linear mixed effect. We estimated individual post-hoc parameters: area under the concentration time curve (AUC) and maximum concentration (Cmax) in the plasma and peripheral compartment. VIPN was assessed using Common Terminology Criteria for Adverse Events (CTCAE) and the pediatric-modified total neuropathy score (ped-mTNS). Overall, 70 PK assessments in 35 children were evaluated. The population estimated that the intercompartmental clearance (IC-Cl), volume of the peripheral compartment (V2), and Cmax were significantly higher in the push group. Furthermore, higher IC-Cl was significantly correlated with VIPN development. Administration of VCR by push led to increased IC-Cl, V2, and Cmax, but were similar to AUC, compared to 1 h infusions. Administration of VCR by 1 h infusions led to similar or higher exposure of VCR without increasing VIPN.
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15
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A Metabolomics Approach for Early Prediction of Vincristine-Induced Peripheral Neuropathy. Sci Rep 2020; 10:9659. [PMID: 32541868 PMCID: PMC7295796 DOI: 10.1038/s41598-020-66815-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/26/2020] [Indexed: 11/28/2022] Open
Abstract
Vincristine is a core chemotherapeutic drug administered to pediatric acute lymphoblastic leukemia patients. Despite its efficacy in treating leukemia, it can lead to severe peripheral neuropathy in a subgroup of the patients. Peripheral neuropathy is a debilitating and painful side-effect that can severely impact an individual’s quality of life. Currently, there are no established predictors of peripheral neuropathy incidence during the early stage of chemotherapeutic treatment. As a result, patients who are not susceptible to peripheral neuropathy may receive sub-therapeutic treatment due to an empirical upper cap on the dose, while others may experience severe neuropathy at the same dose. Contrary to previous genomics based approaches, we employed a metabolomics approach to identify small sets of metabolites that can be used to predict a patient’s susceptibility to peripheral neuropathy at different time points during the treatment. Using those identified metabolites, we developed a novel strategy to predict peripheral neuropathy and subsequently adjust the vincristine dose accordingly. In accordance with this novel strategy, we created a free user-friendly tool, VIPNp, for physicians to easily implement our prediction strategy. Our results showed that focusing on metabolites, which encompasses both genotypic and phenotypic variations, can enable early prediction of peripheral neuropathy in pediatric leukemia patients.
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Bartlett NL. The justification of vincristine dose capping: tradition, tradition…tradition! Leuk Lymphoma 2020; 61:1007-1009. [DOI: 10.1080/10428194.2020.1742907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Nancy L. Bartlett
- Department of Medicine, Washington University in Saint Louis, Saint Louis, MO, USA
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The Multifarious Link between Cytochrome P450s and Cancer. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:3028387. [PMID: 31998435 PMCID: PMC6964729 DOI: 10.1155/2020/3028387] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 12/08/2019] [Accepted: 12/18/2019] [Indexed: 02/07/2023]
Abstract
Cancer is a leading cause of death worldwide. Cytochrome P450s (P450s) play an important role in the metabolism of endogenous as well as exogenous substances, especially drugs. Moreover, many P450s can serve as targets for disease therapy. Increasing reports of epidemiological, diagnostic, and clinical research indicate that P450s are enzymes that play a major part in the formation of cancer, prevention, and metastasis. The purposes of this review are to shed light on the current state of knowledge about the cancer molecular mechanism involving P450s and to summarize the link between the cancer effects and the participation of P450s.
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18
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Genomics and pharmacogenomics of pediatric acute lymphoblastic leukemia. Crit Rev Oncol Hematol 2018; 126:100-111. [PMID: 29759551 DOI: 10.1016/j.critrevonc.2018.04.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/21/2018] [Accepted: 04/03/2018] [Indexed: 12/14/2022] Open
Abstract
Acute lymphoblastic leukaemia (ALL) is a prevalent form of pediatric cancer that accounts for 70-80% of all leukemias. Genome-based analysis, exome sequencing, transcriptomics and proteomics have provided insight into genetic classification of ALL and helped identify novel subtypes of the disease. B and T cell-based ALL are two well-characterized genomic subtypes, significantly marked by bone marrow disorders, along with mutations in trisomy 21 and T53. The other ALLs include Early T-cell precursor ALL, Philadelphia chromosome-like ALL, Down syndrome-associated ALL and Relapsed ALL. Chromosomal number forms a basis of classification, such as, hypodiploid ALL, near-haploid, low-hypodiploid, high-hypodiploid and hypodiploid-ALL. Advances in therapies targeting ALL have been noteworthy, with significant pre-clinical and clinical studies on drug pharmacokinetics and pharmacodynamics. Methotrexate and 6-mercaptopurine are leading drugs with best demonstrated efficacies against childhood ALL. The drugs in combination, following dose titration, have also been used for maintenance therapy. Methotrexate-polyglutamate is a key metabolite that specifically targets the disease pathogenesis, and 6-thioguanine nucleotides, derived from 6-mercaptopurine, impede replication and transcription processes, inducing cytotoxicity. Additionally, glucocorticoids, asparaginase, anthracycline, vincristine and cytarabine that trans-repress gene expression, deprives cells of asparagine, triggers cell cycle arrest, influences cytochrome-P450 polymorphism and inhibits DNA polymerase, respectively, have been used in chemotherapy in ALL patients. Overall, this review covers the progress in genome technology related to different sub-types of ALL and pharmacokinetics and pharmacodynamics of its medications. It also enlightens adverse effects of current drugs, and emphasizes the necessity of genome-wide association studies for restricting childhood ALL.
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Crotti S, Posocco B, Marangon E, Nitti D, Toffoli G, Agostini M. Mass spectrometry in the pharmacokinetic studies of anticancer natural products. MASS SPECTROMETRY REVIEWS 2017; 36:213-251. [PMID: 26280357 DOI: 10.1002/mas.21478] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 06/29/2015] [Indexed: 05/08/2023]
Abstract
In the history of medicine, nature has represented the main source of medical products. Indeed, the therapeutic use of plants certainly goes back to the Sumerian and Hippocrates and nowadays nature still represents the major source for new drugs discovery. Moreover, in the cancer treatment, drugs are either natural compounds or have been developed from naturally occurring parent compounds firstly isolated from plants and microbes from terrestrial and marine environment. A critical element of an anticancer drug is represented by its severe toxicities and, after administration, the drug concentrations have to remain in an appropriate range to be effective. Anyway, the drug dosage defined during the clinical studies could be inappropriate for an individual patient due to differences in drug absorption, metabolism and excretion. For this reason, personalized medicine, based on therapeutic drug monitoring (TDM), represents one of most important challenges in cancer therapy. Mass spectrometry sensitivity, specificity and fastness lead to elect this technique as the Golden Standard for pharmacokinetics and drug metabolism studies therefore for TDM. This review focuses on the mass spectrometry-based methods developed for pharmacokinetic quantification in human plasma of anticancer drugs derived from natural sources and already used in clinical practice. Particular emphasis was placed both on the pre-analytical and analytical steps, such as: sample preparation procedures, sample size required by the analysis and the limit of quantification of drugs and metabolites to give some insights on the clinical practice applicability. © 2015 Wiley Periodicals, Inc. Mass Spec Rev. 36:213-251, 2017.
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Affiliation(s)
- Sara Crotti
- Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico, IRCCS National Cancer Institute, Via Franco Gallini 2, 33081 Aviano (PN), Italy
- Istituto di Ricerca Pediatrica - Città della Speranza, Corso Stati Uniti 4, 35127, Padova, Italy
| | - Bianca Posocco
- Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico, IRCCS National Cancer Institute, Via Franco Gallini 2, 33081 Aviano (PN), Italy
| | - Elena Marangon
- Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico, IRCCS National Cancer Institute, Via Franco Gallini 2, 33081 Aviano (PN), Italy
| | - Donato Nitti
- Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Via Nicolo Giustiniani 2, 35128, Padova, Italy
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico, IRCCS National Cancer Institute, Via Franco Gallini 2, 33081 Aviano (PN), Italy
| | - Marco Agostini
- Istituto di Ricerca Pediatrica - Città della Speranza, Corso Stati Uniti 4, 35127, Padova, Italy
- Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Via Nicolo Giustiniani 2, 35128, Padova, Italy
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van Hasselt JGC, van Eijkelenburg NKA, Beijnen JH, Schellens JHM, Huitema ADR. Design of a drug-drug interaction study of vincristine with azole antifungals in pediatric cancer patients using clinical trial simulation. Pediatr Blood Cancer 2014; 61:2223-9. [PMID: 25175364 DOI: 10.1002/pbc.25198] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 07/01/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND The aim of the current work was to perform a clinical trial simulation (CTS) analysis to optimize a drug-drug interaction (DDI) study of vincristine in children who also received azole antifungals, taking into account challenges of conducting clinical trials in this population, and, to provide a motivating example of the application of CTS in the design of pediatric oncology clinical trials. PROCEDURE A pharmacokinetic (PK) model for vincristine in children was used to simulate concentration-time profiles. A continuous model for body surface area versus age was defined based on pediatric growth curves. Informative sampling time windows were derived using D-optimal design. The CTS framework was used to different magnitudes of clearance inhibition (10%, 25%, or 40%), sample size (30-500), the impact of missing samples or sampling occasions, and the age distribution, on the power to detect a significant inhibition effect, and in addition, the relative estimation error (REE) of the interaction effect. RESULTS A minimum group specific sample size of 38 patients with a total sample size of 150 patients was required to detect a clearance inhibition effect of 40% with 80% power, while in the case of a lower effect of clearance inhibition, a substantially larger sample size was required. However, for the majority of re-estimated drug effects, the inhibition effect could be estimated precisely (REE < 25%) in even smaller sample sizes and with lower effect sizes. CONCLUSION This work demonstrated the utility of CTS for the evaluation of PK clinical trial designs in the pediatric oncology population.
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Affiliation(s)
- J G Coen van Hasselt
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Stamatakos G, Dionysiou D, Lunzer A, Belleman R, Kolokotroni E, Georgiadi E, Erdt M, Pukacki J, Rueping S, Giatili S, d'Onofrio A, Sfakianakis S, Marias K, Desmedt C, Tsiknakis M, Graf N. The Technologically Integrated Oncosimulator: Combining Multiscale Cancer Modeling With Information Technology in the In Silico Oncology Context. IEEE J Biomed Health Inform 2014; 18:840-54. [DOI: 10.1109/jbhi.2013.2284276] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Georgios Stamatakos
- Institute of Communication and Computer Systems, National Technical University of Athens, In Silico Oncology Group, 9 Iroon Polytechniou, Zografos, Greece
| | - Dimitra Dionysiou
- Oncology Group, Institute of Communication and Computer Systems, National Technical University of Athens, GR , Greece
| | | | | | - Eleni Kolokotroni
- Oncology Group, Institute of Communication and Computer Systems, National Technical University of Athens, GR , Greece
| | - Eleni Georgiadi
- Oncology Group, Institute of Communication and Computer Systems, National Technical University of Athens, GR , Greece
| | | | - Juliusz Pukacki
- Poznan Supercomputing and Networking Center (PSNC), Poznan, Poland
| | - Stefan Rueping
- Fraunhofer IAIS, Schloss Birlinghoven, St. Augustin, Germany
| | - Stavroula Giatili
- Oncology Group, Institute of Communication and Computer Systems, National Technical University of Athens, GR , Greece
| | | | | | - Kostas Marias
- Foundation for Research and Technology Hellas, Heraklion, Greece
| | | | - Manolis Tsiknakis
- Department of Informatics Engineering, TEI Crete and the Computational Medicine Laboratory, Institute of Computer Science, FORTH , Heraklion, Greece
| | - Norbert Graf
- University Hospital of the Saarland, Pediatric Haematology and Oncology, Homburg, Germany
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Said R, Tsimberidou AM. Pharmacokinetic evaluation of vincristine for the treatment of lymphoid malignancies. Expert Opin Drug Metab Toxicol 2014; 10:483-94. [PMID: 24512004 DOI: 10.1517/17425255.2014.885016] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Vincristine is a key agent for the treatment of acute lymphoblastic leukemia (ALL) and other lymphoid malignancies. The strong antineoplastic activity of vincristine has been limited by its pharmacological characteristics. AREAS COVERED This paper reviews the role of vincristine in the treatment of lymphoid malignancies. This review summarizes its efficacy and toxicity, and focuses on the pharmacokinetic features of vincristine that affect clinical outcomes. EXPERT OPINION As a single agent, vincristine is associated with brief and incomplete responses, but in combination with other agents, vincristine has dramatically improved the outcomes of lymphoid malignancies such as ALL. Vincristine is a key drug of hyper-fractionated cyclophosphamide, vincristine, doxorubicin and dexamethasone, an intensive chemotherapeutic regimen for the treatment of ALL, and of cyclophosphamid, adriamycin, vincristine and prednisone, which has been used extensively in the treatment of patients with aggressive or indolent lymphomas and Richter syndrome. The strong antileukemic activity of vincristine has been limited by its variable and unpredictable pharmacological characteristics, narrow therapeutic index and neurotoxicity profile. These characteristics prompted the development of liposomal vincristine, which has optimized its clinical application. Liposomal vincristine has promising antileukemic activity, and it is approved by the FDA as a single agent for the treatment of relapsed/refractory Philadelphia chromosome-negative ALL.
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Affiliation(s)
- Rabih Said
- The University of Texas MD Anderson Cancer Center, Department of Investigational Cancer Therapeutics (Phase I Clinical Trials Program) , 1515 Holcombe Blvd., Unit 455, Houston, TX 77030-3722 , USA +1 713 792 4259 ; +1 713 794 3249 ;
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van Hasselt JGC, van Eijkelenburg NKA, Beijnen JH, Schellens JHM, Huitema ADR. Optimizing drug development of anti-cancer drugs in children using modelling and simulation. Br J Clin Pharmacol 2014; 76:30-47. [PMID: 23216601 DOI: 10.1111/bcp.12062] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 11/30/2012] [Indexed: 01/04/2023] Open
Abstract
Modelling and simulation (M&S)-based approaches have been proposed to support paediatric drug development in order to design and analyze clinical studies efficiently. Development of anti-cancer drugs in the paediatric population is particularly challenging due to ethical and practical constraints. We aimed to review the application of M&S in the development of anti-cancer drugs in the paediatric population, and to identify where M&S-based approaches could provide additional support in paediatric drug development of anti-cancer drugs. A structured literature search on PubMed was performed. The majority of identified M&S-based studies aimed to use population PK modelling approaches to identify determinants of inter-individual variability, in order to optimize dosing regimens and to develop therapeutic drug monitoring strategies. Prospective applications of M&S approaches for PK-bridging studies have scarcely been reported for paediatric oncology. Based on recent developments of M&S in drug development there are several opportunities where M&S could support more informative bridging between children and adults, and increase efficiency of the design and analysis of paediatric clinical trials, which should ultimately lead to further optimization of drug treatment strategies in this population.
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Affiliation(s)
- Johan G C van Hasselt
- Department of Clinical Pharmacology, Netherlands Cancer Institute; Department of Pharmacy & Pharmacology, Slotervaart Hospital/Netherlands Cancer Institute, Amsterdam, the Netherlands.
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Kumar V, Ramaswami N, Pandey A, Shukla RC, Sen MR, Sharma SP, Gupta DK, Gangopadhyay AN. Clinico-immunological response to intratumoral versus intravenous neoadjuvant chemotherapy in advanced pediatric solid malignancies. Indian J Med Paediatr Oncol 2013; 34:80-4. [PMID: 24049292 PMCID: PMC3764749 DOI: 10.4103/0971-5851.116183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: There is minimal literature on the use of intralesional chemotherapy in the pediatric age group. We undertook this present study to evaluate the two modalities (intratumoral and intravenous) of giving chemotherapy in terms of toxicity of chemotherapy, hematological parameters, efficacy of chemotherapy in reduction in volume of the tumor as well as resectability of tumor with special emphasis on immunological parameters. Materials and Methods: Advanced cases of Wilms’ tumor and Neuroblastoma were included in the study. Intratumoral chemotherapy was given through 25 G spinal needle under aseptic precautions and ultrasound guidance in the same dose as in systemic chemotherapy. Intravenous group was given chemotherapy in the usual way. Reassessment was carried out after every course of chemotherapy. Results: Group A included 16 cases of Wilms’ tumor and 6 cases of neuroblastoma. In group B, there were 14 cases of Wilms’ tumor and 8 of neuroblastoma. Vomiting, diarrhea, mucositis, and thrombophlebitis were more common in the intravenous group (P<0.05). The fall in Immunoglobulin A, Immunogloblulin G, Immunoglobulin M, and T-cell rosetting was more common in the intravenous group (P<0.05). Seventy percent of patients had completely resectable tumor at the end of 6 doses of intratumoral chemotherapy as compared to 50% resectability in the intravenous group (P<0.05). Conclusion: Intratumoral chemotherapy, besides causing less of the adverse effects and increasing the resecability rate, also causes less suppression of the immune system. This may be offered as an alternative safe and effective modality of treatment for advanced solid tumors.
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Affiliation(s)
- Vijayendra Kumar
- Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Läer S, Barrett JS, Meibohm B. The In Silico Child: Using Simulation to Guide Pediatric Drug Development and Manage Pediatric Pharmacotherapy. J Clin Pharmacol 2013; 49:889-904. [DOI: 10.1177/0091270009337513] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Li LH, Dong H, Zhao F, Tang J, Chen X, Ding J, Men HT, Luo WX, Du Y, Ge J, Tan BX, Cao D, Liu JY. The upregulation of dihydropyrimidine dehydrogenase in liver is involved in acquired resistance to 5-fluorouracil. Eur J Cancer 2013; 49:1752-60. [PMID: 23313143 DOI: 10.1016/j.ejca.2012.12.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 12/03/2012] [Accepted: 12/12/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acquired resistance to 5-fluorouracil (5-FU) is one of the important reasons for failure in 5-FU-based chemotherapy. The upregulation of dihydropyrimidine dehydrogenase (DPD) in tumours was reported as an important factor for acquired 5-FU resistance. The aim of this study is to examine whether intra-hepatic DPD was involved in acquired 5-FU resistance. METHODS HT-29 human colorectal xenograft tumours were established in nude mice. After long-term exposure to 5-FU, some of the tumour became "resistant" and the others remained "sensitive" to 5-FU. DPD expression levels in the livers and tumours of "resistant", "sensitive" or untreated mice were examined, and pharmacokinetics of 5-FU in rats' plasma were investigated. Gimeracil, a DPD inhibitor, was checked whether it could reverse the reduced bioavailability of 5-FU. RESULTS DPD expression was upregulated obviously in tumours of "resistant" mice as reported previously. Importantly, DPD expression was also upregulated significantly in livers of "resistant" mice, compared with those of "sensitive" or untreated mice. Furthermore, the upregulation of DPD expression in livers led to accelerated metabolism of 5-FU. Gimeracil was found to reverse the reduced serum 5-FU concentration. The cultured tumour cells from 5-FU treated mice showed relative sensitivity to higher concentration of 5-FU, even the "resistant" tumour cells. CONCLUSION Our study suggested that the upregulation of DPD in liver may be involved in acquired resistance to 5-FU, and DPD inhibitors or increasing 5-FU dosage may have potential application in overcoming 5-FU acquired resistance.
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Affiliation(s)
- Long-Hao Li
- Department of Medical Oncology, Cancer Center, The State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, No. 37, Guo Xue Xiang, Chengdu 610041, Sichuan Province, China
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Georgiadi EC, Dionysiou DD, Graf N, Stamatakos GS. Towards in silico oncology: adapting a four dimensional nephroblastoma treatment model to a clinical trial case based on multi-method sensitivity analysis. Comput Biol Med 2012; 42:1064-78. [PMID: 23063290 DOI: 10.1016/j.compbiomed.2012.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 07/31/2012] [Accepted: 08/24/2012] [Indexed: 11/28/2022]
Abstract
In the past decades a great progress in cancer research has been made although medical treatment is still widely based on empirically established protocols which have many limitations. Computational models address such limitations by providing insight into the complex biological mechanisms of tumor progression. A set of clinically-oriented, multiscale models of solid tumor dynamics has been developed by the In Silico Oncology Group (ISOG), Institute of Communication and Computer Systems (ICCS)-National Technical University of Athens (NTUA) to study cancer growth and response to treatment. Within this context using certain representative parameter values, tumor growth and response have been modeled under a cancer preoperative chemotherapy protocol in the framework of the SIOP 2001/GPOH clinical trial. A thorough cross-method sensitivity analysis of the model has been performed. Based on the sensitivity analysis results, a reasonable adaptation of the values of the model parameters to a real clinical case of bilateral nephroblastomatosis has been achieved. The analysis presented supports the potential of the model for the study and eventually the future design of personalized treatment schemes and/or schedules using the data obtained from in vitro experiments and clinical studies.
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Affiliation(s)
- Eleni Ch Georgiadi
- In Silico Oncology Group, Institute of Communication and Computer Systems, School of Electrical and Computer Engineering, National Technical University of Athens, Greece
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Cytostatic drugs in infants: A review on pharmacokinetic data in infants. Cancer Treat Rev 2012; 38:3-26. [DOI: 10.1016/j.ctrv.2011.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 03/21/2011] [Accepted: 03/24/2011] [Indexed: 01/11/2023]
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Stamatakos GS, Georgiadi EC, Graf N, Kolokotroni EA, Dionysiou DD. Exploiting clinical trial data drastically narrows the window of possible solutions to the problem of clinical adaptation of a multiscale cancer model. PLoS One 2011; 6:e17594. [PMID: 21407827 PMCID: PMC3048172 DOI: 10.1371/journal.pone.0017594] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 01/28/2011] [Indexed: 11/30/2022] Open
Abstract
The development of computational models for simulating tumor growth and response to treatment has gained significant momentum during the last few decades. At the dawn of the era of personalized medicine, providing insight into complex mechanisms involved in cancer and contributing to patient-specific therapy optimization constitute particularly inspiring pursuits. The in silico oncology community is facing the great challenge of effectively translating simulation models into clinical practice, which presupposes a thorough sensitivity analysis, adaptation and validation process based on real clinical data. In this paper, the behavior of a clinically-oriented, multiscale model of solid tumor response to chemotherapy is investigated, using the paradigm of nephroblastoma response to preoperative chemotherapy in the context of the SIOP/GPOH clinical trial. A sorting of the model's parameters according to the magnitude of their effect on the output has unveiled the relative importance of the corresponding biological mechanisms; major impact on the result of therapy is credited to the oxygenation and nutrient availability status of the tumor and the balance between the symmetric and asymmetric modes of stem cell division. The effect of a number of parameter combinations on the extent of chemotherapy-induced tumor shrinkage and on the tumor's growth rate are discussed. A real clinical case of nephroblastoma has served as a proof of principle study case, demonstrating the basics of an ongoing clinical adaptation and validation process. By using clinical data in conjunction with plausible values of model parameters, an excellent fit of the model to the available medical data of the selected nephroblastoma case has been achieved, in terms of both volume reduction and histological constitution of the tumor. In this context, the exploitation of multiscale clinical data drastically narrows the window of possible solutions to the clinical adaptation problem.
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Affiliation(s)
- Georgios S Stamatakos
- In Silico Oncology Group, Institute of Communication and Computer Systems, School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece.
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Approaches to clear residual chemotherapeutics from indwelling catheters in children with cancer. Ther Drug Monit 2011; 32:741-8. [PMID: 20962707 DOI: 10.1097/ftd.0b013e3181fa3c68] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To develop a method for drug dosing and pharmacokinetic (PK) sampling in children with cancer from a single indwelling central venous catheter that minimized drug contamination. METHODS A benchtop system was designed to simulate dosing and clearing actinomycin-D (AMD) and vincristine (VCR) from central venous catheters. The authors evaluated the effects of flush volume, composition and pH, timed drug instillation, and number of blood-draw return cycles on residual drug concentrations. A proof-of-principle study was conducted in three pediatric patients with cancer with paired PK samples obtained by both central and peripheral catheters. RESULTS Nearly complete removal of drug from the catheter was obtained after five blood-draw return cycles consisting of 5 mL of whole blood. Residual concentration of AMD was 0.18 ± 0.02 ng/mL or 0.16% of the initial infusion concentration. VCR exhibited lower propensity for catheter adsorption than AMD with residual concentrations undetectable after three blood-draw return cycles. In patients in which the clearance procedure was used, higher drug concentrations were generally observed from centrally cleared samples at most time points, but differences relative to peripherally obtained samples were not statistically significant for either AMD or VCR. Two of three patients had higher exposure for AMD based on PK samples obtained from central catheters, whereas exposure for VCR was similar for both sampling catheters in all patients. CONCLUSIONS A reliable procedure to efficiently reduce AMD and VCR contamination during PK sampling has been established and is currently being used in a PK study being conducted by the Children's Oncology Group.
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Bellanti F, Kågedal B, Della Pasqua O. Do pharmacokinetic polymorphisms explain treatment failure in high-risk patients with neuroblastoma? Eur J Clin Pharmacol 2011; 67 Suppl 1:87-107. [PMID: 21287160 PMCID: PMC3112027 DOI: 10.1007/s00228-010-0966-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Accepted: 11/27/2010] [Indexed: 12/30/2022]
Abstract
PURPOSE Neuroblastoma is the most common extracranial solid tumour in childhood. It accounts for 15% of all paediatric oncology deaths. In the last few decades, improvement in treatment outcome for high-risk patients has not occurred, with an overall survival rate <30-40%. Many reasons may account for such a low survival rate. The aim of this review is to evaluate whether pharmacogenetic factors can explain treatment failure in neuroblastoma. METHODS A literature search based on PubMed's database Medical Subject Headings (MeSH) was performed to retrieve all pertinent publications on current treatment options and new classes of drugs under investigation. One hundred and fifty-eight articles wer reviewed, and relevant data were extracted and summarised. RESULTS AND CONCLUSIONS Few of the large number of polymorphisms identified thus far showed an effect on pharmacokinetics that could be considered clinically relevant. Despite their clinical relevance, none of the single nucleotide polymorphisms (SNPs) investigated can explain treatment failure. These findings seem to reflect the clinical context in which anti-tumour drugs are used, i.e. in combination with multimodal therapy. In addition, many pharmacogenetic studies did not assess (differences in) drug exposure, which could contribute to explaining pharmacogenetic associations. Furthermore, it remains unclear whether the significant activity of new drugs on different neuroblastoma cell lines translates into clinical efficacy, irrespective of resistance or myelocytomatosis viral related oncogene, neuroblastoma derived (MYCN) amplification. Elucidation of the clinical role of pharmacogenetic factors in the treatment of neuroblastoma demands an integrated pharmacokinetic-pharmacodynamic approach to the analysis of treatment response data.
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Affiliation(s)
- Francesco Bellanti
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands
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Population pharmacokinetics and pharmacogenetics of vincristine in paediatric patients treated for solid tumour diseases. Cancer Chemother Pharmacol 2010; 68:1191-8. [DOI: 10.1007/s00280-010-1541-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 11/26/2010] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW The therapeutic index of many medications, especially in children, is very narrow with substantial risk for toxicity at doses required for therapeutic effects. This is particularly relevant to cancer chemotherapy, when the risk of toxicity must be balanced against potential suboptimal (low) systemic exposure that can be less effective in patients with higher rates of drug clearance. The purpose of this review is to discuss genetic factors that lead to interpatient differences in the pharmacokinetics and pharmacodynamics of these medications. RECENT FINDINGS Genome-wide agonistic studies of pediatric patient populations are revealing genome variations that may affect susceptibility to specific diseases and that influence the pharmacokinetic and pharmacodynamic characteristics of medications. Several genetic factors with relatively small effect may be combined in the determination of a pharmacogenomic phenotype and considering these polygenic models may be mandatory in order to predict the related drug response phenotypes. These findings have potential to yield new insights into disease pathogenesis, and lead to molecular diagnostics that can be used to optimize the treatment of childhood cancers. SUMMARY Advances in genome technology, and their comprehensive and systematic deployment to elucidate the genomic basis of interpatient differences in drug response and disease risk, hold great promise to ultimately enhance the efficacy and reduce the toxicity of drug therapy in children.
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Affiliation(s)
- Steven W. Paugh
- Hematological Malignancies Program and Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN 38105
| | - Gabriele Stocco
- Hematological Malignancies Program and Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN 38105
| | - William E. Evans
- Hematological Malignancies Program and Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN 38105
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Malnourished Malawian patients presenting with large Wilms tumours have a decreased vincristine clearance rate. Eur J Cancer 2010; 46:1841-7. [DOI: 10.1016/j.ejca.2010.03.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Revised: 01/20/2010] [Accepted: 03/03/2010] [Indexed: 11/22/2022]
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Behan JW, Avramis VI, Yun JP, Louie SG, Mittelman SD. Diet-induced obesity alters vincristine pharmacokinetics in blood and tissues of mice. Pharmacol Res 2010; 61:385-90. [PMID: 20083201 DOI: 10.1016/j.phrs.2010.01.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 01/11/2010] [Accepted: 01/12/2010] [Indexed: 11/30/2022]
Abstract
Obesity is associated with poorer outcome from many cancers, including leukemia. One possible contributor to this could be suboptimal chemotherapy dosing in obese patients. We have previously found that vincristine (VCR) is less effective in obese compared to non-obese mice with leukemia, despite weight-based dosing. In the present study, we administered (3)H-VCR to obese and control mice to determine whether obesity would cause suboptimal VCR exposure. Blood VCR concentrations were fitted with a three-compartment model using pharmacokinetic analysis (two-stage PK) in three subsets of VCR concentrations vs. time method. Tissue and blood VCR concentrations were also analyzed using non-compartmental modeling. Blood VCR concentrations showed a triexponential decay and tended to be slightly higher in the obese mice at all time-points. However, the t(1/2,beta) and t(1/2,gamma) were shorter in the obese mice (9.7 min vs. 44.5 min and 60.3h vs. 85.6h, respectively), resulting in a lower AUC(0-infinity) (13,099 ng/m Lh vs. 15,384 ng/mL h). Had the dose of VCR been "capped", as is done in clinical practice, the AUC(0-infinity) would have been 36% lower in the obese mice than the controls. Tissue disposition of VCR revealed a biexponential decay from spleen, liver, and adipose. Interestingly, VCR slowly accumulated in the bone marrow of control mice, but had a slow decay from the marrow in the obese mice. Thus, obesity alters VCR PK, causing a lower overall exposure in circulation and bone marrow. Given the high prevalence of obesity, additional PK studies should be performed in obese subjects to optimize chemotherapy dosing regimens.
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Affiliation(s)
- James W Behan
- Division of Endocrinology, Diabetes & Metabolism, Childrens Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
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Abstract
Vincristine is one of the most widely used and more effective drugs in paediatric oncology. The dose-limiting toxicity of neuropathy, lack of proven neuroprotective measures and an incomplete understanding of the pharmacokinetics and pharmacogenetics of vincristine have limited its therapeutic potential. Recent advances in the understanding of vincristine pharmacokinetics and pharmacogenetics, and potential methods of preventing neurotoxicity are reviewed which could enable dose escalation and dose individualisation in order to enhance the therapeutic index.
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Affiliation(s)
- Andrew Moore
- Section of Paediatric Oncology, The Institute of Cancer Research, Sutton, United Kingdom.
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Veerman AJ, Kamps WA, van den Berg H, van den Berg E, Bökkerink JPM, Bruin MCA, van den Heuvel-Eibrink MM, Korbijn CM, Korthof ET, van der Pal K, Stijnen T, van Weel Sipman MH, van Weerden JF, van Wering ER, van der Does-van den Berg A. Dexamethasone-based therapy for childhood acute lymphoblastic leukaemia: results of the prospective Dutch Childhood Oncology Group (DCOG) protocol ALL-9 (1997-2004). Lancet Oncol 2009; 10:957-66. [PMID: 19747876 DOI: 10.1016/s1470-2045(09)70228-1] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A population-based cohort of children aged 1-18 years with acute lymphoblastic leukaemia (ALL) was treated with a dexamethasone-based protocol (Dutch Childhood Oncology Group [DCOG] ALL-9). We aimed to confirm the results of the most effective DCOG ALL protocol for non-high-risk (NHR) patients to date (ALL-6), compare results with ALL-7 and ALL-8, and study prognostic factors in a non-randomised setting. METHODS From Jan 1, 1997, until Nov 1, 2004, patients with ALL were treated according to the ALL-9 protocol in eight Dutch academic centres with their affiliated peripheral hospitals. Patients were stratified into NHR and high risk (HR) groups. HR criteria were white-blood-cell count of 50,000 cells per microL or more, T-cell phenotype, mediastinal mass, CNS or testicular involvement, and Philadelphia chromosome or MLL rearrangement; patients who did not fulfil these criteria were deemed to be NHR. The NHR group was treated with a three-drug induction (dexamethasone, vincristine, and asparaginase) for 6 weeks, medium-dose methotrexate for 3 weeks, then maintenance therapy. HR patients received a four-drug induction (as for the NHR patients plus daunorubicin) for 6 weeks, high-dose methotrexate for 8 weeks, and two intensification courses before receiving maintenance therapy. Triple intrathecal medication was given 13 times in NHR patients, 15 times in HR patients (17 times for patients with initial CNS involvement). No patient received cranial irradiation. Maintenance therapy was given until 109 weeks for all patients and consisted of mercaptopurine and methotrexate for 5 weeks, alternated with dexamethasone and vincristine for 2 weeks. Kaplan-Meier analysis was done on an intention-to-treat basis with event-free survival as the primary endpoint. This trial is registered at trialregister.nl, number NTR460/SNWLK-ALL-9. FINDINGS 859 patients were recruited to the study. Complete remission was achieved in 592 (98.5%) of the 601 patients in the NHR group and 250 (96.9%) of the 258 in the HR group. Five patients in the NHR group and four in the HR group died during induction. Median follow-up for patients alive was 72.2 (range 4.8-132.7) months as of August, 2008. 5-year event-free survival was 81% (SE 1%) in all patients: 84% (2%) in NHR patients, and 72% (3%) in HR patients. Isolated CNS relapses occurred in 22 (2.6%) of 842 patients. In a multivariate analysis, DNA index was the strongest predictor of outcome (<1.16 vs >or=1.16; relative risk 0.42, 95% CI 0.22-0.78), followed by age (1-9 vs >or=10 years; 2.23, 1.60-3.11) and white-blood-cell count (<50,000 vs >or=50,000 cells per microL; 1.60, 1.13-2.26). INTERPRETATION The overall results of the dexamethasone-based DCOG ALL-9 protocol are better than those of our previous Berlin-Frankfurt-Münster-based protocols ALL-7 and ALL-8. The results for NHR patients were achieved with high cumulative doses of dexamethasone and vincristine, but without the use of anthracyclines, etoposide, cyclophosphamide, or cranial irradiation, therefore minimising the risk of side-effects. FUNDING Dutch Health Insurers.
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Damen CWN, Israëls T, Caron HN, Schellens JHM, Rosing H, Beijnen JH. Validated assay for the simultaneous quantification of total vincristine and actinomycin-D concentrations in human EDTA plasma and of vincristine concentrations in human plasma ultrafiltrate by high-performance liquid chromatography coupled with tandem mass spectrometry. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2009; 23:763-774. [PMID: 19204931 DOI: 10.1002/rcm.3938] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A sensitive, specific and efficient high-performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS) assay for the simultaneous determination of total vincristine and actinomycin-D concentrations in human plasma and an assay for the determination of unbound vincristine are presented. Electrospray ionization (ESI), atmospheric pressure chemical ionization (APCI) and heated electrospray ionization (H-ESI) were tested as ionization interfaces. For reasons of robustness ESI was chosen followed by tandem mass spectrometry (ESI-MS/MS). For the plasma assay a 30 microL aliquot was protein precipitated with acetonitrile/methanol (50:50, v/v) containing the internal standard vinorelbine and 10 microL volumes were injected onto the HPLC system. To determine unbound vincristine, ultrafiltrate was produced from plasma using 30 kDa centrifugal filter units. The plasma ultrafiltrate was mixed with methanol (50:50, v/v), internal standard vinorelbine was added and 20 microL aliquots were injected onto the HPLC system. Separation was achieved on a 50x2.1 mm i.d. Xbridge C18 column using 1 mM ammonium acetate/acetonitrile (30:70, v/v) adjusted to pH 10.5 with ammonia, run in a gradient with methanol at a flow rate of 0.4 mL/min. HPLC run time was 6 min. The assay quantifies in plasma vincristine from 0.25 to 100 ng/mL and actinomycin-D from 0.5 to 250 ng/mL using plasma sample volumes of only 30 microL. Vincristine in plasma ultrafiltrate can be quantified from 1 to 100 ng/mL. Validation results demonstrate that vincristine and actinomycin-D can be accurately and precisely quantified in human plasma and plasma ultrafiltrate with the presented methods. The assays are now in use to support clinical pharmacological studies in children treated with vincristine and actinomycin-D.
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Affiliation(s)
- Carola W N Damen
- Department of Pharmacy & Pharmacology, Slotervaart Hospital/The Netherlands Cancer Institute, Louwesweg 6, 1066 EC Amsterdam, The Netherlands.
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Abstract
Pharmacogenetics covers the genetic variation affecting pharmacokinetics and pharmacodynamics, and their influence on drug-response phenotypes. The genetic variation includes an estimated 15 million single nucleotide polymorphisms (SNPs) and is a key determinator for the interindividual differences in treatment resistance and toxic side effects. As most childhood acute lymphoblastic leukemia treatment protocols include up to 13 different chemotherapeutic agents, the impact of individual SNPs has been difficult to evaluate. So far focus has mainly been on the widely used glucocorticosteroids, methotrexate, and thiopurines, or on metabolic pathways and transport mechanisms that are common to several drugs, such as the glutathione S-transferases. However, beyond the thiopurine methyltransferase polymorphisms, the candidate-gene approach has not established clear associations between polymorphisms and treatment response. In the future, high-throughput, low-cost, genetic platforms will allow screening of hundreds or thousands of targeted SNPs to give a combined gene-dosage effect (=individual SNP risk profile), which may allow pharmacogenetic-based individualization of treatment.
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Lönnerholm G, Frost BM, Abrahamsson J, Behrendtz M, Castor A, Forestier E, Heyman M, Uges DRA, de Graaf SSN. Vincristine pharmacokinetics is related to clinical outcome in children with standard risk acute lymphoblastic leukemia. Br J Haematol 2008; 142:616-21. [PMID: 18537965 DOI: 10.1111/j.1365-2141.2008.07235.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vincristine is a key drug in the treatment of childhood and adult acute lymphoblastic leukemia (ALL), and many other childhood malignancies. Despite decades of wide clinical use, no data on the correlation between vincristine pharmacokinetics and long-term clinical outcome have been published. We here report clinical data (median follow-up time 10.5 years, range 7.3-12 years) for 86 children with B-cell precursor ALL, in whom vincristine kinetics were studied on treatment day 1. The median total plasma clearance was 429 and 331 ml/min per m(2) and the area under the plasma concentration-time curve (AUC) was 4.49 and 5.40 mg/l x min in relapse and non-relapse patients, respectively (not significant). In standard risk patients, where treatment depends more heavily on vincristine than in other subgroups, the relative risk (RR) of relapse was significantly increased for patients with clearance values above median (RR 5.2; P = 0.036), or AUC values below median (RR 5.8; P = 0.025). Our data suggest a relationship between the antileukemic effect and the systemic exposure of the drug, which warrants further studies.
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Affiliation(s)
- Gudmar Lönnerholm
- Department of Women's and Children's Health, University Children's Hospital, Uppsala, Sweden.
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Quantification of Vincristine and its Major Metabolite in Human Plasma by High-Performance Liquid Chromatography/Tandem Mass Spectrometry. Ther Drug Monit 2008; 30:357-64. [DOI: 10.1097/ftd.0b013e31816b92c9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Stamatakos GS, Dionysiou DD, Graf NM, Sofra NA, Desmedt C, Hoppe A, Uzunoglu NK, Tsiknakis M. The "Oncosimulator": a multilevel, clinically oriented simulation system of tumor growth and organism response to therapeutic schemes. Towards the clinical evaluation of in silico oncology. ACTA ACUST UNITED AC 2008; 2007:6629-32. [PMID: 18003545 DOI: 10.1109/iembs.2007.4353879] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The "Oncosimulator" is at the same time a concept of multilevel integrative cancer and (treatment affected) normal tissue biology, an algorithmic construct and a software tool which aims at supporting the clinician in the process of optimizing cancer treatment on the patient individualized basis. Additionally it is a platform for better understanding and exploring the natural phenomenon of cancer as well as training doctors and interested patients alike. In order to achieve all of these goals it has to undergo a thorough clinical optimization and validation process. This is one of the goals of the European Commission funded integrated project "ACGT: Advancing Clinicogenomic Trials on Cancer". Nephroblastoma (Wilms' tumor) and breast cancer have been selected to serve as two paradigms to clinically specify and evaluate the "Oncosimulator" as well as the emerging domain of in silico oncology.
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Affiliation(s)
- Georgios S Stamatakos
- National Technical University of Athens, Institute of Communications and Computer Systems, Zografos, GR-157 80, Greece.
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Corona G, Casetta B, Sandron S, Vaccher E, Toffoli G. Rapid and sensitive analysis of vincristine in human plasma using on-line extraction combined with liquid chromatography/tandem mass spectrometry. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2008; 22:519-525. [PMID: 18228243 DOI: 10.1002/rcm.3390] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
A simple and rapid method has been developed and validated for the quantitation of vincristine in human plasma by liquid chromatography/tandem mass spectrometry (LC/MS/MS) with atmospheric pressure chemical ionization using on-line solid-phase extraction. The method uses vinblastine as internal standard and the sample preparation is limited just to a plasma protein precipitation step. Further sample clean-up is carried out on-line through a perfusion column preceding an analytical phenyl LC column, the latter directly connected to the mass spectrometer. Quantitation is performed in multiple reaction monitoring mode using the transitions of m/z 825.3 --> 765.3 and 811.3 --> 751.3 for vincristine and vinblastine respectively. The assay was linear (r2 > or =0.99) in a concentration range from 0.1 to 500 ng/mL. Carry-over, measured on the experimental set-up, was less than 0.04%. Recovery for vincristine and the internal standard was within 90-95%. The intra-day and inter-day assay precision ranged from 1.2% to 6.8% RSD while mean percentage deviation from nominal value ranged from 0.01% to 6.1%. The proposed assay was found suitable for pharmacokinetics investigations and clinical therapeutic drug monitoring especially in pediatric cancer patients.
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Affiliation(s)
- Giuseppe Corona
- Division of Experimental and Clinical Pharmacology, National Cancer Institute and Center for Molecular Biomedicine, Aviano (PN), Italy.
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Groninger E, Proost JH, de Graaf SSN. Pharmacokinetic studies in children with cancer. Crit Rev Oncol Hematol 2005; 52:173-97. [PMID: 15582785 DOI: 10.1016/j.critrevonc.2004.08.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2004] [Indexed: 11/23/2022] Open
Abstract
We reviewed the current status of our knowledge of pharmacokinetics and pharmacodynamics of some anti-neoplastic drugs, used in the treatment of childhood cancer. Extrapolation of data from pharmacokinetic studies in adults to the paediatric population is often not feasible. Specific studies in children are needed. Of all reviewed anti-neoplastic drugs methotrexate appears to be most extensively studied. Methotrexate pharmacokinetics is correlated with toxicity and response to therapy, and it has been shown that individualized adaptive dosing of methotrexate is correlated with a better response to therapy without increasing toxicity in children with ALL and osteosarcoma. Of most of the other reviewed anti-neoplastic drugs it is demonstrated that pharmacokinetics is correlated with toxicity, and of some drugs a relationship of pharmacokinetics with response to therapy is demonstrated as well. In case of cytarabine, etoposide, and teniposide, individualized dosing also appears to be feasible. However, there is no evidence that this strategy improves response to therapy. Specifically data on pharmacokinetic and pharmacodynamic correlations and effect of pharmacokinetically guided, individualized dosing are important for the design of optimal cancer chemotherapy for individual patients. Unfortunately for a considerable number of anti-neoplastic drugs these specific data are lacking in children and future research is needed.
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Affiliation(s)
- E Groninger
- Department of Paediatric Oncology Haematology, Beatrix Children's Hospital, Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands.
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Groninger E, Meeuwsen-de Boer T, Koopmans P, Uges D, Sluiter W, Veerman A, Kamps W, de Graaf S. Vincristine pharmacokinetics and response to vincristine monotherapy in an up-front window study of the Dutch Childhood Leukaemia Study Group (DCLSG). Eur J Cancer 2005; 41:98-103. [PMID: 15617994 DOI: 10.1016/j.ejca.2004.10.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2004] [Revised: 09/22/2004] [Accepted: 10/05/2004] [Indexed: 11/27/2022]
Abstract
The relationship between vincristine pharmacokinetics and its antileukaemic effect in children is unknown. Since vincristine plays a key role in the treatment of childhood acute lymphoblastic leukaemia (ALL), it is worthwhile to explore if efficacy can be improved by individual dose adjustment. Therefore, we studied the relationship between vincristine antileukaemic effect and pharmacokinetics in children newly diagnosed with ALL before the start of standard induction chemotherapy. Vincristine plasma concentration was measured by high-pressure liquid chromatography analysis with electrochemical detection. Primary pharmacokinetic parameters were estimated by maximum a posteriori parameter estimation with a Bayesian algorithm using the ADAPT II software package. Secondary pharmacokinetic parameters were calculated from the model. Response to a single dose of vincristine was determined on bone marrow (BM) and peripheral blood (PB) smears after 3 days. Variability of vincristine pharmacokinetics did not explain variability of response to vincristine monotherapy. Our results do not support the clinical application of pharmacokinetically guided adaptation of a standard body surface area-based dose of vincristine.
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Affiliation(s)
- Ellis Groninger
- Departments of Paediatric Haematology Oncology, Beatrix Children's Hospital Groningen, P.O. Box 30 001, RB Groningen 9700, The Netherlands.
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Zwaan CM, Kaspers GJL. Possibilities for tailored and targeted therapy in paediatric acute myeloid leukaemia. Br J Haematol 2004; 127:264-79. [PMID: 15491285 DOI: 10.1111/j.1365-2141.2004.05167.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The clinical outcome of acute myeloid leukaemia (AML) in children has improved considerably using intensive chemotherapy and/or stem cell transplantation. This leads to cure in 50-70% of patients, and also results in significant morbidity and mortality. Hence, we need other ways to improve the cure rate. This review discusses possibilities for tailored therapy, reviewing in vitro cellular drug sensitivity data. The results provide suggestions regarding the adaptation of clinical protocols in certain AML subgroups, although further clinical studies will show whether this is effective. Secondly, we review type 1 genetic abnormalities (such as receptor tyrosine kinase mutations) that result in enhanced survival and proliferation of leukaemic cells, which can be detected in approximately 50% of paediatric AML samples, and are non-randomly associated with French-American-British type and cytogenetic subgroups. FLT3 internal tandem duplication is associated with poor clinical outcome, and may be used for risk-group stratification. The first results with small molecule inhibitors in adult AML do not suggest their use in children as yet. International collaboration is needed to further improve outcome by developing treatment protocols for subgroups of paediatric AML.
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Affiliation(s)
- C M Zwaan
- Department of Paediatric Haematology/Oncology, VU University Medical Center, Amsterdam, The Netherlands.
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Kellie SJ, Koopmans P, Earl J, Nath C, Roebuck D, Uges DRA, De Graaf SSN. Increasing the dosage of vincristine. Cancer 2004; 100:2637-43. [PMID: 15197807 DOI: 10.1002/cncr.20220] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Vincristine (VCR) is widely used to treat patients with malignant disease; among the patients treated with VCR are children with brain tumors. In vitro studies have demonstrated that the cytotoxic activity of VCR is related to both extracellular concentration and duration of exposure. The attainment of higher plasma concentrations by injecting larger bolus doses of VCR has been limited by concerns about neurotoxicity. One possible alternative strategy for enhancing the antitumor efficacy of VCR involves prolonging the duration of in vivo exposure. Therefore, the authors explored the neurotoxicity and pharmacokinetics of VCR administered via a 96-hour continuous infusion after administration of a conventional bolus dose in a pediatric population. METHODS The current study included 16 patients, 11 of whom were males. The median age of the study population was 4.8 years (range, 1.7-15.8 years). The diagnoses included intrinsic pontine glioma (n = 4), ependymoma (n = 5), astrocytoma (n = 3), medulloblastoma/primitive neuroectodermal tumor (PNET; n = 2), ganglioglioma (n = 1), and choroid plexus carcinoma (n = 1). Of the 16 patients, 5 were newly diagnosed, and the remaining 11 had disease recurrences, 8 of which arose after radiotherapy. Treatment included cyclophosphamide 65 mg/kg administered intravenously over 1 hour on Day 1, a bolus of VCR 1.5 mg/m(2) administered intravenously on Day 2, and VCR 0.5 mg/m(2) per 24 hours administered via continuous intravenous infusion on Days 2-5. Thus, a total VCR dose of 3.5 mg/m(2) was administered via infusion over 4 days. Fifteen patients received 2 courses of treatment at 21-28-day intervals, and a total of 31 treatment courses were administered. VCR concentrations in plasma samples were measured using high-performance liquid chromatography. RESULTS Jaw pain, constipation, mild abdominal pain, and depressed reflexes were common. However, only 1 of 31 courses was associated with Grade III toxicity, and no Grade IV toxicity (e.g., cranial nerve palsy, ileus, inappropriate antidiuretic hormone secretion, seizures, hallucinations, etc.) was noted. The steady-state plasma concentration of VCR during continuous infusion ranged from 1 to 3 microg/L in all patients. Responses after 2 courses were evaluated in 14 of 16 patients. A complete response was noted in one patient (astrocytoma), a partial response in three patients (one each with astrocytoma, ependymoma, and PNET), stable disease in seven patients, and disease progression in three patients. CONCLUSIONS Continuous infusion of VCR after a conventional bolus dose plus cyclophosphamide for children with tumors of the central nervous system did not result in significant neurotoxicity and appeared to be a safe strategy for achieving increased systemic exposure.
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Affiliation(s)
- Stewart J Kellie
- Oncology Unit, The Children's Hospital at Westmead, Sydney, Australia.
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Ozgen U, Türköz Y, Stout M, Ozuğurlu F, Pelik F, Bulut Y, Aslan M, Ravindranath Y, Savaşan S. Degradation of vincristine by myeloperoxidase and hypochlorous acid in children with acute lymphoblastic leukemia. Leuk Res 2003; 27:1109-13. [PMID: 12921949 DOI: 10.1016/s0145-2126(03)00098-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Vincristine (VCR) is an effective drug against acute lymphoblastic leukemia (ALL), many solid tumors, but not acute myeloid leukemia. It has been hypothesized that resistance of myeloblasts to VCR is related to myeloperoxidase (MPO) and production of hypochlorous acid (HOCl). We investigated the relationship between VCR degradation and MPO expression and serum HOCl concentrations in pediatric patients with ALL, lymphoma and solid tumors. We studied the sera from 43 children, of which 23 were newly diagnosed and as yet untreated cancer patients, 10 on chemotherapy and 10 healthy control subjects. Patients' sera were incubated with VCR alone or in the presence of taurine (T) or acetaminophen (APAP) and post-incubation VCR and HOCL concentrations were measured. Significant correlations between serum MPO expression, HOCl concentrations and VCR degradation were seen. In the chemotherapy group, MPO-positive patients produced high levels of HOCl and reciprocally low post-incubation VCR levels. HOCl and VCR concentrations in this group were significantly different than other groups studied. Both APAP and T inhibited VCR degradation in the sera of the chemotherapy group but not to the same degree. The effects seen here were consistent for both ALL and the lymphoma/solid tumor cases. Our results indicate that HOCl can increase VCR degradation in vitro in the serum and this effect is significantly more pronounced in pediatric patients undergoing chemotherapy.
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Affiliation(s)
- Unsal Ozgen
- Department of Pediatrics, Inönü University Medical School, Malatya, Turkey.
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