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Chemotherapy

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  • 1. Mohammad akheelOmfs pg
  • 2. Normal cells…•Differentiate, grow, mature, divide–Regulated, balanced; cell birth=cell death•Regulation: intracell signaling–Hyperplasia: new cells prod’d w/ growthstimulus via hormones, endogenous signals–Ex: hyperplasia of endometrial tissue duringmenstrual cycle is normal and necessary
  • 3. BUT if intense, prolongeddemand …• May  cell structural, functional abnormalities– Metaplasia: replacement of one cell type by another• Thicker cell layer better accommodates irritation– Ex: bronchial epithelium chronically irritated ciliated columnar epithelial cells replaced by sevlayers cuboidal epithelium» Note: Replacement cells normal, justdifferent» Reversible
  • 4. – Dysplasia: replacement cells disordered in size,shape• Incr’d mitosis rate• Somewhat reversible, often precancerous– Neoplasia: abnormal growth/invasion of cells• “New growth”• Neoplasm = tumor• Irreversible• Cells replicate, grow w/out control
  • 5. Neoplasms• = Tumors = groups of neoplastic cells• Two major types: benign, malignant• Benign – “noncancerous”– Local; cells cohesive, well-defined borders– Push adjacent tissue away– Doesn’t spread beyond original site– Often has capsule of fibrous connectivetissue
  • 6. • Malignant – grow more rapidly; oftencalled “cancer”– Not cohesive; seldom have capsule– Irregular shape; disrupted architecture– Invade surrounding cells– Can break away to form second tumor•“Metastasis” from 1oto 2osite
  • 7. Cancer (Neoplastic) Cells• May be:– Well-differentiated = retain normal cellfunction• Mimic normal tissue• Often benign– Poorly differentiated = disorganized• Can’t tell tissue of origin• “Anaplastic”
  • 8. Oncogenesis = Process ofTumor Development• Probably multi-step process Decr’d ability to differentiate andcontrol replication and growth
  • 9.  Initation = impt change introduced into cell◦ Probably through DNA alteration◦ >1 event probably needed for tumor prod’n◦ Reversible unless and until: Promotion = biochem event encouragestumor form’n Gen’ly need both initiation and promotion◦ Initiators, promoters may be toxins OR radiationOR viruses)
  • 10.  Most tumors arise “spontaneously” w/out knowncarcinogen exposure, AND Proto-oncogenes can be inherited (ex: “breast cancergene”) BUT environmental agents are known to cause DNAmutations, AND Risk factors known (Ex:◦ Cigarette smoking  lung cancer◦ UV light exposure  skin cancer) Theory: “Genetics loads the gun; the environmentpulls the trigger”
  • 11. Synth DNA precursors,proteins, etc.Premitotic synth ofstructures, mol’s
  • 12. Brody 42.1 – G0
  • 13.  Quiescent phase outside cell cycle Most adult cells Cyclin D in low concent Rb prot hypophosph’d◦ Inhib’s expression prot’s impt to cycle progression◦ Binds E2F transcr’n factors Controls genes impt to DNA repl’n Growth factor binding  act’n to G1
  • 14.  In healthy cells, survival factors signal act’nanti-apoptotic mech’s◦ Cytokines, hormones, cell contact factors Programmed cell death Cascade of proteases initiate process◦ Initiator caspases that act on effector caspases Effector caspase act’n may be through TumorNecrosis Factor Receptor
  • 15.  Second pathway act’d by intracell signals, e.g.DNA damage◦ Players are p53 gene & prot; mitochondrialcytochrome c; Apaf-1 (prot); caspase 9 Effector caspases initiate pathway  cleavagecell constituents  cluster membr-bound“entities” (used to be cell) that arephagocytosed Anti-apoptotic genetic lesions nec for dev’tcancer◦ Apoptosis resistance characteristic of cancer cells
  • 16.  Code for prot’s that regulate cell div/prolif’n whenturned on/off◦ Malfunctions, mutations may  oncogenesis◦ Changes w/ viruses, chem’s: point mutations, geneamplifications, chromosome translocations Two impt routes:◦ Proto-Oncogenes – code for prot’s turning cell div ON Mutations  overexpression  cancer◦ Tumor suppressor genes – code for prot’s turning celldiv OFF Mutations  repression  cancer
  • 17. 50.2 Rang
  • 18.  Result of act’n proto-oncogenes or inact’n tumorsuppressor genes◦ Change in growth factors, receptors Incr’d growth factors prod’d◦ Change in growth factor pathways 2ndmessenger cascades (esp tyr-kinase receptor cascades)◦ Change in cell cycle transducers Cyclins, Cdk’s, Cdk inhibitors
  • 19. ◦ Change in apoptotic mech’s◦ Change in telomerase expression◦ Change in local blood vessels  angiogenesis Note: Genes controlling any of theseprot’s/mech’s can be considered proto-oncogenes or tumor suppressor genes Note: Dev’t malignant cancer depends on sevtransform’ns
  • 20.  Affect cell division◦ Active on rapidly dividing cells Most effective during S phase of cell cycle◦ Many cause DNA damage Damage DNA  init’n apoptosis
  • 21.  Side effects greatest in other rapidly-dividingcells◦ Bone marrow toxicity◦ Impaired wound healing◦ Hair follicle damage◦ Gi epith damage◦ Growth in children◦ Gametes◦ Fetus May themselves be carcinogenic
  • 22.  Solid tumors◦ Growth rate decr’s as neoplasm size incr’s Outgrows ability to maintain blood supply AND Not all cells proliferate continuously◦ Compartments Dividing cells (may be ~5% tumor volume) Only pop’n susceptible to most anticancer drugs Resting cells (in G0); can be stim’d  G1 Not sensitive to chemotherapy, but act’d when therapy ends Cells unable to divide but add to tumor bulk
  • 23.  Suspended cancer cells (leukemias)◦ Killing 99.99% of 1011cancer cell burden, 107neoplasticcells remain◦ Can’t rely on host immunological defense to killremaining cancer cells Diagnosis, treatment difficult if rapidly growing◦ Ex: Burkitt’s lymphoma doubles ~24 h◦ Approx 30 doublings  tumor mass of 2 cm (109cells) May be detected, if not in deep organ◦ Approx 10 add’l doublings  20 cm mass (1012cells) –lethal◦ Therefore, “silent” for first ¾ existence
  • 24.  Cytotoxic Agents◦ Alkylating Agents◦ Antimetabolites◦ Cytotoxic antibiotics◦ Plant derivatives Hormones◦ Suppress nat’l hormone secr’n or antagonizehormone action Misc (mostly target oncogene products)
  • 25. Rand 50.3
  • 26.  Contain chem grps that covalently bind cellnucleophiles Impt properties of drugs◦ Can form carbonium ions C w/ 6 electrons highly reactive React w/ -NH2, -OH, -SH◦ Bifunctional (2 reactive grps) Allow cross-linking
  • 27.  Impt targets◦ G N7 – strongly nucleophilic A N1, A N3, C N3 also targets DNA becomes cross-linked w/ agent◦ Intra- or inter-strand◦  Decr’d transcr’n, repl’n◦  Chain scission, so strand breaks◦  Inappropriate base pairing (alkylated G w/ T) Most impt: S phase repl’n (strands unwound,more susceptible)  G2 block, apoptosis
  • 28. Rang 50.4
  • 29. 42-5 structuresNitrogen Mustards•Loss Cl  intramolec cyclization of side chain Reactive ethylene immonium derivative
  • 30.  Most common Prodrug – liver metab by CYP P450 MFO’s Effects lymphocytes◦ Also immunosuppressant Oral or IV usually SE’s: n/v, bone marrow dpression,hemorrhagic cystitis◦ Latter due to acrolein toxicity; ameliorated w/ SH-donors
  • 31. 42.6 cyclophosph
  • 32. 42.7 nitrosoureaNitrosoureas•Also activated in vivo•Alkylate DNA BUT alk’n prot’s  toxicity
  • 33. Temozolomide•Methylates G, A  improper G-T base pairing
  • 34.  Cl- dissoc’s  reactive complex that reacts w/ H2Oand interacts w/ DNA  intrastrand cross-link (G N7w/ adjacent G O6)  denaturation DNA◦ Nephrotoxic◦ Severe n/v ameliorated w/ 5-HT3 antagonists (decr gastricmotility) Carboplatin – fewer above SE’s, but more myelotoxic
  • 35.  Mimic structures of normal metabolic mol’s◦ Inhibit enz’s competitively OR◦ Inc’d into macromol’s  inappropriate structures Kill cells in S phase Three main groups◦ Folate antagonists◦ Pyr analogs◦ Pur analogs
  • 36.  Folic acid essential for synth purines, andthymidylate Folate: pteridine ring + PABA + glutamate◦ In cells, converted to polyglutamates then tetrahydrofolate (FH4)
  • 37.  Folate  FH4 cat’d bydihydrofolate reductasein 2 steps:◦ Folate  FH2◦ FH2  FH4 FH4 serves as methylgrp donor (1-C unit) todeoxyuridine (dUMP dTMP), alsoregenerating FH2
  • 38.  Higher affinity for enz than does FH2◦ Add’l H or ionic bond forms  Depletion FH4 in cell  depl’n dTMP “thymine-less death”  Inhib’n DNA synth Uptake through folate transport system◦ Resistance through decr’d uptake Metabolites (polyglutamate deriv’s) retained forweeks, months
  • 39. 50.8 Rand
  • 40. Pemetrexed
  • 41. 45.2 RandFYI…
  • 42.  5-Fluorouracil – dUMP analog also worksthrough dTMP synthesis pathway◦ Converted  “fraudulent” nucleotide FdUMP ◦ Competitive inhibitor for thymidylate synthetaseactive site, but can’t be converted to dTMP◦ Covalently binds thymidylate synthetase◦ Mech action uses all 3routes  decr’d DNAsynthesis, also transcr’n/transl’n inhib’n
  • 43.  Gemcitabine◦ Phosph’d  tri-PO4’s “Fraudulent nucleotide”◦ Also inhib’s ribonucleotide reductase  decr’dnucleotide synth Capecitabine is prodrug◦ Converted to 5FU in liver, tumor Enz impt to conversion overexpressed in cancer cells (?)
  • 44.  Cytosine arabinoside◦ Analog of 2’dC◦ Phosph’d in vivo  cytosine arabinoside triphosphate◦ Inhibits DNA polymerase Gemcitabine – araC analog◦ Fewer SE’s
  • 45. http://www.pfeist.net/ALL/arac/images/spongo2.gif42-11Gemcitabine
  • 46.  6-Mercaptopurine, 6-Thioguanine◦ Converted to “fraudulent nucleotides”◦ Inhibit enz’s nec for purine synth Fludarabine◦ Converted to triphosphate◦ Mech action sim to ara-C Pentostatin◦ Inhibits adenosine deaminase Catalyzes adenosine  inosine◦ Interferes w/ purinemetab, cell prolif’n
  • 47. 42-10Fludarabine Pentostatin
  • 48.  Substances of microbial origin that preventmammalian cell division Anthracyclines◦ Doxorubicin Intercalates in DNA Inhibits repl’n via action at topoisomerase II Topoisomerase II catalyzes nick in DNA strands Intercalated strand/topoisomerase complex stabilized permanently cleaved helix
  • 49. ◦ Epirubicin, mitozantrone structurally related◦ SE’s: cardiotoxicity (due to free radical prod’n), bonemarrow suppressionhttp://www.farmakoterapi.uio.no/cytostatika/images/16_1_t.gifMitozantronehttp://www.geocities.com/lubolahchev/Mitoxa4.gif
  • 50. ◦ Dactinomycin Intercalates in DNA minor groove between adjacent GC pairs Interferes w/ RNA polymerase movement  decr’d transcr’n Also may work through topoisomerase II◦ Bleomycin Glycopeptide Chelates Fe, which interacts w/ O2  Gen’n superoxide and/or hydroxyl radicals Radicals degrade DNA  fragmentation, release of free bases Most effective in G2, also active against cells in G0 Little myelosuppression BUT pulmonary fibrosis
  • 51. DactinomycinBleomycin
  • 52.  Work at mitosis Effect tubulin, therefore microtubule activity◦  Prevention spindle form’n OR◦ Stabilize (“freeze”) polymerized microtubules  Arrest of mitosis Other effects due to tubulin defects◦ Phagocytosis/chemotaxis◦ Axonal transport in neurons
  • 53. http://biotech.icmb.utexas.edu/botany/gifs/vdes.gifVinca Alkaloids
  • 54. http://biotech.icmb.utexas.edu/botany/gifs/tax.gifTaxanes: Paclitaxel, Docetaxelhttp://home.caregroup.org/clinical/altmed/interactions/Images/Drugs/docetaxe.gif
  • 55.  Etoposide, teniposide◦ From mandrake root◦ Inhibit mitoch function, nucleoside transport,topoisomerase II Campothecins: irinotecan, topotecan◦ Irinotecan requires hydrolysis  active form◦ Bind, inhibit topoisomerase II◦ Repair is difficult
  • 56. http://www.chemheritage.org/EducationalServices/pharm/chemo/readings/ages/ages04.gifIronotecanhttp://www.cancerquest.org/images/topotecan.gifTopotecanhttp://www.axxora.com/files/formula/lkt-i6933.gif
  • 57.  Tumors der’d from tissues responding tohormones may be hormone-dependent◦ Growth inhib’d by hormone antagonists OR otherhormones w/ opposing actions OR inhibitors of relevanthormone Glucocorticoids◦ Inhibitory on lymphocyte prolif’n◦ Used against leukemias, lymphomas
  • 58.  Estrogens◦ Block androgen effects (ex: fosfestrol)◦ Used to recruit cells in G0  G1, so better targets forcytotoxic drugs Progestogens (ex: megestrol,medroxyprogesterone)◦ Used in endometrial, renal tumors GnRH analogs (ex: goserelin)◦ Inhibit gonadotropin release  decr’d circulatingestrogens
  • 59.  Hormone antagonists◦ Tamoxifen impt in breast cancer treatment Competes w/ endogenous estrogens for receptor Inhibits transcr’n estrogen-responsive genes◦ Flutamide, cyproterone impt in prostate tumors Androgen antagonists◦ Trilostane, aminoglutethimide inhibit sex hormonesynth at adrenal gland◦ Formestane inhibits aromatase at adrenal gland
  • 60. http://www.wellesley.edu/Chemistry/chem227/nucleicfunction/cancer/tamoxifen.gifhttp://www.neurosci.pharm.utoledo.edu/MBC3320/images/Flutamide.gifFormestanehttp://www.axxora.com/files/formula/LKT-F5769.gifTrilostanehttp://img.alibaba.com/photo/50310947/Trilostane.jpg
  • 61. Rang 50.1Antitumor Agents Working through Cell Signalling
  • 62.  EGFR present on many solid tumors Tyr-kinase type receptors Ligand binding  kinase cascade transcription factor synth◦  incr’d cell prolif’n◦  metastasis◦  decr’d apoptosis Cells expressing EGFR resistant tocytotoxins; poor clinical outcome predicted
  • 63.  Cetuximab◦ Monoclonal Ab directed against EGFR Erbitux – Famous anti-EGFR AbDrugs Targeting Growth Factor Receptors
  • 64.  Trastuzumab◦ “Humanized” mousemonoclonal Ab◦ Binds HER2 Membr prot structurallysimilar to EGFR Has integral tyr kinase activity Impt in breast cancer cells◦ May also induce p21 andp27 Cell cycle inhibitorshttp://www.gene.com/gene/products/information/oncology/herceptin/images/moa.jpg
  • 65.  Imatinib (Gleevec, Glivec)◦ Small inhibitor of kinases◦ Inhibits PDGF activity via its tyr kinase receptor◦ Inhibits Bcr/Abl kinase Cytoplasmic kinase impt in signal transduction Unique to chronic myeloid leukemia◦ Also used against non-small cell lung cancer Gefitinib◦ Similar to Imatinib
  • 66. http://www.chemistrydaily.com/chemistry/upload/thumb/9/9a/200px-Imatinib_mesylate.pnghttp://dric.sookmyung.ac.kr/NEWS/jul01/gleevecmech.jpgImatinibGefitinib
  • 67. http://www.wwu.edu/depts/healthyliving/PE511info/cancer/My%20Cancer%20Webs/Symptoms%20and%20Therapy_files/image001.jpg