A critical examination of the mode of action of quinacrine in the reproductive tract in a 2-year rat cancer bioassay and its implications for human clinical use.

A rat carcinogenicity bioassay (CaBio) of quinacrine was reanalyzed to investigate its mode of tumor induction. Quinacrine's effects in the rat uterus when administered as a slurry in methylcellulose were contrasted with the human clinical experience which uses a solid form of the drug, to determine the relevance of the tumors produced in the rat to safe clinical use of quinacrine for permanent contraception (QS). A review was performed of the study report, dose feasibility studies, and clinical evaluations of women who had undergone the QS procedure. The top three doses of quinacrine in the CaBio exceeded the maximum tolerated dose, and produced chronic damage, including inflammation, resulting in reproductive tract tumors. Chronic inflammation was significantly correlated with the tumors; there was no evidence of treatment-related tumors in animals without chronic inflammation or other reproductive system toxicity. Because such permanent uterine damage and chronic toxicity have not been observed in humans under therapeutic conditions, we conclude that this mode of action for tumor production will not occur at clinically relevant doses in women who choose quinacrine for permanent contraception.

Quinacrine-induced occlusive fibrosis in the human fallopian tube is due to a unique inflammatory response and modification of repair mechanisms.

Quinacrine has been widely used in treatment of parasitic diseases such as malaria and giardiasis, and in the treatment of autoimmune diseases. Quinacrine has also been used as an effective substitute for surgical contraception by causing occlusion of the fallopian tube. This minimally invasive treatment protocol involves intrauterine insertion of the drug in the form of pellets and has been studied in humans in a number of countries, including the United States. Despite its development in the 1970s, the cellular and molecular events induced by quinacrine in the human fallopian tube have not been described. Here we describe a plausible mechanism for quinacrine action in the fallopian tube. This is manifested as an acute pro-inflammatory response in the uterus and fallopian tube, characterized by loss of epithelial cell adhesion. This response relies on properties of gated channels found on the surface of epithelial cells in the reproductive tract. While the uterus returns to normal, the inflammatory response affects the uterotubal junction and transmural segment of the human fallopian tube, and initiates formation of mature collagen in the lumen of the fallopian tube, resulting in its permanent occlusion. The response within the fallopian tube appears similar to the protective mechanisms that have evolved in women to minimize the likelihood of systemic infection from Neisseria gonorrhoeae, and to some extent from Chlamydia trachomatis. This review could assist in development of experimental models used in investigating the mechanisms of fibrotic responses in humans as well as development of techniques for permanent non-surgical female contraception.

An alternative interpretation of, "A lifetime cancer bioassay of quinacrine administered into the uterine horns of female rats".

This companion article offers an alternative interpretation for the quinacrine-induced uterine tumors observed in a 2-year bioassay in rats (CaBio, Cancel et al., 2010), and provides additional data from two new experiments that support a different interpretation and analysis. Our major premise is that the design of the Cancel et al. bioassay was flawed, particularly regarding dose selection that allowed for misinterpretation of carcinogenic activity. We feel the totality of the information provided herein dictates that the doses (70/70, 70/250 and 70/350 mg/kg quinacrine) causing uterine tumors in their study clearly exceeded the maximum tolerated dose (MTD) typically administered in chronic cancer studies. Our new data support this conclusion and serve to explain the development of lesions, especially the uterine tumors, they have reported. We argue that the rat uterus is not a valid surrogate for the human fallopian tube. Further, we maintain that quinacrine is not genotoxic in vivo, as suggested in their paper. In summary, we believe that quinacrine is not carcinogenic in rats at doses that do not exceed the MTD.