Statins inhibit ABCB1 and ABCG2 drug transporter activity in chronic myeloid leukemia cells and potentiate antileukemic effects of imatinib.

Despite undisputed success of tyrosine kinase inhibitors in the therapy of chronic myeloid leukemia (CML), development of drug resistance and inability to cure the disease challenge clinicians and researchers. Additionally, recent reports regarding cardiovascular toxicities of second and third generation tyrosine kinase inhibitors prove that there is still a place for novel therapeutic combinations in CML. We have previously shown that statins are able to modulate activity of chemotherapeutics or antibodies used in oncology. Therefore, we decided to verify that statins are able to potentiate antileukemic activity of imatinib, still a frontline treatment of CML. Lovastatin, a cholesterol lowering drug, synergistically potentiates antileukemic activity of imatinib in cell lines and in primary CD34+ CML cells from patients in different phases of the disease, including patients resistant to imatinib with no detectable mutations. This effect is related to increased intracellular concentration of imatinib in CD34+ CML cells and cell lines measured using uptake of (14)C-labeled imatinib. Lovastatin does not influence influx but significantly inhibits efflux of imatinib mediated by ATP-binding cassette (ABC) transporters: ABCB1 and ABCG2. The addition of cholesterol completely reverses these effects. Statins do not affect expression of ABCB1 and ABCG2 genes. The effects are drug-class specific, as observed with other statins. Our results suggest that statins may offer a valuable addition to imatinib in a select group of CML patients.

Interleukin 12: still a promising candidate for tumor immunotherapy?

Interleukin 12 (IL-12) seemed to represent the ideal candidate for tumor immunotherapy, due to its ability to activate both innate (NK cells) and adaptive (cytotoxic T lymphocytes) immunities. However, despite encouraging results in animal models, very modest antitumor effects of IL-12 in early clinical trials, often accompanied by unacceptable levels of adverse events, markedly dampened hopes of the successful use of this cytokine in cancer patients. Recently, several clinical studies have been initiated in which IL-12 is applied as an adjuvant in cancer vaccines, in gene therapy including locoregional injections of IL-12 plasmid and in the form of tumor-targeting immunocytokines (IL-12 fused to monoclonal antibodies). The near future will show whether this renewed interest in the use of IL-12 in oncology will result in meaningful therapeutic effects in a select group of cancer patients.

Synergistic antitumor effect of JAWSII dendritic cells and interleukin 12 in a melanoma mouse model.

One of the possible ways to augment dendritic cell (DC) efficacy in presentation of tumor antigens to effector T cells is pulsing them with tumor-cell lysates and incubation with certain immunostimulators. We present the results of an immunotherapeutic approach in a murine B78-H1 model using as a vaccine JAWSII DCs in combination with IL-12. Prior to the in vivo experiments, phenotypic characterization of JAWSII cells was performed and optimal conditions for stimulation of these cells were established. As no production of IL-12 by JAWSII cells was found, injections of this cytokine were introduced to vaccination protocols. Three vaccination schedules have been tested: i) prophylactic, ii) therapeutic-intratumoral, and iii) therapeutic-systemic. In all the protocols, vaccination with pulsed + stimulated JAWSII cells in combination with IL-12 was superior to the treatment with either agent alone and led to eradication of the tumor in several cases. The results of the study may be helpful in planning optimal DC-based therapeutic protocols in cancer patients.

Statins impair glucose uptake in tumor cells.

Statins, HMG-CoA reductase inhibitors, are used in the prevention and treatment of cardiovascular diseases owing to their lipid-lowering effects. Previous studies revealed that, by modulating membrane cholesterol content, statins could induce conformational changes in cluster of differentiation 20 (CD20) tetraspanin. The aim of the presented study was to investigate the influence of statins on glucose transporter 1 (GLUT1)-mediated glucose uptake in tumor cells. We observed a significant concentration- and time-dependent decrease in glucose analogs' uptake in several tumor cell lines incubated with statins. This effect was reversible with restitution of cholesterol synthesis pathway with mevalonic acid as well as with supplementation of plasma membrane with exogenous cholesterol. Statins did not change overall GLUT1 expression at neither transcriptional nor protein levels. An exploratory clinical trial revealed that statin treatment decreased glucose uptake in peripheral blood leukocytes and lowered (18)F-fluorodeoxyglucose ((18)F-FDG) uptake by tumor masses in a mantle cell lymphoma patient. A bioinformatics analysis was used to predict the structure of human GLUT1 and to identify putative cholesterol-binding motifs in its juxtamembrane fragment. Altogether, the influence of statins on glucose uptake seems to be of clinical significance. By inhibiting (18)F-FDG uptake, statins can negatively affect the sensitivity of positron emission tomography, a diagnostic procedure frequently used in oncology.

Interleukin 15 as a promising candidate for tumor immunotherapy.

Interleukin 15 participates in the development of important immune antitumor mechanisms. It activates CD8(+) T cells, natural killer (NK) cells, NK T cells, and can promote the formation of antitumor antibodies. IL-15 can also protect T effector cells from the action of T regulatory cells and reverse tolerance to tumor-associated antigens. In pre-clinical studies IL-15 has been found to demonstrate potentiated antitumor effects following pre-association with IL-15Rα, or when used in combination with chemotherapy, adoptive therapy, monoclonal antibodies, and tumor vaccines. Although a clinical trial based on application of IL-15 in tumor patients has already begun, it is important to be aware of its potential side effects, including induction of autoimmunity and promotion of proliferation, survival, and dissemination of some tumor cells.

Antitumor effects of the combination of cholesterol reducing drugs.

There are a number of potential mechanisms linking cholesterol homeostasis to processes that are tightly linked with carcinogenesis. Statins, which are inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoAR), the rate-limiting enzyme in the mevalonic acid synthesis pathway, exert cytostatic and cytotoxic effects towards tumor cells. It seems that the cytostatic and cytotoxic effects of statins result from blocking protein prenylation, leading to inhibition of isoprenoid compound synthesis. Another compound which affects cholesterol metabolism is the plant alkaloid berberine. The aim of this study was to investigate potential antitumor effects of lovastatin combined with berberine. Combined with berberine, lovastatin appeared to exert potentiated cytostatic and/or cytotoxic effects against human MDA-MB231 breast cancer and murine Panc 02 pancreatic cancer cells. The obtained results indicated that the effect of berberine is not dependent on blocking protein prenylation in cells, and the toxic effect of lovastatin combined with berberine is reversed by addition of the substrates of this pathway to the level brought out by lovastatin alone. Lovastatin-berberine combination caused cell cycle inhibition in G1 phase after 48 h of incubation with drugs. In a Panc 02 pancreatic cancer model in mice, lovastatin-berberine combination slightly, but significantly, slowed down tumor growth. Taking into account the number of patients treated with the investigated drugs one may suppose that the described interactions may be of clinical value.

Genetic modification of T cells improves the effectiveness of adoptive tumor immunotherapy.

Appropriate combinations of immunotherapy and gene therapy promise to be more effective in the treatment of cancer patients than either of these therapeutic approaches alone. One such treatment is based on the application of patients' cytotoxic T cells, which can be activated, expanded, and genetically engineered to recognize particular tumor-associated antigens (TAAs). Because T cells recognizing TAAs might become unresponsive in the process of tumor development as a result of tumor evasion strategies, immunogenic viral antigens or alloantigens could be used for the expansion of cytotoxic T cells and then redirected through genetic engineering. This therapeutic approach has already demonstrated promising results in melanoma patients and could be used in the treatment of many other tumors. The graft-versus-leukemia, or more generally graft-versus-tumor, reaction based on the application of a donor lymphocyte infusion can also be ameliorated through the incorporation of suicide genes into donor lymphocytes. Such lymphocytes could be safely and more extensively used in tumor patients because they could be eliminated should a severe graft-versus-host reaction develop.

Cardiotoxicity of the anticancer therapeutic agent bortezomib.

Recent case reports provided alarming signals that treatment with bortezomib might be associated with cardiac events. In all reported cases, patients experiencing cardiac problems were previously or concomitantly treated with other chemotherapeutics including cardiotoxic anthracyclines. Therefore, it is difficult to distinguish which components of the therapeutic regimens contribute to cardiotoxicity. Here, we addressed the influence of bortezomib on cardiac function in rats that were not treated with other drugs. Rats were treated with bortezomib at a dose of 0.2 mg/kg thrice weekly. Echocardiography, histopathology, and electron microscopy were used to evaluate cardiac function and structural changes. Respiration of the rat heart mitochondria was measured polarographically. Cell culture experiments were used to determine the influence of bortezomib on cardiomyocyte survival, contractility, Ca(2+) fluxes, induction of endoplasmic reticulum stress, and autophagy. Our findings indicate that bortezomib treatment leads to left ventricular contractile dysfunction manifested by a significant drop in left ventricle ejection fraction. Dramatic ultrastructural abnormalities of cardiomyocytes, especially within mitochondria, were accompanied by decreased ATP synthesis and decreased cardiomyocyte contractility. Monitoring of cardiac function in bortezomib-treated patients should be implemented to evaluate how frequently cardiotoxicity develops especially in patients with pre-existing cardiac conditions, as well as when using additional cardiotoxic drugs.

Bortezomib modulates surface CD20 in B-cell malignancies and affects rituximab-mediated complement-dependent cytotoxicity.

Unresponsiveness to rituximab treatment develops in many patients prompting elucidation of underlying molecular pathways. It was recently observed that rituximab-resistant lymphoma cells exhibit up-regulation of components of the ubiquitin-proteasome system (UPS). Therefore, we investigated in more detail the role of this system in the regulation of CD20 levels and the influence of proteasome inhibitors on rituximab-mediated complement-dependent cytotoxicity (R-CDC). We observed that incubation of Raji cells with rituximab leads to increased levels of ubiquitinated CD20. However, inhibition of the UPS was not associated with up-regulation of surface CD20 levels, although it significantly increased its ubiquitination. Short-term (24 hours) incubation of Raji cells with 10 or 20 nM bortezomib did not change surface CD20 levels, but sensitized CD20(+) lymphoma cells to R-CDC. Prolonged (48 hours) incubation with 20 nM bortezomib, or incubation with 50 nM bortezomib for 24 hours led to a significant decrease in surface CD20 levels as well as R-CDC. These effects were partly reversed by bafilomycin A1, an inhibitor of lysosomal/autophagosomal pathway of protein degradation. These studies indicate that CD20 levels are regulated by 2 proteolytic systems and that the use of proteasome inhibitors may be associated with unexpected negative influence on R-CDC.

Statins can modulate effectiveness of antitumor therapeutic modalities.

Despite significant, frequently very strong, antiproliferative and tumoricidal effects of statins demonstrated in vitro, their antitumor effects in animal models are modest, and their efficacy in clinical trials has not been proven. As such, statins seem unlikely to be ever regarded as antitumor agents. However, statins are regularly taken by many elderly cancer patients for the prevention of cardiovascular events. Owing to their pleiotropic effects in normal and tumor cells, statins interact in various ways with many antitumor treatment modalities, either potentiating or diminishing their effectiveness. Elucidation of these interactions might affect the choice of treatment to be planned in cancer patients as some combinations might be contraindicated, whereas others might elicit potentiated antitumor effects but at a cost of increased general toxicity. Some other combinations might induce either comparable or even stronger antitumor effects, but with a beneficial concomitant reduction of specific side effects. Most of the studies reviewed in this article have been carried in vitro or in experimental tumor models, but clinical relevance of the findings is also discussed.

Statins potentiate cytostatic/cytotoxic activity of sorafenib but not sunitinib against tumor cell lines in vitro.

The aim of this study was to investigate the potential cytostatic/cytotoxic effects of HMG-CoA reductase inhibitors and two orphan drugs registered for the treatment of advanced renal cell carcinoma, i.e. sorafenib and sunitinib against several different tumor cell lines. Cytostatic/cytotoxic effects were measured using crystal violet or MTT reduction assays. Cell cycle regulation was investigated using flow cytometry and Western blotting. The combination of lovastatin and sorafenib (but not sunitinib) produced synergistic cytostatic/cytotoxic effects against all tested tumor cell lines. In this study, an impairment of the protein prenylation, especially geranylgeranylation, resulted predominantly in the potentiation of the cytostatic/cytotoxic activity of sorafenib, in cell cycle arrest in G1 phase, and, in poor induction of apoptosis. Moreover, due to the fact that it has been well documented that sorafenib compromises the heart function, we studied the interaction of lovastatin and sorafenib using rat cardiomyoblast line H9c2. The combination showed strong synergistic cardiotoxic effects. Statins and tyrosine kinase inhibitors were used at doses that are achievable clinically, which makes the combination promising for future studies, especially in urooncology, bearing in mind possible cardiotoxic effects.

Proteasome inhibition potentiates antitumor effects of photodynamic therapy in mice through induction of endoplasmic reticulum stress and unfolded protein response.

Photodynamic therapy (PDT) is an approved therapeutic procedure that exerts cytotoxic activity toward tumor cells by inducing production of reactive oxygen species such as singlet oxygen. PDT leads to oxidative damage of cellular macromolecules, including proteins that undergo multiple modifications such as fragmentation, cross-linking, and carbonylation that result in protein unfolding and aggregation. Because the major mechanism for elimination of carbonylated proteins is their degradation by proteasomes, we hypothesized that a combination of PDT with proteasome inhibitors might lead to accumulation of carbonylated proteins in endoplasmic reticulum (ER), aggravated ER stress, and potentiated cytotoxicity toward tumor cells. We observed that Photofrin-mediated PDT leads to robust carbonylation of cellular proteins and induction of unfolded protein response. Pretreatment of tumor cells with three different proteasome inhibitors, including bortezomib, MG132, and PSI, gave increased accumulation of carbonylated and ubiquitinated proteins in PDT-treated cells. Proteasome inhibitors effectively sensitized tumor cells of murine (EMT6 and C-26) as well as human (HeLa) origin to PDT-mediated cytotoxicity. Significant retardation of tumor growth with 60% to 100% complete responses was observed in vivo in two different murine tumor models (EMT6 and C-26) when PDT was combined with either bortezomib or PSI. Altogether, these observations indicate that combination of PDT with proteasome inhibitors leads to potentiated antitumor effects. The results of these studies are of immediate clinical application because bortezomib is a clinically approved drug that undergoes extensive clinical evaluations for the treatment of solid tumors.

Interleukin 15 augments antitumor activity of cytokine gene-modified melanoma cell vaccines in a murine model.

Many studies have demonstrated that interleukin 15 (IL-15) is a cytokine with strong antitumor properties and have suggested its potential use in tumor immunotherapy. IL-15 exerts its effect on innate and acquired immunity with the most prominent action in NK cells and CD8(+) memory T cells. Therefore, many authors have proposed that IL-15 could be a good candidate for augmenting the efficacy of vaccination strategies. In our experiments, in a model of B78-H1 murine transplantable melanoma, tumor-bearing mice were treated with different cytokine-gene modified tumor cell vaccines (producing TNF-alpha, GM-CSF, IL-12 or IL-6/sIL-6R) followed by a series of IL-15 injections. In order to investigate the infiltration of treated tumors by leukocytes, immunohistochemical staining was performed. In every case, the combined therapy was superior to the treatment with either a vaccine or IL-15 alone. Tumors treated with the combination of B78-H1 melanoma cells secreting IL-12 (B78/IL-12 vaccine) and IL-15 were heavily infiltrated by granulocytes. IL-15, either alone or in combination with the B78/IL-12 vaccine, influenced infiltration of tumors with CD3(+) lymphocytes, CD4(+)and CD8(+). To our knowledge, this is the first report that shows the universal genetically-modified tumor cell vaccine-augmenting properties of IL-15. The cytokine can be useful as an adjuvant in cancer gene therapy in humans.

Statins impair antitumor effects of rituximab by inducing conformational changes of CD20.

BACKGROUND: Rituximab is used in the treatment of CD20+ B cell lymphomas and other B cell lymphoproliferative disorders. Its clinical efficacy might be further improved by combinations with other drugs such as statins that inhibit cholesterol synthesis and show promising antilymphoma effects. The objective of this study was to evaluate the influence of statins on rituximab-induced killing of B cell lymphomas. METHODS AND FINDINGS: Complement-dependent cytotoxicity (CDC) was assessed by MTT and Alamar blue assays as well as trypan blue staining, and antibody-dependent cellular cytotoxicity (ADCC) was assessed by a 51Cr release assay. Statins were found to significantly decrease rituximab-mediated CDC and ADCC of B cell lymphoma cells. Incubation of B cell lymphoma cells with statins decreased CD20 immunostaining in flow cytometry studies but did not affect total cellular levels of CD20 as measured with RT-PCR and Western blotting. Similar effects are exerted by other cholesterol-depleting agents (methyl-beta-cyclodextrin and berberine), but not filipin III, indicating that the presence of plasma membrane cholesterol and not lipid rafts is required for rituximab-mediated CDC. Immunofluorescence microscopy using double staining with monoclonal antibodies (mAbs) directed against a conformational epitope and a linear cytoplasmic epitope revealed that CD20 is present in the plasma membrane in comparable amounts in control and statin-treated cells. Atomic force microscopy and limited proteolysis indicated that statins, through cholesterol depletion, induce conformational changes in CD20 that result in impaired binding of anti-CD20 mAb. An in vivo reduction of cholesterol induced by short-term treatment of five patients with hypercholesterolemia with atorvastatin resulted in reduced anti-CD20 binding to freshly isolated B cells. CONCLUSIONS: Statins were shown to interfere with both detection of CD20 and antilymphoma activity of rituximab. These studies have significant clinical implications, as impaired binding of mAbs to conformational epitopes of CD20 elicited by statins could delay diagnosis, postpone effective treatment, or impair anti-lymphoma activity of rituximab.

Ciglitazone, an agonist of peroxisome proliferator-activated receptor gamma, exerts potentiated cytostatic/cytotoxic effects against tumor cells when combined with lovastatin.

Thiazolidinediones are ligands of PPAR-gamma, a member of the nuclear receptor family. These drugs have shown promising pre-clinical activity in tumor models but clinical studies failed to confirm their beneficial effect. We have studied the in vitro antitumor effects of a combination of ciglitazone, a thiazolidinedione drug, and lovastatin, an inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme A reductase. We observed a marked synergism in several different tumor cell lines resulting from both inhibition of cell proliferation and induction of apoptosis. These results strongly suggest that combining PPAR-gamma agonists with statins can produce significant antitumor effects.

Erythropoietin reduces cisplatin-induced neurotoxicity without impairment of cytotoxic effects against tumor cells.

Cisplatin, a widely used chemotherapeutic is approved for the management of various solid tumors. Administration of cisplatin is associated with induction of significant toxicities that include neurotoxicity and nephrotoxicity, the latter leading to severe and debilitating anemia. Since erythropoietin, a hematopoietic growth factor that corrects chemotherapy-induced anemia, reduces transfusion requirements and seems to improve the patient's quality of life, has been shown to exert cytoprotective effects we decided to investigate its direct influence on cisplatin-induced neurotoxicity against primary cortical neurons isolated from rats. We observed that pre-treatment of neurons with erythropoietin significantly protects these cells from cisplatin-induced cytotoxicity. These effects correlated with amelioration of cisplatin-mediated activation of ERK1/2 kinases and decreased cleavage of caspase 3. Similarly to erythropoietin, a selective ERK1/2 inhibitor significantly reduced cisplatin-induced cytotoxicity against neuronal cells. Importantly, using the same experimental setting we did not observe any protection from cisplatin cytotoxicity against four established tumor cell lines. Altogether our studies confirm that erythropoietin might be an effective cytoprotective agent that reduces cisplatin-induced neurotoxicity.

Potentiated antitumor effects of the combination treatment with statins and pamidronate in vitro and in vivo.

The aim of the present study was to examine the potential antitumor activity of lovastatin and other statins together with pamidronate, a second generation bisphosphonate (BP), against tumor cell lines. Cytostatic/cytotoxic effects were measured using crystal violet assay. Regulation of the cell cycle and induction of apoptosis were evaluated using flow cytometry and Western blotting, migration of tumor cells was measured in a scratch wound assay and their invasiveness was measured with a Matrigel-invasion assay. Antitumor effects of the combination treatment were evaluated in a murine PANC 02 pancreatic adenocarcinoma model. Combination of pamidronate and lovastatin produced potentiated cytostatic/cytotoxic effects against breast and pancreatic cancer cell lines. The combination was also effective in inhibition of tumor cell adhesion to collagen IV and fibronectin and interfered with migration and invasiveness of tumor cells. Neither pamidronate nor lovastatin alone affected tumor growth in mice but the combination treatment resulted in retardation of tumor growth and prolongation of mouse survival. The combination of statins and pamidronate, a second generation bisphosphonate, demonstrates promising antitumor effects at doses readily achievable in patients. This combination holds promise for future clinical studies.

Berberine, a natural cholesterol reducing product, exerts antitumor cytostatic/cytotoxic effects independently from the mevalonate pathway.

The aim of this study was to investigate the role of the mevalonate pathway in the cytostatic/cytotoxic effects of berberine, a natural plant alkaloid that reduces cholesterol concentration. Berberine as well as lovastatin, an inhibitor of the mevalonate pathway, exerted dose-dependent cytostatic/cytotoxic effects against human breast cancer cells (MDA-MB231). Although the mevalonate pathway metabolites (mevalonic acid, farnesyl pyrophosphate, geranylgeranyl pyrophosphate) effectively reversed cytostatic/cytotoxic effects of lovastatin against MDA-MB231 cells, they were not effective in influencing the cytostatic/cytotoxic effects of berberine. The cytostatic/cytotoxic effects of berberine do not seem to result from inhibition of the mevalonate pathway.

Topical ALA-PDT modifies neutrophils' chemiluminescence, lymphocytes' interleukin-1beta secretion and serum level of transforming growth factor beta1 in patients with nonmelanoma skin malignancies A clinical study.

BACKGROUND: Photodynamic therapy (PDT) has been recognized as a noninvasive therapeutic approach for the effective treatment of tumors. It has been shown in studies conducted on malignant cell lines and various animal tumor models, that the interaction of photosensitizing substances with light leads to the release of cytotoxic substances and stimulates the immune response. PURPOSE: The aim of our study was to analyze the immune system response in patients undergoing photodynamic therapy due to basal cell carcinoma (BCC). METHODS: Patients with skin malignancies have been treated by 10% delta-aminolevulinic acid (ALA) (Medac GmbH, Wedel, Germany) topically and light from a diode laser. Blood samples were obtained from each patient twice in the same day: before and 4h after photodynamic treatment procedure. In patients' serum the concentration of transforming growth factor beta1 (TGF-ß1) was determined. Additionally the study has been conducted on lymphocytes and granulocytes from peripheral blood. In cell culture supernatants the concentration of interleukin 1beta (IL-1ß), interleukin 2 (IL-2), interleukin 6 (IL-6), tumor necrosis factor alpha (TNFα), the percentile composition of patients' lymphocytes and the chemiluminescence of neutrophils have been measured. RESULTS: We have observed a significant increase (p=0.015) in the intensity of the neutrophil chemiluminescence and significant diminution (p=0.006) of IL-1ß concentration in supernatants. Similarly the serum level of TGF-ß1 has been significantly decreased (p<0.001). CONCLUSION: It is very likely that human immune system activity is modified by topical ALA-PDT and may potentially contribute to its final outcome.

The influence of photodynamic therapy on the immune response.

Photodynamic therapy (PDT) is a clinically approved therapeutic modality used for the management of several types of tumors as well as non-malignant diseases. Most of the effects of this treatment regimen result from direct action of singlet oxygen and reactive oxygen species. However, accumulating evidence indicates that antitumor effects are also mediated by indirect stimulation of inflammatory and immune responses. These responses include rapid local infiltration of tumors by neutrophils and macrophages accompanied by systemic release of inflammatory mediators. This early response can initiate and translate into a more precise immune reaction that involves activation of specific T lymphocytes that seem to be necessary for the ultimate control of residual tumor cells. Although still incompletely understood, PDT can not only activate but also suppress the immune response depending on several variables. This review summarizes the influence of PDT on the immune response and discusses its importance in the management of human diseases.