[Angiogenesis inhibitors for the systemic treatment of metastatic renal cell carcinoma: sunitinib, sorafenib, bevacizumab and temsirolimus]. / Angiogeneseremmers voor de systemische behandeling van gemetastaseerd niercelcarcinoom: sunitinib, sorafenib, bevacizumab en temsirolimus.

Treatment of patients with metastatic renal cell carcinoma is evolving rapidly due to the advent of novel targeted therapies. Improved knowledge of the underlying pathogenesis has led to the development of drugs that modulate the dominant signal transduction pathways for this disease, which results in inhibition of angiogenesis. Recent evidence indicates that the receptor tyrosine kinase inhibitor sunitinib prolongs progression-free survival compared with interferon-alpha, especially in patients with intermediate risk. Immunotherapy with interferon-alpha or high-dose interleukin-2 should still be considered for low-risk patients, particularly those with clear-cell tumours and metastases of the lung only. In patients who fail treatment with interferon-alpha, sorafenib has been shown to improve progression-free survival. High-risk patients may benefit from treatment with temsirolimus, which inhibits mammalian target of rapamycin (mTOR) kinase activity and has shown to improve overall survival. These angiogenesis inhibitors did not receive mention in the recently published guideline 'Renal cell carcinoma'.

[Better treatment for patients with colorectal liver metastases]. / Betere behandelingsmogelijkheden voor patiënten met colorectale levermetastasen.

Three patients, 61, 58 and 63 years old, presented with non-resectable liver metastases from colorectal cancer. The first patient, a man, who had a solitary lesion in the liver and severe cardiovascular morbidity, was successfully treated with laser-induced interstitial thermotherapy. The second patient, a woman, had large multiple liver metastases and two concomitant isolated pulmonary metastases. Following chemotherapy with fluorouracil, leucovorin and oxaliplatin, all lesions were downsized and a hemihepatectomy and pulmonary wedge resections were able to be performed in two stages. At the last follow-up, both patients were disease-free after 12 and 24 months respectively. The third patient, a man, presenting with multiple synchronous liver metastases, showed a significant decrease of hepatic tumour involvement after six courses of capecitabine. At present he is in a good condition and his disease is stable. Surgical resection ofcolorectal liver metastases leads to a 5-year survival rate of up to 45% in selected patients. Unfortunately, only 10 to 20% of patients are amenable to surgical resection. In the remaining group, a combination of new treatment options using local tumour ablative therapies and novel chemotherapeutic regimens provide alternative strategies with the potential of long-term survival.

Up-regulation of vascular endothelial growth factor production by iron chelators.

Agents that modulate cellular iron availability have been studied for their antitumor activity. Based on encouraging in vitro studies, the iron chelator deferoxamine (DFO) has been used in clinical studies to treat cancer patients. The observation that DFO induced macular edema in several cancer patients led to the present investigation of vascular endothelial growth factor (VEGF) as a possible mediator of the encountered side effects. Both normal and malignant cell lines were incubated with DFO and a variety of other iron chelators. DFO, at concentrations achievable in humans, induced a 3-5-fold increase in VEGF mRNA expression in all cell lines studied. This increased VEGF mRNA expression was dose and time dependent. A panel of structurally different iron chelators induced an even more potent increase in VEGF mRNA expression. The DFO-induced increase in VEGF mRNA expression translated into 6- and 4-fold increases in VEGF protein secretion in conditioned media of retinal pigment epithelial and C6 glioblastoma cells, respectively. These findings suggest that VEGF may act as a mediator of the side effects induced by iron chelation therapy. In addition, because VEGF is an important regulator of angiogenesis, iron chelators should be given with caution to cancer patients.

Comparison of different iron chelators as protective agents against acute doxorubicin-induced cardiotoxicity.

Doxorubicin (Dox) is a widely used antineoplastic agent. Irreversible cardiomyopathy is a serious and dose-limiting side effect after chronic administration. The iron chelating bispiperazinedione ICRF-187 is currently the only drug which affords protection against Dox-induced cardiotoxicity. To compare the protective value of structurally unrelated iron chelators, isolated mice atria were exposed to Dox (30 microM) and either the hydroxamate desferrioxamine (DFO, 200 and 500 microM), EDTA (200 microM) or the hydroxypridones CP44 (200 microM), CP51 (200 microM), and CP93 (200 microM) and ICRF-187 (200 and 500 microM). The nitroxide TEMPO (5 mM) lacks iron chelating properties but was used to prevent redox cycling or iron and scavenge superoxide. All iron chelators, except EDTA. CP93 and CP44, were modestly protective against a Dox-induced decrease in contractile force. As a single agent the hydroxypridones decreased atrial contractile force. At a concentration of 200 microM, DFO was the most effective protector of the chelators tested. However, this effect disappeared when a concentration of 500 microM was used. This in contrast to ICRF-187 for which a concentration-dependent inhibition of Dox-induced decrease in contractile force was observed. TEMPO exerted a biphasic response consisting of a two-fold increase in contractile force, followed by a decrease in force and irregular contractions. In this model TEMPO lacked any perspective as a cardioprotectant. We conclude that at 200 microM. DFO was the most effective agent to afford protection against Dox-mediated atrial malfunction. However, at 500 microM, DFO was not effective whereas ICRF-187 afforded partial protection. Hydroxipyridones were found to be of limited value because of a negative inotropic effect on the isolated atria.

The in vitro response of human tumour cells to desferrioxamine is growth medium dependent.

Iron chelating agents have been demonstrated to inhibit tumour cell growth. However, in vitro and in vivo results using desferrioxamine a hexadentate iron chelating agent, for anti-cancer treatment are not always in agreement. Therefore, we have studied the response of three human tumour cell lines (HL-60 promyelocytic leukaemia, MCF-7 breast cancer and HepG2 hepatoma), grown in culture medium supplemented with either human pooled (HPS) or fetal bovine serum (FBS), to desferrioxamine. Desferrioxamine, at micromolar concentrations, induced severe cytotoxicity in all tumour cell lines grown in FBS medium. When grown in HPS medium, comparable desferrioxamine cytotoxicity was observed in the millimolar range. The addition of 50% saturated human transferrin to FBS medium resulted in protection against desferrioxamine cytotoxicity. HL-60 cells were further studied for iron metabolism characteristics. HL-60 cells, grown in medium with FBS, were found to have an 8.4 fold increase in surface transferrin receptor (TfR) expression (P < 0.001) as compared with HL-60 cells grown in medium with HPS. However, iron uptake of HPS cultured HL-60 cells, after incubation with saturated human transferrin, was higher, resulting in a higher concentration of iron in HPS cultured HL-60 cells as compared with FBS cultured cells (1.72 +/- 0.02 mumol/g protein v. 1.32 +/- 0.14 mumol/g protein; P < 0.001). Using desferrioxamine it was shown that TfR expression is dependent on the biological availability of iron in the cell. Consistent with the lower iron content in FBS cultured cells, we conclude that the cytotoxicity of desferrioxamine is dependent on the ability of cells to replenish cellular iron stores from the culture medium. Cells grown in FBS medium lack this ability and are therefore more susceptible to desferrioxamine.