Mechanisms of cisplatin-induced ototoxicity and prevention.

Cisplatin is a widely used chemotherapeutic agent to treat malignant disease. Unfortunately, ototoxicity occurs in a large percentage of patients treated with higher dose regimens. In animal studies and in human temporal bone investigations, several areas of the cochlea are damaged, including outer hair cells in the basal turn, spiral ganglion cells and the stria vascularis, resulting in hearing impairment. The mechanisms appear to involve the production of reactive oxygen species (ROS), which can trigger cell death. Approaches to chemoprevention include the administration of antioxidants to protect against ROS at an early stage in the ototoxic pathways and the application of agents that act further downstream in the cell death cascade to prevent apoptosis and hearing loss. This review summarizes recent data that shed new light on the mechanisms of cisplatin ototoxicity and its prevention.

Ginkgo biloba extract (EGb 761) protects against cisplatin-induced ototoxicity in rats.

HYPOTHESIS: A standardized Ginkgo biloba extract, EGb 761, may have protective effect against cisplatin-induced ototoxicity in rats. BACKGROUND: Cisplatin-induced ototoxicity is a major dose-limiting side effect in anticancer chemotherapy. Cisplatin-induced ototoxicity has been correlated to depletion of the cochlear antioxidant system and increased lipid peroxidation. EGb 761 contains potent antioxidants capable of scavenging free radicals, inhibiting nitric oxide synthesis, reducing lipid peroxidation, and protecting against apoptosis. The purpose of this study was to investigate the effect of EGb 761 on cisplatin-induced ototoxicity in rats. METHODS: Male Wistar rats were divided into four groups and were treated as follows: 1) vehicle control; 2) cisplatin (13 mg/kg, intraperitoneally) plus vehicle; 3) EGb 761 (200 mg/kg, intraperitoneally); and 4) EGb 761 plus cisplatin. Auditory brainstem responses (ABRs) were measured pretreatment and 72 hours posttreatment, and threshold shifts were analyzed. Endocochlear potentials (EPs) were also obtained at 72 hours posttreatment. Cochleae were harvested and processed for scanning electron microscopy after completion of auditory testing. RESULTS: Cisplatin-treated rats showed significant ABR threshold shifts across all frequencies (click, and 2-, 4-, 8-, 16-, and 32-kHz tones) compared with each of the other groups (p < 0.001). Rats treated with EGb 761 plus cisplatin did not show significant ABR threshold shifts (p > 0.05). Similarly, the EPs of cisplatin-treated rats were decreased significantly approximately 50% in comparison with the other groups (p < 0.001). The EPs of EGb 761 plus cisplatin-treated rats were decreased less than 20% compared with vehicle control group or the EGb 761 only group (p < 0.01). The scanning electron microscopy observation indicated severe outer hair cell loss in the basal turn of cochleae of cisplatin-treated rats, whereas outer hair cells remained intact in the rats treated with EGb 761 plus cisplatin. CONCLUSION: These results demonstrate that EGb 761 protects against cisplatin-induced ototoxicity.

Ototoxicity: therapeutic opportunities.

Two major classes of drugs currently in clinical use can cause permanent hearing loss. Aminoglycoside antibiotics have a major role in the treatment of life-threatening infections and platinum-based chemotherapeutic agents are highly effective in the treatment of malignant disease. Both damage the hair cells of the inner ear, resulting in functional deficits. The mechanisms underlying these troublesome side effects are thought to involve the production of reactive oxygen species in the cochlea, which can trigger cell-death pathways. One strategy to protect the inner ear from ototoxicity is the administration of antioxidant drugs to provide upstream protection and block the activation of cell-death sequences. Downstream prevention involves the interruption of the cell-death cascade that has already been activated, to prevent apoptosis. Challenges and opportunities exist for appropriate drug delivery to the inner ear and for avoiding interference with the therapeutic efficacy of both categories of ototoxic drugs.

Protection against cisplatin ototoxicity by adenosine agonists.

Cisplatin is a commonly used antineoplastic agent that causes ototoxicity through the formation of reactive oxygen species (ROS). Previous studies have shown that cisplatin causes an upregulation of A(1) adenosine receptor (A(1)AR) in the cochlea, and that application of the adenosine agonist, R-phenylisopropyladenosine (R-PIA), to the round window (RW) results in significant increases in cochlear glutathione peroxidase and superoxide dismutase. These data suggest that adenosine receptors (ARs) are an important part of the cytoprotective system of the cochlea in response to oxidative stress. The purpose of the current study was to investigate the effect of various adenosine agonists on cisplatin ototoxicity using RW application. Auditory brainstem response (ABR) thresholds were recorded in anesthetized chinchillas at 1, 2, 4, 8 and 16kHz. The auditory bullae were surgically opened, and 1mM R-PIA, 10microM 8-cyclopentyl-1,3-dipropylxanthine (DPCPX)/R-PIA (1mM) cocktail, 100microM 2-chloro-N-cyclopentyladenosine (CCPA), 2-[4-(2-p-carboxy-ethyl)phenylamino]-5'-N-ethylcarboxamidoadenosine (CGS) or vehicle were applied to the RW. After 90min, the remaining solution was removed and cisplatin was applied to the RW. The bullae were closed and the animals recovered for 72h, after which, follow-up ABRs were performed. Cochleae were harvested for scanning electron microscopy (SEM) and for lipid peroxides. Pre-administration of the A(1)AR agonists R-PIA or CCPA significantly reduced cisplatin-induced threshold changes at all but the highest test frequency. In addition, A(1)AR agonists protected against cisplatin-induced hair cell damage and significantly reduced cisplatin-induced lipid peroxidation. Co-administration of the A(1)AR antagonist, DPCPX, completely reversed the protective effects of R-PIA. In contrast, pretreatment with CGS-21680, an A(2A) adenosine receptor (A(2A)AR) agonist, significantly increased cisplatin-induced threshold changes. Our findings are consistent with the notion that the A(1)AR contributes significantly to cytoprotection in the cochlea, and thereby protects against hearing loss.

Cisplatin up-regulates the adenosine A(1) receptor in the rat kidney.

Cisplatin, a widely used anticancer drug, produces significant oto- and nephrotoxicity. Previous data from our laboratory, using cultured cell lines, indicated that cisplatin increases the expression of the adenosine A(1) receptor subtype through generation of reactive oxygen species and activation of nuclear factor-kappa B (NF-kappa B). Since the adenosine A(1) receptor plays an important role in normal renal physiology, this study was performed to determine whether cisplatin modulates adenosine A(1) receptor expression in vivo and whether these receptors play a role in the nephrotoxicity. Male Sprague-Dawley rats, treated with cisplatin (8 mg/kg), developed nephrotoxicity within 3 days, as demonstrated by increased serum creatinine and blood urea nitrogen. Cisplatin also produced a significant increase in malondialdehyde, apoptosis and necrosis in the kidney. The above changes were associated with a time-dependent increase in the expression of adenosine A(1) receptor, as determined by radioligand binding assays, Western blotting and immunocytochemistry, and an increase in adenosine A(1) receptor transcripts. Administration of selective and nonselective antagonists of the adenosine A(1) receptor produced either no change or exacerbated the nephrotoxicity produced by cisplatin. These data indicate that cisplatin can regulate the adenosine A(1) receptor in the kidney and suggest a cytoprotective role of this receptor subtype against cisplatin-induced nephrotoxicity.

Round window pH manipulation alters the ototoxicity of systemic cisplatin.

The effect of manipulation of pH on the ototoxicity of systemic cisplatin was studied in Wistar rats. After control auditory brainstem responses (ABR) were performed, the auditory bullae were opened and acidic (pH 6.0), neutral (pH 7.4) or basic (pH 9.0) phosphate-buffered saline (PBS) was applied to fill the round window niche (RWN). After 30 min, 13 mg/kg cisplatin solution or saline was administered intraperitoneally. After 3 days, follow-up ABRs were performed and cochleae were processed for morphological analysis. Animals that received basic PBS on the RWN and cisplatin intraperitoneally had significantly smaller ABR threshold shifts compared to rats pretreated with neutral pH buffer (P<0.05). Animals that received acidic PBS on the RWN and systemic cisplatin showed significantly greater ABR threshold shifts compared to those pretreated with neutral pH buffer (P<0.05). No significant threshold changes were observed in animals that received buffer of any pH on the RWN, followed by saline intraperitoneally. Semiquantitative analysis of hair cell survival confirmed a protective effect by basic PBS against cisplatin and a synergistic effect by acidic PBS on cisplatin ototoxicity (P<0.05). It appears that changes in cochlear pH can modulate the ototoxic effects of systemically applied cisplatin.

Influence of pH on the ototoxicity of cisplatin: a round window application study.

Cisplatin is an antineoplastic agent that produces a number of dose-limiting side effects, including ototoxicity. We investigated the effect of pH on cisplatin ototoxicity. Auditory brainstem responses (ABR) were recorded in chinchillas. Then the auditory bullae were opened and acidic (pH=6.5), neutral (pH=7.4) or alkaline (pH=10.2) phosphate-buffered saline (PBS) was applied to the round window membrane. After 30 min, any remaining solution was removed and cisplatin solution was applied to the round window membrane. After 3 days, follow-up ABRs were performed and the cochleae were processed for morphological analysis. Neutral PBS+cisplatin administration resulted in profound threshold changes at all frequencies. Acidic PBS+cisplatin administration showed had a trend of increased threshold changes, but the change did not reach statistical significance. However, the degree of hair cell loss was significantly higher than that of the neutral PBS-cisplatin group. Alkaline PBS significantly reduced cisplatin-induced threshold changes (P<0.05) compared to the neutral PBS group. Because the pH of cisplatin solution was 6.0, pH 6.0 PBS was applied to round window membrane. This acidic PBS solution did not cause any hearing impairment. These results demonstrate that pH can modulate the ototoxic effects of cisplatin.

Aminoguanidine reduces cisplatin ototoxicity.

Cisplatin is known to cause high-frequency neurosensory hearing loss. While reactive oxygen species have been shown to play a role, reactive nitrogen species have been implicated, but not proven to be involved, in cisplatin ototoxicity. The purpose of the present study was to investigate the role of nitric oxide (*NO) in cisplatin ototoxicity by administering aminoguanidine (AG), a relatively specific inhibitor of inducible nitric oxide synthase (iNOS), in conjunction with cisplatin. Rats were injected with cisplatin, AG, or both. Auditory brainstem evoked responses (ABR) were measured before and 3 days after cisplatin administration. The cochlear tissue was then assayed for *NO and malondialdehyde. Cisplatin alone caused significant ABR threshold shifts at all stimuli tested, whereas AG alone caused no shifts. There was a significant reduction in threshold shift for clicks and 16 kHz tone bursts (but not 32 kHz) when AG was given with cisplatin. The malondialdehyde concentration (but not the *NO concentration) in the AG/cisplatin group was significantly lower than that of the cisplatin group. This suggests that AG reduces cisplatin ototoxicity by directly scavenging hydroxyl radicals. The iNOS pathway may play a role in the generation of free radicals and hearing loss resulting from cisplatin administration, but this conclusion was not supported by our data.

Noise induces A1 adenosine receptor expression in the chinchilla cochlea.

Adenosine plays a major cytoprotective role during ischemia and conditions of oxidative stress. Previous studies in our laboratory indicate that oxidative stress induces expression of the A1 adenosine receptor (A1AR) via activation of nuclear factor (NF)-kappaB. In this study, we tested whether noise exposure could induce oxidative stress and determine whether this induces expression of the A1AR in the chinchilla cochlea. Chinchillas were exposed to a 96 dB 4 kHz octave band of noise for 6 h of daily exposure, followed by an 18 h noise-free period. This noise paradigm resulted in threshold shifts of 10-60 dB over the frequency range (1-16 kHz) tested. Radioligand binding studies for the A1AR indicate a significant increase in receptor ( approximately 2-fold) expression soon after the first noise exposure period (usually within approximately 8 h of the initiation of noise), which gradually returned to basal levels by day 7. The rise in A1AR levels was followed by a significant increase in malondialdehyde levels by day 3, which also recovered by day 7. Assessment of the activity of NADPH oxidase in the cochlea indicates a significant increase in enzyme activity which was evident by approximately 8 h following initiation of noise exposure, and which persisted for at least up to day 3. Electrophoretic mobility shift assays indicate that the increase in A1AR was associated with a significant increase in NF-kappaB activity following noise exposure. We conclude that noise exposure induces A1AR expression, which might be mediated, in part, through generation of reactive oxygen species and activation of NF-kappaB.

In vitro evaluation of three-dimensional single-walled carbon nanotube composites for bone tissue engineering.

The purpose of this study was to develop three-dimensional single-walled carbon nanotube composites (SWCNT/PLAGA) using 10-mg single-walled carbon nanotubes (SWCNT) for bone regeneration and to determine the mechanical strength of the composites, and to evaluate the interaction of MC3T3-E1 cells via cell adhesion, growth, survival, proliferation, and gene expression. PLAGA (polylactic-co-glycolic acid) and SWCNT/PLAGA microspheres and composites were fabricated, characterized, and mechanical testing was performed. MC3T3-E1 cells were seeded and cell adhesion/morphology, growth/survival, proliferation, and gene expression analysis were performed to evaluate biocompatibility. Imaging studies demonstrated microspheres with uniform shape and smooth surfaces, and uniform incorporation of SWCNT into PLAGA matrix. The microspheres bonded in a random packing manner while maintaining spacing, thus resembling trabeculae of cancellous bone. Addition of SWCNT led to greater compressive modulus and ultimate compressive strength. Imaging studies revealed that MC3T3-E1 cells adhered, grew/survived, and exhibited normal, nonstressed morphology on the composites. SWCNT/PLAGA composites exhibited higher cell proliferation rate and gene expression compared with PLAGA. These results demonstrate the potential of SWCNT/PLAGA composites for musculoskeletal regeneration, for bone tissue engineering, and are promising for orthopedic applications as they possess the combined effect of increased mechanical strength, cell proliferation, and gene expression.