Activation of human peripheral blood T cells does not lead to increased P-glycoprotein expression.

The expression of P-glycoprotein (Pgp) on normal human lymphocytes, and its drug exclusion capacity, implies that Pgp might be involved in cytokine secretion. We used two-color flow cytometry to detect simultaneously Pgp expression and IL-2 accumulation in resting and mitogen-activated human lymphocytes. Among resting lymphocytes from five healthy donors less than 1% were Pgp+ as determined by reactivity with the anti-Pgp monoclonal antibody (mAb) 4E3. The percentage of Pgp+ lymphocytes increased to 3% after 24 hr of mitogenic stimulation that induced maximal production of cytoplasmic IL-2. The percentage of lymphocytes that coexpressed membrane Pgp and cytoplasmic IL-2 accounted for < 10% of the total IL-2 producing lymphocytes. Finally, mitogen-induced cytoplasmic IL-2 accumulation was enhanced by stimulation in the presence of monensin but not the Pgp functional inhibitor verapamil. Because mAb 4E3 detected lower than expected numbers of Pgp+ lymphocytes, we compared the binding of mAbs MRK16 and 4E3 concomitant with doxorubicin (DOX)-uptake by K562 and R7 tumor cells and purified CD8+ lymphocytes. The MRK16 mAb was found to be sensitive but not very specific (30%). In contrast, the sensitivity of 4E3 was equivalent to MRK16 (98%) and was highly specific (98.5%). There was also a positive association between DOX efflux and the level of Pgp expression as detected by 4E3 but not MRK16. Thus, human T cells do not markedly up-regulate their expression of functional Pgp molecules as detected by mAb 4E3 following activation, suggesting that Pgp does not play a major role in IL-2 secretion by activated T cells.

Effects of P-glycoprotein modulators on etoposide elimination and central nervous system distribution.

In this study, P-glycoprotein modulator effects on pharmacokinetics and central nervous system distribution of the chemotherapeutic agent etoposide were evaluated. The multidrug resistance transporter P-glycoprotein is expressed in normal tissues, and its physiological function is thought to be an excretory and/or protective one. To examine this further, we evaluated etoposide under steady-state and bolus dose conditions. In microdialysis infusion studies, etoposide 15 mg/kg/hr was administered to 12 rats. Rats received sodium cyanide (1 or 100 mM), trifluoperazine (30 mM) or cyclosporine (4.14 mM) via microdialysis probe at 3.5 hr after etoposide infusion initiation. High-dose sodium cyanide (100 mM) increased the etoposide BBR,corr from 0.09 +/- 0.03 to 0.85 +/- 0.35. Similarly, trifluoperazine significantly increased the BBR,corr (0.05 +/- 0.02 vs. 1.30 +/- 0.43), whereas cyclosporine had no effect. In bolus studies, etoposide (10-12 mg/kg) was given alone or concomitant to cyclosporine (5 mg/kg) or tamoxifen (13.5 mg/kg). Control etoposide total systemic clearance (ml/min/kg) was 29.3 +/- 13.0 vs. 16.0 +/- 1.9 and 22.6 +/- 5.3 for cyclosporine and tamoxifen treatments, respectively. Etoposide nonrenal clearance (ml/min/kg) values for cyclosporine (12.0 +/- 1.6) and tamoxifen (18.1 +/- 3.6) treatments was also decreased from controls (23.5 +/- 10.5). Etoposide renal clearance (ml/min/kg) values (5.7 +/- 2.5) were not significantly different from cyclosporine (4.0 +/- 0.7) or tamoxifen (4.6 +/- 1.7) treatments, respectively. In this study, the ability of sodium cyanide and trifluoperazine to alter etoposide BBR,corr, demonstrated that etoposide distribution into brain is partly controlled by an active transport process. Similarly, the results indicate cyclosporine inhibits etoposide transport at the canalicular membrane and/or etoposide P-450 metabolism.

Analysis of blood T-cell cytokine expression in B-chronic lymphocytic leukaemia: evidence for increased levels of cytoplasmic IL-4 in resting and activated CD8 T cells.

The cytoplasmic cytokines of purified blood T cells (CD4/CD8) in B-CLL patients (n = 5) and controls (n = 5) were evaluated by flow cytometry. The mean levels of cytoplasmic IL-4 were significantly elevated in resting and activated B-CLL CD8 cells compared to control CD8 cells. IL-4 cytoplasmic levels were comparable for resting B-CLL and control CD4 cells but greater for B-CLL activated CD4 cells. The mean fluorescence intensity of B-CLL CD8 cytoplasmic IL-4 was 4-5-fold greater, indicating higher IL-4 density per CLL CD8 than control CD8 cells. Both CLL CD4 and CD8 cells post-activation had higher levels of cells double positive for cytoplasmic IL-4 and interferon. These data indicate that freshly isolated CD8 and CD4 blood T cells from B-CLL patients have significantly elevated (above control) levels of commitment to expression of IL-4. Since IL-4 has an important modulatory impact on CLL and normal B cells, this observation has implications regarding the biology of B-CLL.

The potential of a novel polyamine transport inhibitor in cancer chemotherapy.

The polyamines, putrescine (PUT), spermidine (SPD) and spermine (SPM), are a family of low molecular weight organic cations that are essential for cell growth, differentiation and neoplastic transformation. The marked compensatory increase in extracellular polyamine influx may be a reason for the unsatisfactory clinical chemotherapeutic effect of polyamine synthesis blockers like difluoromethylornithine (DFMO). In this study, a polymeric conjugate of SPM (poly-SPM) that blocks the import of polyamines into mammalian cells was used to test the potential therapeutic exploitation of the polyamine transport system in anticancer therapy. Our results indicate that a temperature-dependent polyamine transport system is expressed in two human cancer cell lines, MES-SA uterine sarcoma cells, K562 leukemic cells and their respective multiple drug resistance (MDR) positive counterparts, Dx5 and K562/R7 cells. The V(max) values for 14C-PUT and 14C-SPD uptake were significantly higher in MES-SA than in Dx5 cells, whereas the respective Km values were significantly lower. Addition of 20 microM poly-SPM reduced both the uptake of 14C-polyamines and the cellular polyamine contents in both cancer cell lines. In addition, the poly-SPM conjugate evoked a concentration-dependent cytotoxicity in MES-SA and K562 cells and their MDR-positive variants. Presence of aminoguanidine, an amine oxidase blocker, failed to alter the IC50 values generated with poly-SPM, which indicates that this polymer is not a substrate for amine oxidase. Moreover, coadministration of 25 microM SPD reversed the cytotoxic effect exerted by poly-SPM on both the MES-SA and Dx5 cells as reflected by an increase in their IC50 values. Relative to parental cells, the MDR-positive variants exhibited a lower 14C-polyamine uptake rate and were more resistant to the cytotoxic effect of poly-SPM. Pretreatment with 1 mM DFMO for 24 hr significantly increased polyamine transport, but failed to reduce intracellular SPM contents or exert a cytotoxic effect in both cancer cell lines. On other hand, the combination of DFMO and poly-SPM produced a greater depletion of polyamine content accompanied by a higher cytotoxicity than either agent alone. These results provide the first direct evidence that pharmacologic interruption of polyamine uptake may be an effective approach to cancer therapy. In addition, it appears that expression of MDR influences polyamine transport and renders cells more resistant to the cytotoxic effects of SPM polymer.

Modulation effects of cyclosporine on etoposide pharmacokinetics and CNS distribution in the rat utilizing microdialysis.

In the present study, we evaluated the pharmacokinetics of the chemotherapeutic agent etoposide (ET) under steady-state conditions and examined its extent of distribution into the CNS of conscious animals. An i.v. infusion of 15 mg/kg/hr was administered to nine rats. Each of the nine rats also received the potent multidrug resistance (MDR) modulator cyclosporine (CSA). Upon the addition of CSA, the i.v. treated animals demonstrated a 53% decrease in ET clearance. This decrease resulted in a greater than 2-fold increase in the steady-state concentrations of ET> The corrected brain-blood ratio (BBR (corr)) was 0.36 +/- 0.18 prior to CSA treatment, and although CNS concentrations increased upon the addition of CSA, there was no increase in the BBR(corr) (0.24 +/- 0.10). The present study demonstrates that the increase of ET in the CNS following CSA is a result of a decrease in ET systemic clearance and not an inhibition of ET efflux from the CNS.

Reversal of doxorubicin, etoposide, vinblastine, and taxol resistance in multidrug resistant human sarcoma cells by a polymer of spermine.

We have previously described the synthesis of a cytotoxic polymeric conjugate of spermine (Poly-SPM) which is able to inhibit the transport of polyamines (spermine, spermidine, and putrescine) into normal and malignant cells. Recent studies examining the toxicity of Poly-SPM in parental and multidrug resistant (MDR) cancer cells have revealed a cross-resistance in the MDR variant Dx5 to the toxic effects of the conjugate in the MDR-positive cells. There were also differences in spermine and putrescine uptake rates between parental and MDR-positive with the MDR-positive cells having a lower Vmax and a higher Km. The ability of this Poly-SPM to reverse MDR was examined in MDR variants (Dx5 cells) of the human sarcoma cell line MES-SA. The cells express high levels of the mdr1 gene product, P-glycoprotein, and are 25-to 60-fold resistant to doxorubicin (DOX), etoposide (VP-16), vinblastine (VBL), and taxol (TAX). Cytotoxicity was measured by the MTT [3-(4,5-dimethyldiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay. Poly-SPM (50 microM) lowered the drug concentration IC50 values in the Dx5 cells by 37-fold with VBL, 42-fold with DOX, 29-fold with VP-16, and 25-fold with TAX when compared to the control IC50 values without Poly-SPM. This reversal of resistance was concentration dependent, decreasing 17-fold with DOX, 6.1-fold with VBL, 19-fold with VP-16, and 5-fold with TAX when 25 microM Poly-SPM was used. No modulation was observed in the parental cell line MES-SA, which does not express the mdr1 gene. Poly-SPM had no influence on the IC50 of non-MDR chemotherapeutic agents such as cisplatin. The modulation studies correlated with the ability of Poly-SPM to reverse the cellular accumulation defect of [3H]-VBL and [3H]-TAX in the Dx5 but not MES-SA cells. Pretreatment of the Dx5 cell with alpha-difluoromethylornithine (DFMO at 2 and 5 microM) for 24 h increased the function of the MDR transporter to further decrease the cellular accumulation of VBL and TAX when compared to untreated cells. DFMO pretreatment is known to upregulate the polyamine transporter(s). These findings show that, in addition to inhibiting polyamine transport, Poly-SPM reverses MDR in Dx5 cells, suggesting a potential relationship between the polyamine influx transporter and the MDR efflux pump. This potential functional link between the polyamine influx transporter(s) and the MDR efflux transporter (P-glycoprotein) offers a novel approach to inhibiting this form of drug resistance.

A novel polymeric spermine conjugate inhibits polyamine transport in pulmonary artery smooth muscle cells.

The polyamines putrescine, spermidine and spermine (SPM) are low molecular weight organic cations that play essential intracellular regulatory roles in cell growth and differentiation. Whereas both de novo polyamine synthesis and transmembrane transport regulate cell polyamine contents, exploitation of pathways as pharmacologic targets has been limited by the lack of agents which specifically block polyamine transport. We now report the synthesis and biologic activity of novel polymeric glutaraldehyde conjugates of putrescine, spermidine and SPM which act at the cell membrane to inhibit polyamine uptake in cultured bovine pulmonary artery smooth muscle cells. Each conjugate caused dose-related inhibition of [14C]polyamine transport in pulmonary artery smooth muscle cells with the polymeric SPM conjugate being most effective in inhibiting the uptake of all three polyamines. Polymeric SPM failed to impair uptake of neutral or charged amino acids or to associate with pulmonary artery smooth muscle cells in a temperature-dependent manner. The polymeric SPM conjugate caused substantial decreases in cell polyamine contents which were associated with concentration-dependent cytotoxicity. Spectroscopic analyses of the polymeric SPM conjugate indicated that its molecular weight was 25 +/- 0.5 kDa, which is equivalent to approximately 90 monomeric--HN(CH2)3NH(CH2)4NH(CH2)3NH(CH2)5--units. These findings indicate that reduced polymeric glutaraldehyde conjugates of the polyamines may function as specific inhibitors of polyamine transport and thus provide a basis for examination of polyamine transport as a pharmacologic target in disorders characterized by dysregulated cell growth and differentiation.

MDR expression in normal tissues. Pharmacologic implications for the clinical use of P-glycoprotein inhibitors.

The use of drugs such as calcium channel blocker agents and cyclosporins as an approach to reverse the MDR phenomenon in controlled clinical trials has demonstrated the combination of these agents to markedly alter the pharmacokinetics of a number of cytotoxins associated with MDR characteristics, including doxorubicin, etoposide, paclitaxel, and vincristine. These effects are likely to be the combined effects of MDR modulators to produce decreased metabolism of the cytotoxins via the cytochrome P-450 system and decreased biliary and renal transport/excretion. It still remains to be established if the mdr1 gene is a primary drug transporter in these organs. Specificity of MDR modulators for drug metabolism and excretion requires further study, because some modulators of MDR, such as progesterone, have shown no interaction with cytotoxins (that is, doxorubicin) in clinical trials. Trials to date have indicated many modulators of MDR at doses which achieve concentrations that reverse MDR in vitro may lead to alterations of tissue function and enhance toxicity to normal tissue. In vitro data suggest many MDR modulators will enhance hematologic toxicity, beyond that predicted by the increased exposure from pharmacokinetic effects. When these interactions occur, it has been necessary to reduce the dosages of the cytotoxins in the range of 40% to 50% in most trials, if similar normal tissue toxicity--that is, myelosuppression or neuropathy--is expected. However, these empiric dose modifications in the absence of concurrent pharmacokinetic monitoring could compromise tumor exposure. Other toxicities that may be enhanced during the use of MDR modulators are nausea and vomiting, consistent with the hypothesis for a disruption of blood-brain barrier function, and augmented vinca alkaloid-associated autonomic and peripheral neuropathies. Future laboratory studies should define more effective modulators and the role of the mdr1 gene in normal tissue toxicology. These trials should focus on defining the pharmacokinetic and toxicologic interactions between the modulators and antineoplastic agents and formulate dosing guidelines for their testing in pivotal phase II and controlled phase III trials.

A phase I trial of 5-day continuous infusion cisplatin and interferon alpha.

Combination therapy of cisplatin with interferon alpha (IFN) has been shown in several in vitro as well as in vivo models to be synergistic. In order to decrease toxicity seen with cisplatin, 5-day continuous infusions, in place of bolus administration, have been introduced. This led us to investigate the combination of 5-day continuous infusion cisplatin with repeated IFN dosing in a phase I cisplatin dose escalation study. A group of 17 patients were enrolled in this trial. The maximum tolerated dose (MTD) of cisplatin was 20 mg/m2 per day when combined with 3 x 10(6) units IFN given three times a week. The dose-limiting toxicities seen included thrombocytopenia, leukopenia, and nausea and vomiting. Pharmacokinetic analyses of free (unbound or ultrafilterable) platinum revealed that the decay curve fitted a monoexponential model. Pharmacokinetic parameters of cisplatin were found to correlate with toxicity. Both increases in the maximum concentration of cisplatin achieved (Cpmax) as well as the area-under-the-curve (AUC) for free platinum, correlated with the incidence of nausea and vomiting (both acute and delayed) and hematological toxicities (leukopenia and thrombocytopenia). None of the patients exhibited significant changes in renal function while on this study. The free platinum levels were higher than found in similar studies evaluating comparable cisplatin infusions alone. The enhanced toxicities seen in this trial may be explained by the results of an in vitro study using human plasma spiked with cisplatin and IFN that revealed decreased protein binding of cisplatin by 2.5-3.0-fold. Of the 17 patients treated, two non-small cell lung cancer patients obtained a partial response and one malignant melanoma patient obtained complete resolution of a malignant pleural effusion. Considering the acceptable toxicity seen in this trial, we recommend phase II trials be conducted with continuous infusion cisplatin with IFN in the treatment of non-small cell lung cancer.

Cytomegalovirus colitis after 5-fluorouracil and interferon-alpha therapy.

Cytomegalovirus (CMV) infection is an opportunistic viral infection primarily affecting immunocompromised patients. Patients with inflammatory bowel disease have an increased risk for developing CMV infections of the gastrointestinal tract. While receiving continuous infusion of 5-fluorouracil and interferon-alpha, a 72-year-old woman with stage IV pancreatic carcinoma developed severe colitis with diarrhea that was refractory to conventional antidiarrheals. A biopsy specimen from the colon revealed CMV inclusions, which were confirmed by immunofluorescence. The patient was given ganciclovir 210 mg (5 mg/kg) every 12 hours for 14 days, and the diarrhea resolved after approximately 8 days of therapy. This is the first reported case of CMV colitis associated with combination 5-fluorouracil and interferon-alpha therapy.

Molecular targets in oncology: implications of the multidrug resistance gene.

The curative potential of chemotherapy for a number of tumor types has been obscured by the fact that many patients initially have striking remissions but later relapse and die. At the time of relapse many patients manifest resistance to a wide array of structurally unrelated antineoplastic agents, hence the term multidrug resistance (MDR). Other tumor types, such as those arising in the colon, kidneys, liver, and lungs, tend to exhibit poor response to available cytotoxic drugs. The MDR phenomenon includes cross-resistance among the anthracyclines (doxorubicin, daunorubicin), the epipodophyllotoxins (etoposide, teniposide), the vinca alkaloids (vinblastine, vincristine), taxol, and other compounds. In vitro studies in cell culture indicate that this form of resistance is associated with amplification or overexpression of the mdr1 gene. The mdr1 gene codes for the expression of a cell surface protein, P-glycoprotein (P-gp), which acts as an energy-dependent efflux pump that transports drugs associated with MDR out of the cell before cytotoxic effects occur. The protein is expressed in normal human tissues such as the gastrointestinal tract, liver, and kidneys, where it is thought to serve as an excretory pathway for xenobiotic drugs and toxins. Preliminary studies demonstrated the presence of P-gp in tumor samples from patients with acute leukemia, multiple myeloma, lymphomas, and a variety of solid tumors. A number of drugs are able to reverse MDR, including calcium-channel blockers, phenothiazines, quinidine, antimalarial agents, antiestrogenic and other steroids, and cyclosporine. Limited results from clinical trials with small numbers of patients suggest that the addition of verapamil, diltiazem, quinine, trifluoperazine, or cyclosporine to chemotherapeutic regimens has the potential to reverse MDR; however, toxicities limit their clinical usefulness. A number of trials are under way to identify more active and less toxic modulators of MDR.

Phase I trial of etoposide with cyclosporine as a modulator of multidrug resistance.

PURPOSE: To determine the maximum-tolerated dose (MTD) of cyclosporine (CsA) infusion administered with etoposide for 3 days in patients with cancer. PATIENTS AND METHODS: Of the 72 registered patients, 26 were treated initially with CsA and etoposide. Forty-six received etoposide alone until disease progression, and 31 of these proceeded to CsA and etoposide. CsA was administered as a 2-hour loading dose (LD) and as a 3-day continuous infusion (CI); doses were escalated from 2 to 8 mg/kg LD and 5 to 24 mg/kg/d CI. RESULTS: Fifty-seven patients were treated with 113 cycles of CsA with etoposide. Steady-state serum CsA levels (nonspecific immunoassay) more than 2,000 ng/mL were achieved in 91% of the cycles at CsA doses > or = 5 mg/kg LD and > or = 15 mg/kg/d CI. The major dose-related toxicity of CsA was reversible hyperbilirubinemia, which occurred in 78% of the courses with CsA levels > 2,000 ng/mL. Myelosuppression and nausea were more severe with CsA and etoposide. Other CsA toxicities included hypomagnesemia, 60%; hypertension, 29%; and headache, 21%. Nephrotoxicity was mild in 12% and severe in 2% of the cycles. Tumor regressions occurred in four patients after the addition of CsA (one non-Hodgkin's lymphoma, one Hodgkin's disease, and two ovarian carcinomas). Biopsy procedures for tumors from three of the four patients who responded were performed, and the results were positive for mdr1 expression. CONCLUSIONS: Serum CsA levels of up to 4 mumol/L (4,800 ng/mL) are achievable during a short-term administration with acceptable toxicities when administered in combination with etoposide. The CsA dose that is recommended in adults is a LD of 5 to 6 mg/kg, followed by a CI of 15 to 18 mg/kg/d for 60 hours. CsA blood levels should be monitored and the doses should be adjusted to achieve CsA levels of 2.5 to 4 mumol/L (3,000 to 4,800 ng/mL). Reversible hyperbilirubinemia may be a useful marker of inhibition by CsA of P-glycoprotein function. When used with high-dose CsA, etoposide doses should be reduced by approximately 50% to compensate for the pharmacokinetic effects of CsA on etoposide (Lum et al, J Clin Oncol, 10:1635-1642, 1992).

Alteration of etoposide pharmacokinetics and pharmacodynamics by cyclosporine in a phase I trial to modulate multidrug resistance.

PURPOSE: To determine the effects of high-dose cyclosporine (CsA) infusion on the pharmacokinetics of etoposide in patients with cancer. PATIENTS AND METHODS: Sixteen patients were administered 20 paired courses of etoposide and CsA/etoposide. Etoposide was administered daily for three days, alone or with CsA, which was delivered by a loading dose and 3-day infusion. Etoposide was measured by high-performance liquid chromatography (HPLC) and serum CsA by nonspecific immunoassay. Etoposide pharmacokinetics included area under the concentration-time curve (AUC), total and renal clearance (CL), half-life (T1/2), and volume of distribution at steady state (Vss). RESULTS: CsA concentrations more than 2,000 ng/mL produced an increase in etoposide AUC of 80% (P less than .001), a 38% decrease in total CL (P < .01), a > twofold increase in T1/2 (P < .01), and a 46% larger Vss (P = .01) compared with etoposide alone. CsA levels ranged from 297 to 5,073 ng/mL. Higher CsA levels (< 2,000 ng/mL v > 2,000 ng/mL) resulted in greater changes in etoposide kinetics: Vss (1.4% v 46%) and T1/2 (40% v 108%). CsA produced a 38% decrease in renal and a 52% decrease in nonrenal CL of etoposide. Etoposide with CsA levels > 2,000 ng/mL produced a lower WBC count nadir (900/mm3 v 1,600/mm3) compared with baseline etoposide cycles. CONCLUSIONS: High-dose CsA produces significant increases in etoposide systemic exposure and leukopenia. These pharmacokinetic changes are consistent with inhibition by CsA of the multidrug transporter P-glycoprotein in normal tissues. Etoposide doses should be reduced by 50% when used with high-dose CsA in patients with normal renal and liver function. Alterations in the disposition of other multidrug resistance (MDR)-related drugs should be expected to occur with modulation of P-glycoprotein function in clinical trials.

Reversal by cefoperazone of resistance to etoposide, doxorubicin, and vinblastine in multidrug resistant human sarcoma cells.

The cephalosporins are a family of semisynthetic antibiotics, some of which have structural features associated with substrates for the multidrug transporter, P-glycoprotein. The activity of a series of six cephalosporins in reversing multidrug resistance (MDR) was examined in MDR variants (Dx5 cells) of the human sarcoma line MES-SA. Dx5 cells express high levels of the mdr1 gene product P-glycoprotein and are 25- to 30-fold resistant to doxorubicin (DOX), etoposide (VP-16), and vinblastine (VBL). Cytotoxicity was measured by the MTT assay. Cefoperazone (1.0 mM) was the most effective modulator of MDR, lowering the IC50 for VP-16 by 29-fold (29x), for VBL by 16x, and for DOX by 14x. Ceftriaxone at 1.0 mM produced 10x modulation of VP-16 cytotoxicity, 8x for DOX, and 2x for VBL. The reversal of resistance was concentration dependent, decreasing to 4x and 5x, respectively, for DOX with 0.25 mM cefoperazone and ceftriaxone. No modulation of cytotoxicity was observed in the parental MES-SA cells, which do not express mdr1. Cefazolin, cefotetan, cephradine, and ceftazidime were ineffective, producing less than 5x modulation of DOX at 1.0 mM. Among these cephalosporins, cefoperazone and ceftriaxone were the most highly protein bound in the media (30 and 52%), and the most lipid soluble, with octanol/water partitioning coefficients of -0.49 and -0.60. Varying the serum concentration in medium from 5 to 50% had less than a two-fold effect on the modulation of MDR by ceftriaxone. The ability to reverse MDR among these agents is associated with lipid solubility, high protein binding, a polycyclic planar geometry, and the presence of the piperazine group in cefoperazone. These data and the potential for achieving high tissue concentrations indicate that cefoperazone merits further study as a modulator of MDR.