Evaluation of the porphyrinogenic risk of antineoplastics.

The use of antineoplastics is common in cancer therapy, and some of them have been associated with the development of porphyria in patients with cancer. However, knowledge of their effects on the haeme metabolic pathway is at present scarce and unclear. So, the present study evaluates the porphyrinogenic ability of nine antineoplastics (both alkylating and non-alkylating). These were tested either alone or in conjunction with 3,5-diethoxycarbonyl-1,4-dihydrocollidine (latent porphyria model) in chick embryos and in mice. The results obtained suggest that the use of cyclophosphamide, azathioprine, 5-fluorouracil, busulphan, procarbazine and hexamethylmelamine be avoided in the treatment of porphyric patients. On the other hand, dacarbazine, chlorambucil and melphalan are non-porphyrinogenic. We also provide evidence showing that neither the presence of the mustard group in the structure of the antineoplastic nor alterations in ferrochelatase or protoporphyrinogen oxidase activities are responsible for the porphyrinogenic ability of cyclophosphamide.

Hexamethylmelamine is a potent inducer of deletions in male germ cells of Drosophila melanogaster.

Chemotherapy-related second tumors constitute a matter of concern in cancer treatment. Therefore, it is of great interest to elucidate the mechanisms by which cytostatic drugs exert their mutagenic and/or carcinogenic activity besides the anticancer effect and the possible relationship among them. A useful and informative approach to this problem is the analysis of the mutation spectra induced by these drugs in eukaryotic organisms. Sequence analysis of the mutations induced by hexamethylmelamine, a crosslinking agent extensively used in the treatment of ovarian cancer, in male germ cells of Drosophila was conducted using the v locus as reporter gene. Both intra-locus and multi-locus deletions were induced whereas based changes were almost absent. Thus, it is proposed that deletions are likely to be involved in the generation of second malignancies in hexamethylmelamine-treated patients. It has to be stressed that systems, such as v, capable of efficiently recovering mutations caused by big losses of DNA, should be used for the study of mutational spectra induced by cross-linking agents.

The hypermutability conferred by the mus308 mutation of Drosophila is not specific for cross-linking agents.

The hypersensitivity of the mus308 mutant of D. melanogaster to cross-linking agents has been suggested to be the consequence of a possible defect of this mutant in DNA cross-link repair. Moreover, the mus308 mutation has been proposed as an animal model for the study of Fanconi's anemia. In order to obtain more information about the function controlled by this locus, we have measured the mutability of the mus308 mutant to several mutagens with different modes of action using the sex-linked recessive lethal test. We show that this mutation confers hypermutability not only to the cross-linking agents tested, hexamethylphosphoramide and hexamethylmelamine, but to the point mutagen N-ethyl-N-nitrosourea as well, whereas the response to methyl methanesulfonate was normal. The results suggest that the mus308 locus is not defective in a repair pathway specific for cross-links but is rather involved in a step of a more general post-replication repair process responsible for the removal of non-excised adducts.

Hexamethylmelamine: pharmacology and mechanism of action.

Several conclusions can be drawn from a review of HMM preclinical and clinical pharmacology data. The drug is extensively metabolized by animals and by man. The drug is well absorbed following oral administration to animals, but oral bioavailability is low due to first pass metabolism. Based on limited human data and more complete animal data, absorption of HMM following oral administration may be quite high in man. We do not yet know the oral bioavailability of HMM in patients, but again based primarily on animal studies, oral bioavailability is most likely low and variable due to extensive first pass metabolism. Systemic exposure to HMM and demethylated metabolites following oral administration varies greatly from patient to patient and is sometimes quite low. Most patients are, however, exposed to a substantial fraction of the administered dose when determined by urinary recovery of the total dose (based on parent drug and metabolites or total radioactivity) or by the total plasma AUC of parent drug and all metabolites. Systemic exposure to HMM following intravenous administration is clearly greater and less variable than following oral administration. An unresolved question is whether the highly variable and often low systemic exposure after oral administration compromise antitumor activity when compared to intravenous administration. A key issue is whether or not one accepts the hypothesis that metabolism is a prerequisite for antitumor activity. The metabolic activation studies do not rule out other mechanisms of HMM antitumor activity. Modest activity of HMM was observed after prolonged exposure to cells which did not metabolize the drug. However, most of the accumulated data are consistent with the metabolic activation hypothesis. Certainly HMM has clinical activity when administered by mouth. If metabolism is required, then exposure to the total dose (parent drug and metabolites) could be of significance even when exposure to HMM is low, since every demethylated metabolite must have come ultimately from the initial HMM demethylation. We do not know whether the initial metabolic reaction (occurring in the liver rather than in the tumor) provides sufficient exposure of tumor to reactive species. Specifically, does the variable HMM plasma AUC seen after oral administration lead to variable delivery of potentially reactive species to tumor (by rapid breakdown and/or further metabolism of MPMM before it leaves the gut and/or liver) or are quantities of MPMM delivered to tumor comparable to those delivered following intravenous administration. The issue of rate of MPMM formation compared to rate of breakdown and ultimate delivery to tumor has been noted by Judson and Rutty.(ABSTRACT TRUNCATED AT 400 WORDS)

Hexamethylmelamine: activity in lymphoma and other tumors.

Hexamethylmelamine, an orally administered substituted melamine, has single agent activity in lymphoma (39% PR + CR), cervical cancer (28% PR), transitional carcinoma of the bladder (27% PR + CR), and Bilharzial bladder cancer (38% PR). Toxicity is mild and reversible and is manifested by myelosuppression, neurotoxicity and gastrointestinal toxicity. The potential role of hexamethylmelamine in combination chemotherapy in the diseases in which it has single agent activity is largely unexplored and should be investigated in clinical trials.

Selecting drug combinations based on total equivalent dose (dose intensity)

We describe a mathematical model for selecting cytotoxic drugs and dosages for a combination regimen based on the antitumor activities of the drugs given as single agents and their organ-specific maximum tolerated doses. The regimen defined maximizes an approximate measure of antitumor effect subject to constraints on combined toxicity. This approach does not assume that the underlying dose-response curve is steep; nor does it assume that maximally dose-intense regimens are clinically appropriate in all situations. Whether the identified regimen is superior to standard treatments should be determined by prospective, randomized clinical trials. Determining which drugs to combine and in what proportions to combine them offers combinatorially huge numbers of possibilities. The method described here offers one approach to identifying combinations worthy of evaluation in prospective trials.

Mathematical and biostatistical methods for designing and analyzing complex chemical interactions.

In this presentation, statistical methods for designing and analyzing experiments evaluating a mixture of drugs/chemicals are discussed. These methods are promising in that they are not limited by the number of interacting agents in the combination. Several examples are given and a discussion of the results follows.

Hexamethylmelamine: a critical review of an active drug.

Hexamethylmelamine is an s-triazine that began clinical trials during the 1960s based on its level of antitumor activity in murine tumor models. Phase I studies were performed using an oral formulation given in divided doses for varying numbers of days. The most frequently reported toxicities included nausea, vomiting, abdominal cramps, anorexia, weight loss and malaise. Less frequently reported toxicities were anemia, thrombocytopenia, leucopenia and peripheral neuropathy. Clinical antitumor activity was noted in the phase I studies in a variety of tumor types. Since then a large number of studies have been performed using hexamethylmelamine as a single agent and in a variety of combinations. Unfortunately, almost none of these studies sought to define the utility of this drug relative to other treatments for the diseases in which it showed activity, or to define the contribution of this drug to the activity of any given combination. Thus its role in the treatment of patients with malignancies remains undefined.

Effect of cimetidine and ranitidine on the metabolism and toxicity of hexamethylmelamine.

In a rat model, doses of 20-120 mg/kg of cimetidine prolonged in a dose-related manner the half-life of hexamethylmelamine by 29%-80%, while doses of 1-25 mg/kg of ranitidine did not. Administration of 120 mg/kg of cimetidine with a single 350-mg/kg dose of hexamethylmelamine increased toxicity from LD30 to LD75 (P = 0.005). When combined with 25 mg/kg of ranitidine, a statistically insignificant (P = 0.16) 15% increase in hexamethylmelamine toxicity was noted. These studies indicate that cimetidine but not ranitidine increases the toxicity of hexamethylmelamine through inhibition of microsomal metabolism.

Pentamethylmelamine: review of an aqueous analog of hexamethylmelamine.

The s-triazine derivatives have shown preclinical antitumor activity against several histologic types. The most widely used compound of this class in the clinic, hexamethylmelamine, has been largely restricted to oral use because of its low solubility and lack of stability in solutions suitable for parenteral administration. New analogs were sought which were soluble and stable and retained antitumor activity. Pentamethylmelamine (PMM), the monodemethylated derivative, showed these promising characteristics. Preclinical toxicology studies of PMM in mice, dogs, and monkeys showed toxic manifestations that involved the hematopoietic, lymphatic, renal, male reproductive, gastrointestinal, and nervous systems; these changes were both infusion-rate- and dose-dependent. Clinical phase I trials of PMM were performed using a variety of infusion durations and frequency schedules. The dose-limiting toxic effect common to all of these trials was protracted nausea and vomiting. In addition, some studies reported dose-limiting central nervous system manifestations in the form of agitation, drowsiness, somnolence, and even coma. Mild to moderate hematologic changes were noted. Because of the severity and frequency of the gastrointestinal and central nervous system toxic effects observed in the completed trials, no new clinical trials of PMM sponsored by the National Cancer Institute are planned. However, the interest in finding a clinically useful parenteral triazine continues.

Weak mutagenicity to Salmonella of the formaldehyde-releasing anti-tumour agent hexamethylmelamine.

Hexamethylmelamine (HEMLA) is a metabolism-dependent formaldehyde-releasing agent related in structure to hexamethylphosphoramide (HMPA). Both compounds are known to be mutagenic to Drosophila. HMPA, in common with the other formaldehyde-releasing agents studied, is non-mutagenic to Salmonella. The present paper describes the mutagenicity of HEMLA to strain TA100 of Salmonella typhimurium. Activity is dependent upon both the use of a pre-incubation assay protocol and on high concentrations of Aroclor-induced rat liver in the S9 mix. HMPA was inactive under similar conditions of test.

Central side effects of pentamethylmelamine: biochemical and behavioural studies.

The central side effects of pentamethylmelamine (PMM), an antitumoral agent, were studied on brain neurotransmitters from the biochemical and behavioural points of view. PMM causes a dose-related reduction in the body temperature and motility of mice. 100 mg/kg of PMM lowers the levels of noradrenaline (NA) and raises 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG) in the telencephalon. A similar dose increased striatal levels of dopamine (DA) metabolites, homovanillic acid (HVA) and dihydroxyphenylacetic acid (DOPAC), at earlier times (30 min), reducing their levels at 2 hr. These effects disappear at longer times (4 hr). No changes were observed in the levels of 3-methoxytyramine (3-MT), the extraneuronal metabolite of DA. The serotonin metabolite 5-hydroxyindolacetic acid (5HIAA) was almost not affected. PMM and its metabolites do not displace [3H]-spiroperidol from mouse striatal binding sites. These data show that some of the neurological effects induced by PMM are associated with changes in the metabolism and/or release of brain catecholamines but are not mediated by direct action on DA receptors.

Reproduction and teratology studies on hexamethylmelamine in the rat and rabbit.

The antineoplastic drug hexamethylmelamine (HMM) was evaluated for effects on reproduction and postnatal development in the rat and on embryonal and fetal development in the rat and rabbit. Daily po treatment of male rats for 62 days with doses of 0, 10, 20, or 40 mg/kg/day resulted in testicular atrophy, reduced fertility, and a possible dominant lethal mutagenic effect at the higher two dose levels. Alterations in morphology and function of the beta cells of the pancreatic islets were observed after treatment of males for more than 28 days with 20 or 40 mg/kg/day. The same dose levels administered to female rats for 14 days prior to breeding and through Day 13 or 20 of gestation had no adverse effects on fertility, but the highest dose was embryocidal and postnatal survival was decreased at both the 20- and 40-mg/kg/day dose levels. Similar effects on postnatal survival were observed when the drug was administered by gavage to rats during the last week of gestation and throughout the lactation period. Treatment of pregnant rats throughout organogenesis (Days 6 to 15) or for 4-day intervals during organogenesis (Days 6 to 9, 9 to 12, or 12 to 15) with po doses ranging from 20 to 80 mg/kg/day resulted in decreased body weight gain and food consumption, an increased resorption rate in dams receiving 80 mg/kg/day on Days 6 to 9, and decreased fetal weights at all dose levels and most treatment intervals. The incidence of minor skeletal defects was increased among litters of HMM-treated groups. Major fetal malformations were limited in number but were considered treatment related. Treatment of pregnant rabbits po on Days 6 to 18 of gestation with doses of 0, 20, 40, or 60 mg/kg/day did not result in an embryocidal or teratogenic effect. Treatment with 60 mg/kg/day did, however, result in decreased kit weights, indicating a mild embryo-fetotoxic effect.

Pancreatic beta cell vacuolation in rats after oral administration of hexamethylmelamine.

The effects of hexamethylmelamine (HMM) on morphology and function of the endocrine pancreas were investigated following the induction of a diabetic-like syndrome in a reproduction study in rats. Doses of 0, 20, 40, or 80 mg/kg/day were administered once daily, by gavage, to groups of 10 male and 10 female Sprague-Dawley rats for up to 77 days. Signs of toxicity were observed at all treatment levels and were of such severity at 80 mg/kg/day that this group was terminated after 8 days of treatment. Measurement of serum glucose levels revealed a dose- and time-related hyperglycemia in rats from the 20- and 40-mg/kg/day groups with levels exceeding 700 mg/dl in some rats after 77 days of treatment. Reversal of the hyperglycemia after discontinuing treatment with HMM occurred in some rats receiving 20 mg/kg/day, whereas the effects of higher doses were still present following a 2-month recovery period. Microscopically, there were hydropic degeneration of renal tubular epithelium and vacuolation of pancreatic beta cells. Ultrastructurally, vesiculation of the Golgi-smooth membrane reticular complex and a marked reduction in the number of insulin granules were observed. It appeared that HMM exerted a disruptive effect on the production of insulin at or prior to the level of the Golgi complex. The severity and time course of morphologic changes and hyperglycemia were dependent on dose and duration of treatment.

The curative action of hexamethylmelamine on intramuscularly or intracerebrally implanted Yoshida sarcoma.

Curative effects of hexamethylmelamine (HMM, NSC 13875) against intramuscularly or intracerebrally implanted Yoshida sarcoma depend on the schedules. A twice daily oral administration over a 2-week period showed a significant chemotherapeutic advantage over a single daily administration. The observed curative effect depends on the tumour site and on its mass. The Yoshida sarcoma seems to be one of the most suitable test models for HMM or related derivatives.

Hexamethylmelamine and pentamethylmelamine: an update.

An updated review of the anticancer agents hexamethylmelamine (HMM) and its water-soluble analog pentamethylmelamine (PMM) is presented. Severe gastrointestinal and hematologic toxicity have limited the use of HMM drug combinations in ovarian cancer. Combinations involving HMM, cyclophosphamide, cisplatin, and doxorubicin in advanced ovarian cancer have resulted in only moderate response rates, with little to no change in median survival of previously treated patients. HMM now is being studied in previously untreated patients with advanced disease, in combination with these agents. In lung cancer, HMM continues to be a part of intensive and other regimens for the treatment of small-cell and non-small-cell carcinoma, although the value of the HMM is yet to be determined. Future trials have been recommended to determine whether HMM has a role in the treatment of endometrial and prostatic carcinomas. Five phase I studies of PMM have demonstrated severe, dose-limiting gastrointestinal and central nervous system toxicities. Thus, this agent may offer little advantage over HMM. Further phase I studies, with different PMM dosage schedules, are necessary before phase II studies can be recommended.

Phase II trial of combination chemotherapy of colonic cancer with 5-fluorouracil, mitomycin C, and hexamethylmelamine.

HexMF consists of hexamethylmelamine 150 mg/m2 D2-15, mitomycin C (MMC) 10 mg/m2 D2 and 5-fluorouracil (5-FU) 30 mg/kg/day as a continuous infusion D1-5 in 4-5 week cycles. It was designed as an alternative to treating patients with standard single agents in sequence, thereby preventing the testing of new drugs as part of primary therapy. Median survival was 12+ months for patients with measurable and 18+ months for patients with nonmeasurable colorectal cancer. It was 9+ months from the onset of secondary chemotherapy. Toxicity included severe thrombocytopenia (50%), severe leukopenia (25%), and moderate stomatitis (50%). Only one instance of leukopenia was life-threatening. The MMC and 5-FU infusion skeleton provides an attractive strategy for testing new drugs as primary therapy. HexMF itself has a potentially broad antitumor spectrum and excellent acceptance by patients. It is suitable for additional phase II trials.

Phase II trial of combination chemotherapy for pancreatic cancer with 5-fluorouracil, mitomycin C, and hexamethylmelamine.

A combination consisting of hexamethylmelamine 150 mg/m2 D2-15, mitomycin C 10 mg/m2 D2 and 5-fluorouracil 30 mg/kg/day as a continuous infusion for 5 days, in 4-5 week cycles, underwent phase II trial as primary therapy for 21 patients with regional and metastatic cancer of the pancreas. Median survival from the onset of therapy was 43 weeks. There were 2 complete responses, 4 minor responses and 6 stable diseases for more than 6 months. Nonambulatory patients were among the responders. There was only 1 life-threatening toxicity (thrombocytopenia) and only 33% of patients had clinically silent severe hematological toxicity. The regimen is well tolerated, active and associated with excellent survival. This regimen is suitable for further confirmatory trials.

Hexamethylmelamine chemotherapy for disseminated endometrial cancer.

To evaluate the role of hexamethylmelamine (HMM) in the treatment of endometrial cancer, 20 women with metastatic or recurrent endometrial carcinoma received HMM orally at a dose of 8 mg/kg/day. Six patients (30%) showed a partial response, with a median duration of response of 3.5 months and a range of 1 to 7 months. Two patients responded to HMM as a second-line agent following previous treatment with nonhormonal chemotherapy. There were no complete responses. The major toxicities noted with HMM therapy were nausea, vomiting, and neurotoxicity. In 6 patients (30%), therapy with HMM was discontinued because of toxicity. Although HMM is active against endometrial cancer when given at a dose of 8 mg/kg/day, it appears to have limited usefulness because toxicity precludes its prolonged administration.