Arch Biochem Biophys 1999 Mar 15;363(2):283-295
Departement de Chimie et Biochimie, Universite du Quebec a Montreal, CP 8888, Succursale Centre Ville, Montreal, Quebec, H3C 3P8, Canada
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Regional hyperthermia has potential for human cancer treatment, particularly in combination with systemic chemotherapy or radiotherapy. The mechanisms involved in heat-induced cell killing are currently unknown. Hyperthermia may increase oxidative stress in cells, and thus, oxidative stress could have a role in the mechanism of cell death. We use hydrogen peroxide as a model oxidant to improve understanding of interactions between heat and oxidative stress. Heat increased cytotoxicity of hydrogen peroxide in Chinese hamster ovary cells. Altered levels of cellular antioxidants should create an imbalance between prooxidant and antioxidant systems, thus modifying cytotoxic responses to heat and to oxidants. We determine the involvement of the two cellular antioxidant defenses against peroxides, catalase and the glutathione redox cycle, in cellular sensitivity to heat, to hydrogen peroxide, and to heat combined with the oxidant. Defense systems were either inhibited or increased. For inhibition studies, intracellular glutathione was diminished to less than 15% of its initial level by treatment with l-buthionine sulfoximine (1 mM, 24 h). Inhibition of catalase was achieved with 3-amino-1,2,4-triazole (20 mM, 2 h), which caused a 80% decrease in endogenous enzyme activity. To increase antioxidants, cells were pretreated with the thiol-containing reducing agents, N-acetyl-l-cysteine, 2-oxo-4-thiazolidine carboxylate, and 2-mercaptoethane sulfonate. These compounds increased intracellular glutathione levels by 30%. Catalase activity was increased by addition of exogenous enzyme to cells. We show that levels of glutathione and catalase affect cellular cytotoxic responses to heat and hydrogen peroxide, either used separately or in combination. These findings are relevant to mechanisms of cell killing at elevated temperatures and suggest the involvement of oxidative stress. Copyright 1999 Academic Press.
PMID: 10068450
Department of Medical Oncology, Ancona, Italy.
Twenty-two patients, with locally advanced unresectable and/or metastatic pancreatic carcinoma, received weekly administration of cisplatin 40 mg m(-2), 5-fluorouracil 500 mg m(-2), epidoxorubicin 35 mg m(-2), 6S stereoisomer of leucovorin 250 mg m(-2) and glutathione 1.5 mg m(-2), supported by a daily administration of lenograstim at a dose of 5 microg kg(-1). Nineteen patients were men and three were women. Median age was 63 years (range 47-70). At study entry, pain was present in 15 out of 22 patients (68%) with a mean value of Scott-Huskisson scale of 27.6+/-23.8, whereas a weight loss >10% was present in 15 patients. After eight weekly treatments, three partial responses were achieved for a response rate of 13% (95% CI 0-26%), five patients had stable disease and 14 progressed on therapy. Pain was present in 9 out of 22 patients (40%) with a mean value of Scott-Huskisson scale of 12.3+/-18.4. Eight patients (36%) (three partial response and five stable disease) had a positive weight change. Toxicity was mild: WHO grade III or IV toxicity was recorded in terms of anaemia in 7 out of 188 cycles (3.7%), of neutropenia in 9 out of 188 cycles (4.7%) and of thrombocytopenia in 3 out of 188 cycles (1.5%). Median survival of all patients was 6 months. The outcome of this intensive chemotherapy regimen does not support its use in pancreatic cancer.
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PMID: 10027318, UI: 99149564
Department of Pharmaceutical Chemistry, College of Pharmaceutical Sciences, Kasturba Medical College, Manipal, Karnataka, 576 119, India. info@mahe.ernet.in
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We have investigated the effect of phenolic antioxidants on cisplatin-induced cytotoxicity in vero (African Green Monkey Kidney) cells and in rat renal cortical slices in vitro, and on cisplatin-induced nephrotoxicity in rats in vivo. Incubation of cisplatin with vero cells resulted in time- and concentration-dependent cytotoxicity, as characterized by decreased tryphan blue exclusion (TBE) and increased release of lactate dehydrogenase (LDH) into the medium. Cisplatin also caused reduction of glutathione (GSH) in a concentration-dependent manner. In the rat renal cortical slices model, incubation of cisplatin for 120 min caused an increase in malondialdehyde (MDA), a decrease in GSH and inhibited p-aminohippurate (PAH) uptake in a concentration-dependent manner. Among phenolic antioxidants, isoeugenol (IG) was found to be more active against cisplatin-induced cytotoxicity in vero cells as well as in rat renal cortical slices than eugenol (EG) and dehydrozingerone (DZ). However none of the test compounds were able to arrest the reduction of the GSH content induced by cisplatin in either the vero cells or the renal cortical slice model. Administration of cisplatin (3 mg/kg) i.p. to rats resulted in significant reduction of body weight, and elevation of blood urea nitrogen (BUN) and serum creatinine. Treatment with IG 10 mg/kg i.p. 1 h before cisplatin resulted in partial but significant protection against the cisplatin-induced reduction of body weight, and elevation of BUN and serum creatinine, the protection being 34, 46, and 62%, respectively. EG and DZ (10 mg/kg, i.p.) were found to be inactive in vivo. Because IG is a potent free radical scavenger and protects against cisplatin-induced toxicitiy, the present results have many clinical implications in chemotherapy and thus warrants further investigation.
PMID: 9990138
National Cancer Institute, Division of Clinical Sciences, Medicine Branch, National Naval Medical Center, Bethesda, Maryland 20889-5105, USA.
Expression and function of the TRAIL apoptotic pathway was investigated in normal and malignant breast epithelial cells. Glutathione-S-transferase (GST)-TRAIL extracellular domain fusion proteins were produced to analyze TRAIL-induced apoptosis. Only GST-TRAIL constructs containing regions homologous to the Fas self-association and ligand binding domains could induce apoptosis. GST-TRAIL induced significant (>90%) apoptosis in just one of eight normal and one of eight malignant breast cell lines. All other lines were relatively resistant to TRAIL-induced apoptosis. Activating TRAIL receptors DR4 and DR5 were expressed in all normal and malignant breast cell lines. The inhibitory receptor TRID was highly expressed in one of four normal and two of seven malignant breast cell lines. DR4, DR5, or TRID expression did not correlate with sensitivity to TRAIL-induced apoptosis. Incubation of cell lines with doxorubicin or 5-fluorouracil significantly augmented TRAIL-induced apoptosis in most breast cell lines. By fractional inhibition analysis, the toxicity of the combination of TRAIL and doxorubicin or 5-fluorouracil was synergistic compared with either agent alone. In contrast, melphalan and paclitaxel augmented TRAIL-induced apoptosis in few cell lines, and methotrexate did not augment it in any cell line. Augmentation of TRAIL-induced apoptosis by doxorubicin or 5-fluorouracil was mediated through caspase activation. This was evidenced by the fact that chemotherapy agents that synergized with TRAIL (e.g., doxorubicin) themselves caused cleavage of caspase-3 and poly(ADP-ribose) polymerase (PARP), and their toxicity was blocked by the caspase inhibitor Z-Val-Ala-Asp(OMe)-CH2 (ZVAD-fmk). The combination of TRAIL and doxorubicin caused significantly greater caspase-3 and PARP cleavage, and the combined toxicity also was inhibited by ZVAD-fmk. In contrast, chemotherapy agents that did not augment TRAIL-induced apoptosis (e.g., methotrexate) caused minimal caspase-3 and PARP cleavage by themselves, and their toxicity was not inhibited by ZVAD-fmk. These drugs also did not increase caspase-3 or PARP cleavage when combined with TRAIL. In summary, few breast cell lines are sensitive to TRAIL-induced apoptosis, and no difference in sensitivity is found between normal and malignant cell lines. Treatment with chemotherapy provides an approach to sensitize breast cancer cells to TRAIL-induced apoptosis.
PMID: 9973225, UI: 99137510
[Article in French]
Service de Rhumatologie, Hopital Kremlin-Bicetre.
OPTIMAL CHEMOTHERAPY DOSE: The goal of cancer chemotherapy is to eradicate the malignant disease while minimizing severe toxic effects. There is an optimal chemotherapy dose intensity above which palliation is adversely affected by toxicity; below this level the effect is also adverse because of a low rate of tumor response. METHODS FOR REDUCING TOXICITY: There are several methods by which one can reduce the toxicity of cancer chemotherapy, such as the application of rationally designed dosage schedules, alternative routes of administration, biochemical modulation, and the development of drug camers and analogs. Growth factors, interleukins can accelerate the recovery of the hematopoietic cell population after chemotherapy. CHEMOPROTECTORS: Chemoprotectors achieve selective protection of normal tissues. These include mercaptoethanesulfonate (Mesna) for oxazophosphorouros, the cardioprotectant iron chelator, cardioxane, the nucleophilic tripeptide glutathione, and perhaps aminothiolaminofostine. QUALITY OF LIFE: Considerable effort has been made to reduce the negative effect of chemotherapy-induced nausea and vomiting on the quality of life of cancer patients. 5 HT3 receptor antagonist plus dexamethasone led to a significantly higher rate of control of emetic episodes after chemotherapy.
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PMID: 9893705, UI: 99109583
Committee on Clinical Pharmacology, University of Chicago, Illinois 60637, USA.
Cancer chemotherapy is limited by significant inter-individual variations in responses and toxicities. Such variations are often due to genetic alterations in drug metabolising enzymes (pharmacokinetic polymorphisms) or receptor expression (pharmacodynamic polymorphisms). Pharmacogenetic screening prior to anticancer drug administration may lead to identification of specific populations predisposed to drug toxicity or poor drug responses. The role of polymorphisms in specific enzymes, such as thiopurine S-methyltransferases (TPMT), dihydropyrimidine dehydrogenase (DPD), aldehyde dehydrogenases (ALDH), glutathione S-transferases (GST), uridine diphosphate glucuronosyl-transferases (UGTs) and cytochrome P450 (CYP 450) enzymes in cancer therapy are discussed in this review.
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PMID: 9893619, UI: 99109497
Department of Neurology, University of Tubingen, School of Medicine, Germany.
BACKGROUND: Human malignant gliomas are resistant to chemotherapy. Here, we examine the modulation of drug-induced cytotoxicity and clonogenic cell death of glioma cells by antioxidants. MATERIALS AND METHODS: We studied the effects on drug toxicity of three structurally unrelated antioxidants, N-acetylcysteine, superoxide dismutase or phenyl-N-tert-butyl-alpha-phenylnitrone, in acute cytotoxicity and clonogenic cell death assays in LN-18, LN-229 and T98G cells. Two fluorescent dyes, 2',7'-dichlorodihydroJluorescein diacetate (DCF-Hr2) and dihydro-rhodamine-123, were used to monitor free radical formation after drug exposure. RESULTS: The antioxidants inhibited acute cytotoxicity and clonogenic cell death induced by cisplatin in all cell lines but had little effect on the toxicity of BCNU, doxorubicin, VM26, vincristine, cytarabine or camptothecin. Cisplatin toxicity was not associated with free radical formation and was not potentiated by L-buthionine-[S,R]-sulfoximine-induced glutathione depletion. CONCLUSION: Antioxidants specifically inhibit cisplatin cytotoxicity of human malignant glioma cells in the absence of drug-induced free radical formation.
PMID: 9891515, UI: 99108664
Rochelle Belfer Chemotherapy Foundation Laboratory, the Division of Neoplastic Diseases, the Division of Hematology, the Department of Medicine, Mount Sinai Medical Center, New York, NY 10029-6547, USA.
Arsenic trioxide (As2O3) induces clinical remission in acute promyelocytic leukemia (APL) with minimal toxicity and apoptosis in APL-derived NB4 cells at low (1 to 2 micromol/L) concentration. We examined the basis for NB4 cell sensitivity to As2O3 to identify experimental conditions that would render other malignant cells responsive to low concentrations of As2O3. The intracellular glutathione (GSH) content had a decisive effect on As2O3-induced apoptosis. Highly sensitive NB4 cells had the lowest GSH and the sensitivity of other cell lines was inversely proportional to their GSH content. The t(14;18) B-cell lymphoma cell line had low GSH levels and sensitivity to As2O3 at levels slightly higher than in APL cells. Experimental upmodulation of GSH content decreased the sensitivity to As2O3. Ascorbic acid and buthionine sulfoxide (BSO) decreased GSH to a greater extent, and rendered malignant cells more sensitive to As2O3. As2O3-induced apoptosis was not enhanced by ascorbic acid in normal cells, suggesting that the combination of ascorbic acid and As2O3 may be selectively toxic to some malignant cells. Ascorbic acid enhanced the antilymphoma effect of As2O3 in vivo without additional toxicity. Thus, As2O3 alone or administered with ascorbic acid may provide a novel therapy for lymphoma.
PMID: 9864170, UI: 99081626
Department of Medical Oncology, Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands.
We have established ten transplantable human soft-tissue sarcoma (STS) xenografts grown as subcutaneous tumours in the nude mouse. Nine xenografts originated from patients that needed chemotherapy in the course of their disease. The xenografts were tested for their sensitivity to maximum tolerated doses of five anti-cancer agents. Growth of treated tumours was expressed as a percentage of control tumour growth and a growth inhibition > 75% was measured for doxorubicin in 20% of the STS xenografts, for cyclophosphamide in 30%, for ifosfamide in 20%, for vincristine in 20%, whereas etoposide was not effective in the STS xenografts. In three out of ten STS xenografts MDR1 mRNA was detectable, but this was not related to the resistance against doxorubicin, vincristine or etoposide. Topoisomerase IIalpha mRNA expression levels did not reflect sensitivity to doxorubicin or etoposide. In all STS tissues, however, these levels were lower than topoisomerase IIalpha mRNA in a drug-sensitive human ovarian cancer xenograft. Glutathione concentrations and the activities of glutathione S-transferase, glutathione peroxidase and glutathione reductase were not related to resistance against the alkylating agents or doxorubicin. Of interest, in all STS tissues, glutathione S-transferase pi was the predominant isoenzyme present. In conclusion, chemosensitivity of the STS xenografts reflects clinical response rates in phase II trials on the same compounds in adult STS patients. Relatively low levels of topoisomerase IIalpha mRNA may partly account for intrinsic resistance against, for example, doxorubicin. Additional factors must contribute to moderate responsiveness to alkylating agents.
PMID: 9862568, UI: 99077384
Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina 29425-2230, USA.
Members of the glutathione S-transferase (GST) family of detoxification enzymes play a role in chemotherapy resistance in certain cancers but have not been directly implicated as agents whose absence may predispose tissues to hormonally induced tumorigenesis. Here we report the development of a polyclonal antiserum to a hamster mu class GST, and immunohistochemical analysis of alpha, mu, and pi class GSTs to study the effects of hormone treatment on their expression in reproductive tract tissues of male golden Syrian hamsters. These animals develop leiomyosarcomas in the vas deferens after treatment with testosterone propionate (TP) and 17beta-estradiol (E2). High levels of all three GST classes were detected throughout the reproductive tract epithelium of control animals. In 100% of the experimental animals, 4 weeks of treatment either with E2 alone, or with E2 plus TP promoted a complete loss of immunostaining for alpha and mu class GSTs, but not for pi class GSTs, only in the epithelial lining of the vas deferens. In contrast, treatment with TP alone resulted in moderate hyperplasia of smooth muscle in the proximal vas deferens, with no cellular atypia and no changes in immunoreactivity of any of the GST classes. The consistent and site-specific nature of these results strongly suggests a functional role for GSTs in hormonally induced carcinogenic process. (J Histochem Cytochem 47:91-98, 1999)
PMID: 9857216, UI: 99075938
Department of Obstetrics and Gynecology, Niigata University School of Medicine, Japan.
OBJECTIVE: To clarify immunohistochemically the correlation between glutathione S-transferase pi (GST pi) expression of surgically resected specimens and clinical response in ovarian cancer and to evaluate ascites cytology using GST pi staining. STUDY DESIGN: Eighty-seven patients with ovarian cancer underwent initial debulking surgery and received cisplatin-based chemotherapy after surgery. Immunostaining for GST pi was performed on formalin-fixed sections of the patients' tumors. The cytologic slides of 24 cases were acquired for evaluation of GST pi staining. RESULTS: Of 87 surgically resected specimens, 55 (63.2%) were GST pi positive. Twenty-five of 28 patients (89.3%) who showed no response to chemotherapy had GST pi-positive tumor cells. The predictive value of positive GST pi staining for drug resistance was 75.8% (25/33). Of 18 cases that were GST pi positive in surgically resected specimens, 17 were positive in ascites cytology. Five cases were negative in both resected specimens and ascites cytology. There was a significant correlation in the GST pi labelling index between resected specimen and ascites cytology from the same case; the correlation coefficient was .701 and P value < .001. CONCLUSION: Overexpression of GST pi is related to resistance to cisplatin, and GST pi staining of ascites cytology can be used in pretherapeutic assessment of patients with ovarian cancer.
PMID: 9850649, UI: 99067635
Oncologia Sperimentale C, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy. acosta@istitutotumori.mi.it
The predictive role in terms of pathological response and prognostic role of biomarkers such as GST-pi, p53, bcl-2 and bax expression, immuno-histochemically detected, and of the S-phase cell fraction, autoradiographically determined as thymidine labeling index (TLI), were investigated within a prospective randomized phase III clinical trial on squamous-cell carcinoma of the oral cavity, including surgery or primary chemotherapy (PCT), which foresaw the prospective determination of biological markers. Pathological response was defined as the achievement after PCT of a pathological complete remission or the presence of microresidual disease. The study was performed on tumors obtained from a series of 100 previously untreated patients with resectable T2-4N0-2M0 carcinoma. All biomarkers were unrelated, except for an inverse relation between TLI and GST-pi and a direct relation between bcl-2 and bax expression. In patients treated with surgery alone, 3-year disease-free survival (DFS) appeared to be weakly, but not significantly, related only to GST-pi and p53 expression. In patients treated with PCT, pathological response and DFS were independent of p53 expression and cell proliferation. Conversely, low GST-pi and bax expression were indicative of pathological response but lost relevance as predictors of DFS, whereas absence of bcl-2 was associated with high probability of 3-year DFS in the overall series as well as in non-responding patients. Within this latter sub-set, all patients with bcl-2-positive tumors relapsed within 1 year of surgery, whereas a 60% probability of 3-year DFS was observed for patients with bcl-2-negative tumors (p = 0.02). This interim analysis appears to indicate that some biofunctional markers can provide information on pathological response to PCT and could help in understanding treatment efficacy at a cellular level.
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PMID: 9842971, UI: 99057105
Center for Study and Research on Obesity, Department of Pharmacology, Chemotherapy and Medical Toxicology, School of Medicine, LITA Vialba, L. Sacco Hospital, University of Milan, Milano, Italy.
[Medline record in process]
1. In the present work, we study the effect of NO on the proliferation and differentiation of brown fat cells in primary cultures. 2. Brown fat precursor cells isolated from rat brown adipose tissue were cultured for 8 days until confluence and treated daily with the NO donating agents, S-nitroso-acetyl penicillamine (SNAP) or S-nitroso-L-glutathione (GSNO). Both agents (300 microM) decreased cell proliferation approximately 8 fold on day 8. The inhibitory effect of NO was unlikely to be due to cytotoxicity since (i) cells never completely lost their proliferation capacity even after 8 days of exposure to repeated additions of SNAP or GSNO, and (ii) the inhibitory effect was reversible after removal of the media containing NO donors. 3. Daily treatment with nitric oxide synthase inhibitors, such as NG-nitro-L-arginine methyl ester (L-NAME, 300 microM), led to the stimulation of cell proliferation by 44+/-5%, n=3, suggesting that NO, endogenously produced in brown adipocytes, may be involved in modulating cell growth. 4. Daily treatment with both SNAP or GSNO induced significant mitochondriogenesis, measured as the mitochondrial conversion of 3-[4,5-dimethylthiazol-2-yl-]-2,5-diphenyl tetrazolium bromide (MTT) to formazan, whilst daily treatment with L-NAME was without effect. 5. The inhibition of cell proliferation by NO donors was accompanied by the expression of two genes coding for peroxisome proliferator activated receptor-gamma and uncoupling protein-1, which are upregulated during differentiation. 6. Increasing cyclic GMP in cells by 8-bromo-cyclic GMP (100-1000 microM) did not reproduce the observed NO effects on either cell number or gene expression. On the other hand, chronic treatment with the inhibitor of the NO-stimulated guanylyl cyclase, 1H-[1,2,4]oxadiazole[4,3-a]quinoxalin-1-one (ODQ), reduced the expression of peroxisome proliferator activated receptor-gamma and uncoupling protein-1.
PMID: 9831929, UI: 99048769
Department of Comparative Medicine, College of Veterinary Medicine, University of Tennessee, Knoxville 37901, USA.
BACKGROUND: In this report we describe the establishment, characterization, and research utility of a cell line derived from a dog having a spontaneously occurring osteosarcoma (COS) made resistant to the cytotoxic effects of cisplatin chemotherapy. MATERIALS AND METHODS: Established cells from passage 31 (COS31) were exposed to increasing sublethal concentrations of cisplatin in vitro. RESULTS: A 2.2-fold increase in glutathione-S-transferase (GST) activity was found to be induced in this cell line (COS31/rCDDP) compared to parent cells. Furthermore, these cells were 7.8-fold more resistant to the cytotoxic effects of higher concentrations of cisplatin compared to parent cells. Ethacrynic acid was found to inhibit GST enzymatic activity and increase cisplatin cytotoxicity in resistant COS31 (COS31/rCDDP) cells. CONCLUSIONS: Inhibiting the function of GST with ethacrynic acid pretreatment in humans and dogs with osteosarcoma may result in more tumor cells than normal cells killed in vivo by cisplatin, thus significantly prolonging lifespan without increasing host toxicity.
PMID: 9827351, UI: 99044600
Department of Urology, National Taiwan University Medical College, Taipei, ROC.
Megestrol acetate (MGA) is being widely used for the improvement of appetite and performance status in patients receiving chemotherapy, especially cisplatin-containing therapy. However, little is known about whether MGA has an effect on cisplatin cytotoxicity. We have investigated this using two transitional carcinoma cell lines, i.e. the cisplatin-sensitive parental line NTUB1 and the resistant daughter line NTUB1/P. Combined effects of MGA and cisplatin were assayed with a microculture chemosensitivity method. We explored the level changes of several cisplatin detoxification mechanisms, including metallothionein (MT), glutathione S-transferase-pi (GST-pi) and glutathione (GSH) levels in cells treated with or without MGA. After treatment with 10 microns MGA for 24 h, the cisplatin IC50s of NTUB1 and NTUB1/P increased 1.4- (p = 0.03) and 1.6- (p = 0.02) fold, respectively. By median effect analysis, the combinations of MGA and cisplatin in the two cells appeared to produce an antagonistic interaction. By Northern analysis, MT transcript levels in both cells were significantly upregulated after treatment with MGA, as compared to those without treatment. Exposure to MGA in either sensitive or resistant cells did not alter GST-pi levels as shown by immunoblotting analysis. Cellular GSH content was increased only in NTUB1/P (p = 0.0036) but remained unchanged in NTUB1 cells (p = 0.29) after MGA exposure. In conclusion, MGA may antagonize cisplatin cytotoxicity by upregulating cellular MT and GSH levels. Use of MGA in cisplatin-containing chemotherapy may impair tumor response by antagonizing cisplatin antitumor activity.
PMID: 9823432, UI: 99040766
Division of Medical Oncology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania 15213, USA.
The activity of the enzyme O6-alkylguanine-DNA-alkytransferase (AGAT) protects cells from the cytotoxic effects of alkylating agents. This Phase II trial was designed to assess the efficacy of a strategy designed to modulate the resistance to carmustine (BCNU) mediated by AGAT using streptozocin (STZ) in patients with advanced refractory melanoma. Seventeen patients who had failed prior chemotherapy were treated with STZ at 500 mg/m2 daily for 4 days with BCNU at 150 mg/m2 on day 3. Peripheral blood lymphocytes for assay of AGAT activity levels were collected prior to therapy and following the third dose of STZ. There were two partial responses in the 15 patients evaluable for response (13%). Most patients received only a single cycle of therapy due to rapidly progressive disease. Two patients developed fatal pulmonary toxicity, and one developed myelodysplasia. Other toxicities included transient rises in liver function tests. AGAT levels decreased by a mean of 53% in 9 patients but actually increased over baseline in 3 patients while on therapy. Based on these data, BCNU and STZ are not an effective combination for the therapy of advanced refractory melanoma, and pulmonary toxicity due to this combination appears to be increased compared with BCNU alone. STZ is not an effective modulator of AGAT activity when given on this schedule. New strategies designed to deplete AGAT activity using O6-benzylguanine or temozolomide should be explored with careful attention to the possibility that this approach may potentiate both the toxicity and efficacy of BCNU.
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PMID: 9816278, UI: 99035126
Department of Otolaryngology, Kanazawa University, Kanazawa, Ishikawa 920, Japan.
The glutathione S-transferases (GSTs) play an important role in the cell's defense against toxic substances. The GSTs are a family of enzymes produced by several genes that interact with distinct but overlapping substrates and that may play a role in resistance of tumor cells to several chemotherapeutic agents. We examined the correlation between expression of GSTs determined by immunohistochemistry and clinical response to platinum-based chemotherapy in 51 patients with head and neck cancer, who received a total of 56 courses of chemotherapy. The overall response rate for the 56 chemotherapy treatment courses was 48%. The overall response rate (complete response + partial response) for patients with low GST scores was 88% (21 of 24), whereas among the patients with high GST scores, the overall response rate was 19% (6 of 32; P = 0.001). Patients with a low GST score were 4.7 times more likely to respond to chemotherapy than patients with high GST scores. GST scores corresponded to response in 84% of cases. Among 23 patients treated with neoadjuvant chemotherapy, the overall response rate for patients with low GST scores was 100% (14 of 14), whereas among the patients with high GST scores, the overall response rate was 44% (4 of 9; P = 0.002). Among 33 patients treated with chemotherapy for relapsed disease, the overall response rate for patients with low GST scores was 70% (7 of 10), whereas among the patients with high GST scores, the overall response rate was 8.6% (2 of 23; P < 0.001). We conclude that GST expression correlates well with response to platinum-based chemotherapy in head and neck cancer.
PMID: 9816141, UI: 99035221
Cancer Research Unit, Medical School, University of Newcastle. Newcastle upon Tyne, NE2 1JX United Kingdom. Chicago, Illinois 60637, USA.
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PMID: 9815780, UI: 99111029
Departments of Investigational Therapeutics, Urologic Oncology, Roswell Park Cancer Institute, Buffalo, New York 14263, USA.
Glutathione (GSH) levels were measured in 13 human tumor cell lines derived from carcinomas of the bladder, ovary, and colon and from melanoma and glioblastoma. High levels were found in four of five bladder cell lines. The average GSH concentration in the bladder cell lines was approximately 6-fold higher than in the non-bladder cell lines. Because this difference suggested the possibility of elevation of GSH in urothelial neoplasia, we measured GSH in bladder tumor tissue from patients with transitional cell carcinoma (TCC) of the bladder (Group I, n = 17). GSH was also measured in two types of control tissues: (a) nontumor bladder tissue from patients with TCC or a history of TCC of the bladder (Group II, n = 23); and (b) bladder tissue from patients without bladder cancer (Group III, n = 14). Thirteen sets of paired specimens of tumor and nontumor bladder tissue from the same patient were evaluated. The tissues were flash-frozen, and GSH was measured after histological assessment of the same samples. Free and total GSH (free + mixed disulfides) were measured by a high-performance liquid chromatography assay with fluorescence detection and expressed as nanomoles/mg protein. The mean free GSH (+/- SD) for groups I, II, and III was 32.0 +/-18.7, 17.3 +/- 11.4, and 9.3 +/- 4.0, respectively, and the mean total GSH was 45.9 +/- 32.5, 23.7 +/- 17.1, and 12.2 +/- 6.7. The respective differences between groups (I and II, I and III, and II and III) were statistically significant for both free and total GSH (Ps ranging from <0.0001 to </=0.05). Free and total GSH were higher in tumor than in nontumor tissue in 11 of 13 paired specimens (free, 29.5 +/- 20.4 versus 18.7 +/- 11.7, P = 0.017; total, 41.7 +/- 33.8 versus 24.9 +/- 18.4, P = 0.005). No correlation was found between GSH levels and the proportion of tumor cells in the tissue. Influence of smoking on GSH expression could not be assessed because 81% of the patients with TCC had a smoking history. Similarly, because only 11% had prior cytotoxic chemotherapy, the influence of prior cytotoxic exposure on GSH could not be assessed. The results indicate: (a) significantly higher levels of GSH in TCC compared to tumor-free bladder tissue; and (b) higher GSH levels in nontumor bladder tissue from patients with bladder cancer than from patients without TCC. The clinical implications of this work include the possibility that GSH may play a role in the resistance of bladder cancer to chemotherapy and may be associated with bladder carcinogenesis.
PMID: 9815751, UI: 99111000
McGill University Centre for Translational Research in Cancer, Lady Davis Research Institute, Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec, HST-1E2 Canada.
Glutathione S-transferase (GST) represents a multifunctional enzyme family consisting of four known cytosolic isoforms (alpha, mu, pi, and Phi) that detoxify a variety of xenobiotic chemicals and may confer resistance to both chemotherapeutic drugs and carcinogens in various experimental models. GST-pi has already been extensively studied in clinical specimens, including breast cancer. We studied the immuno-histochemical distribution and relative immunopositivity of GST-alpha and GST-mu, based on a grading system for immunointensity, in samples of 51 neoplastic and 46 normal breast samples and 12 lymph node metastases from patients treated with intensive chemotherapy and bone marrow transplant. In normal breast tissue, GST-alpha localized predominantly to the cytoplasm of scattered cells lining the luminal aspects of the ducts. Occasional cells showed both cytoplasmic and nuclear GST-alpha immunoreactivity. GST-mu was stained in myoepithelial cells preferentially as well as in occasional ductal cells (including apocrine epithelium), vascular smooth muscle, and plasma cells. GST-alpha and GST-mu were detected in 22 of 51 (43%) and 24 of 48 (50%) invasive cancers, respectively. In paired samples of normal and malignant tissue from the same patient, GST-alpha immunostaining in cancers was significantly less intense compared to that of normal breast tissue in 13 of 41 (32%) cases. No such trend was found for GST-mu in paired samples. Neither GST-alpha nor GST-mu immunopositivity in tumor or nonneoplastic breast was found to correlate with relapse-free or overall survival in this clinical context; however, the apparent decreased expression of GST-alpha in malignant versus normal breast epithelial cells could have important implications in breast carcinogenesis.
PMID: 9815734, UI: 99110983
Section of Molecular Therapeutics, Department of Experimental Pediatrics, Division of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, 77030, USA.
The glutathione S-transferase (GST)-pi gene is overexpressed in many human cancers and preneoplastic lesions and is associated with failure of cancer chemotherapy and poor patient survival. Although GST-pi overexpression in tumors of the central nervous system has been observed, the prognostic and/or clinical relevance of this overexpression has, to date, not been investigated. In this study, we analyzed the level of GST-pi expression and its subcellular localization in 61 primary gliomas and correlated the results with tumor histology, patient age, and patient survival. We observed a strong positive correlation between the level of GST-pi expression and tumor grade and between the presence of GST-pi in glioma cell nuclei and patient age. Univariate and multivariate Cox regression analyses and Kaplan-Meier curves showed the level of GST-pi expression and its nuclear localization to be inversely correlated with patient survival. Relative risk for death of patients with high versus low tumor GST-pi expression was 3.2 (P = 0.0069) by univariate analysis and 2.6 (P = 0.036) by multivariate analysis. The relative risk of death associated with the presence of nuclear GST-pi in glioma cells was 3.9 (P = 0.0001) by univariate analysis and 4.4 (P < 0.0001) by multivariate analysis. These data indicate that high GST-pi expression in tumor cells and the presence of the GST-pi protein in tumor cell nuclei are associated with clinically more aggressive gliomas and are strong predictors of poor patient survival.
PMID: 9815622, UI: 99111180
Department of Pharmacology, University of Minnesota Medical School, Minneapolis, Minnesota 55455, USA. slade001@maroon.tc.umn.edu
Molecular determinants of cellular sensitivity to cyclophosphamide, long the mainstay of chemotherapeutic regimens used to treat metastatic breast cancer, include class 1 and class 3 aldehyde dehydrogenases (ALDH-1 and ALDH-3, respectively), which catalyze the detoxification of this agent. Thus, interindividual variation in the activity of either of these enzymes in breast cancers could contribute to the wide variation in clinical responses that are obtained when such regimens are used to treat these malignancies. Consistent with this notion, ALDH-1 levels in primary and metastatic breast malignancies were found to range from 1-276 and 8-160 mIU/g tissue, respectively, and those of ALDH-3 range from 1-242 and 6-97 mIU/g tissue, respectively. ALDH-1 and ALDH-3 levels in normal breast tissue predicted the levels of these enzymes in primary and metastatic breast malignancies present in the same individuals. Confirming and extending the observations of others, levels of glutathione, a molecular determinant of cellular sensitivity to various DNA cross-linking agents including cyclophosphamide, and of DT-diaphorase, glutathione S-transferases, and cytochrome P450 1A1, each of which is known to catalyze the detoxification/toxification of one or more anticancer agents (although not of cyclophosphamide), also varied widely in primary and metastatic breast malignancies. Given the wide range of ALDH-1, ALDH-3, and glutathione levels that were observed in malignant breast tissues, measurement of their levels in normal breast tissue and/or primary breast malignancies prior to the initiation of chemotherapy is likely to be of value in predicting the therapeutic potential, or lack thereof, of cyclophosphamide in the treatment of metastatic breast cancer, thus providing a rational basis for the design of individualized therapeutic regimens when treating this disease.
PMID: 9815579, UI: 99111137
Antibiotics Laboratory, The Institute of Physical and Chemical Research (RIKEN), Saitama, Japan.
A novel anticancer drug, cytotrienin A, isolated from Streptomyces sp., induces apoptosis (or programmed cell death) in human promyelocytic leukemia HL-60 cells within 4 h. To elucidate the mechanism of this process, we performed an in-gel kinase assay using myelin basic protein (MBP) as a substrate and found the activation of kinase with an apparent molecular mass of 36 kDa (p36 MBP kinase). The dose of cytotrienin A required to activate p36 MBP kinase was consistent with that required to induce apoptotic DNA fragmentation in HL-60 cells. This p36 MBP kinase was activated with kinetics distinct from the activation of JNK (c-Jun N-terminal kinase)/stress-activated protein kinase and p38 MAPK (mitogen-activated protein kinase). Importantly, the p36 MBP kinase was immunologically different from MAPK superfamily molecules such as ERK1, JNK isoforms, and p38 MAPK. In addition, the p36 MBP kinase activation and apoptotic DNA fragmentation were inhibited by antioxidants such as N-acetylcysteine and reduced-form glutathione. The p36 MBP kinase activation was also observed during hydrogen peroxide (H2O2) and okadaic acid-induced apoptosis. Although a specific inhibitor of caspase-3-like proteases (Ac-DEVD-CHO) or a specific inhibitor of caspase-1-like proteases (Ac-YVAD-CHO) did not block the cytotrienin A-, H2O2-, or okadaic acid-induced apoptosis, a broad specificity inhibitor of caspases (Z-Asp-CH2-DCB) strongly inhibited the apoptosis of HL-60 cells. Surprisingly, Z-Asp-CH2-DCB inhibited the activation of p36 MBP kinase induced by cytotrienin A or H2O2, but did not inhibit the activation of JNK/stress-activated protein kinase and p38 MAPK. Taken together, these results indicate that p36 MBP kinase activation is downstream of the activation of Z-Asp-CH2-DCB-sensitive caspases, and reactive oxygen species could be included in the apoptotic events. Moreover, according to the Western blotting using the antibodies against MST1/Krs2 or MST2/Krs1, it is suggested that the p36 MBP kinase is an active proteolytic product of MST1/Krs2 and MST2/Krs1, which are originally cloned by virtue of its homology to the budding yeast Ste20 kinase. Thus, the p36 MBP kinase might be a common component of the diverse signaling pathways leading to apoptosis, and controlling this p36 MBP kinase pathway might be a novel strategy for cancer chemotherapy.
PMID: 9809995, UI: 99025867
Department of Hematology/Oncology, Azienda Ospedaliera S. Salvatore, Pesaro, Italy.
BACKGROUND: Inactivation of the p53 gene has been reported to be associated with resistance to chemotherapy. The authors evaluated the significance of p53 status to the clinical outcomes of patients with locally advanced, unresectable gastric carcinoma (LAGC) who received chemotherapy. METHODS: Thirty chemotherapy-naive patients with LAGC received weekly administration of cisplatin 40 mg/m2, epi-doxorubicin 35 mg/m2, 5-fluorouracil 500 mg/m2, 6S-leucovorin 250 mg/m2, and glutathione 1500 mg/m2. After eight administrations of these agents, patients were assessed for response. Biopsy specimens of primary tumors were analyzed for p53 status using monoclonal antibody Bp53-12. RESULTS: Characteristics of patients were as follows: The median age was 66 years (range, 44-70 years); 18 were males and 12 were females. Eastern Cooperative Oncology Group performance status was 0 for 14 patients and 1 for 16. Histology was intestinal for 13 patients; for 17, it was diffuse. The site of the primary tumor was the cardia in 8 patients, the body of the stomach in 13, and the antrum in 9. The response rate (assessed with CT scan and endoscopy) for patients with p53 negative tumors was significantly higher than for those with overexpression of p53 (71% vs. 12%, P=0.004). CONCLUSIONS: p53 status analyzed before chemotherapy seems to be associated with response to treatment in patients with LAGC. This may provide a useful guide to selecting neoadjuvant chemotherapy for these patients.
PMID: 9806649, UI: 99021486
Department of Obstetrics and Gynaecology, North Staffordshire Hospital, Stoke-on-Trent, England.
Epithelial ovarian cancer is generally associated with a poor outcome, although the mechanisms that determine survival and progression-free interval (PFI) are unclear. Data from ovarian tumors showing associations between (a) null genotypes at the glutathione S-transferase GSTM1 and GSTT1 loci and expression of p53 protein and (b) outcome and expression of p53 suggest that polymorphism at these loci is a factor determining outcome. Accordingly, we have studied the association between the GSTM1 null and GSTT1 null genotypes and survival and PFI in 148 women with epithelial ovarian cancer. Although we did not find an association between individual genotypes and outcome, women with both GSTM1 null and GSTT1 null genotypes demonstrated poorer survival (P = 0.001) and reduced PFI (P = 0.003). Thus, no cases with both these genotypes survived past 42 months postdiagnosis. In contrast, 43% of the women without this combination survived beyond this time. Because response to chemotherapy is a major factor determining outcome in ovarian cancer, we also examined the data for associations between the glutathione S-transferase genotypes and response to such treatment. Thus, in 78 patients treated with chemotherapy, the combination of GSTM1 null and GSTT1 null was associated with unresponsiveness to primary chemotherapy (P = 0.004); none of the eight patients with both these genotypes responded, compared with 38 of 70 (54%) of patients with other genotype combinations. The effect of the combination of genotypes on survival and PFI was lost in a multivariate model that included response to chemotherapy as a confounding factor. This suggests that the combination of GSTM1 null/GSTT1 null is associated with outcome because of its influence on response to chemotherapy. These preliminary findings may provide a basis for the selection of patients for treatment with chemotherapeutic agents.
PMID: 9796976, UI: 99011000
Department of Neurology, University of Tubingen, Medical School, Germany.
Dexamethasone (DEX)-mediated inhibition of drug-induced, but not CD95 ligand-induced, apoptosis in malignant glioma cells correlates with wild-type p53 status. Here, we examined mechanisms underlying DEX-mediated protection from apoptosis. DEX did not induce p53 expression in two p53 wild-type cell lines (U87MG, LN-229) and did not alter drug-induced p53 accumulation. Forced expression of temperature-sensitive p53val135 in mutant conformation failed to prevent accumulation of endogenous wild-type p53 but acted in a transdominant negative manner to inhibit p53-mediated, camptothecin-induced p21WAF1/CIP1 expression. p53val135-transfected cells retained responsiveness to DEX at restrictive temperature, suggesting that p53 activity is not required for cytoprotection. Forced expression of wild-type p53val135 abrogated the protective effect of DEX, suggesting redundant cytoprotective effects of DEX and p53. Indeed, DEX induced moderate accumulation of p21WAF1/CIP1 in U87MG, LN-229 and p53 mutant LN-18 cells, but not in p53 mutant LN-308 or T98G cells. LN-18 is also the p53 mutant cell line with the best cytoprotective response to DEX. p21WAF1/CIP1 accumulation occurred in the absence of changes in p21WAF1/CIP1 mRNA expression. Wild-type p53 was not required for this DEX effect since DEX induced p21WAF1/CIP1 accumulation in p53val135-transfected LN-229 cells, too. DEX failed to induce p21WAF1/CIP1 expression or cytoprotection in untransformed rat astrocytes. The same lack of modulation of p21WAF1/CIP1 expression and drug toxicity was observed in p21(+/+), p21(+/-) and p21(-/-) human colon carcinoma cells. Paradoxically, while only p21(+/+) and p21(+/-) mouse embryonic fibroblasts showed enhance p21WAF1/CIP1 levels after exposure to DEX, only p21(-/-) fibroblasts were protected from drug toxicity by DEX. The present study links DEX-mediated protection from cancer chemotherapy to a p53-independent pathway of regulating p21WAF1/CIP1 expression in glioma cells but this effect appears to cell type-specific.
PMID: 9794234, UI: 99008336
Department of Gynecology and Obstetrics, Department of Radiology, Faculty of Medicine, Kyoto University, Sakyo-ku, Kyoto, 606, Japan. konishi@kuhp.kyoto-u.ac.jp
OBJECTIVE: To identify the clinicopathological and chemoresistant factors predicting the response to neoadjuvant chemotherapy and the patient prognosis in high-risk cervical carcinomas. METHODS: We retrospectively reviewed 47 patients with locally advanced or bulky cervical carcinoma treated with two courses of intraarterial infusion of cisplatin, doxorubicin, mitomycin C, and 5-fluorouracil (5-FU), followed by radical hysterectomy at our hospital between 1988 and 1995. Expressions of the chemoresistance-related proteins, such as P-glycoprotein, glutathione S-transferase pi (GST-pi), and proliferating cell nuclear antigen (PCNA) in the tumor cells, were examined by immunohistochemistry using pretreatment biopsy specimens. These results were compared with the chemotherapeutic response, which was evaluated by magnetic resonance imaging (MRI) and histopathology. Outcome of the patients was also studied. RESULTS: Chemotherapeutic effect of either complete (CR) or partial (PR) response on MRI was obtained in 36 of the 47 (86%) patients. Poor response to chemotherapy was significantly correlated with P-glycoprotein expression (P < 0.005) and low PCNA labeling (P < 0. 05), but not GST-pi expression in the tumor cells. Independent prognostic factors for patient survival were parametrial involvement and lymph node metastasis. Neither the expression of GST-pi nor PCNA was correlated with the patient survival. CONCLUSION: Assessment of the expression of P-glycoprotein and PCNA is potentially useful for the prediction of tumor response to neoadjuvant chemotherapy for cervical carcinomas. Copyright 1998 Academic Press.
PMID: 9790789, UI: 99009291
Department of Experimental Oncology, Hollings Cancer Center, Medical University of South Carolina, Charleston 29425, USA.
PURPOSE: Evidence suggests that viral proteins such as simian virus large T-antigen (SV40 TAg) play a role in the response of cancer cells to chemotherapeutic agents. In this study, we investigated whether SV40 TAg-immortalized human mesothelial cells express drug resistance-related proteins and display resistance to chemotherapy, and whether SV40 TAg transformation affects apoptosis. METHODS: We determined the mRNA and protein levels of the multidrug resistance-associated protein (MRP), gamma-glutamylcysteine synthetase heavy subunit (gamma-GCSh), and P-glycoprotein (product of the MDR1 gene) by RT-PCR and Western blotting, respectively, in normal human mesothelial (NHM) cell and SV40 TAg-transformed human mesothelial (Met-5A) cells. The effect of increasing concentrations of doxorubicin (DOX) on these cells was investigated using an MTT cytotoxicity assay, and the glutathione (GSH) content was measured spectrophotometrically. DOX accumulation in these cells was measured by treating the cells with [14C]DOX followed by scintillation counting. Cytoplasmic bNA fragmentation due to apoptosis following DOX treatment of the cells was quantitated by ELISA. RESULTS: We showed that the MRP and gamma-GCSh genes, but not MDR1, are coordinately overexpressed in Met-5A cells compared with NHM cells. Expression of MRP protein as detected by an anti-MRP antibody correlated with increased GSH levels and decreased accumulation of [14C]DOX in Met-5A cells compared with NHM cells. However, Met-5A cells were twofold more sensitive to DOX than NHM cells. In addition, quantitative measurement of apoptosis when cells were treated with 0.05 and 0.5 microM DOX revealed that drug-induced apoptotic cell death was increased about 1.4- and 3.0-fold, respectively, in Met-5A cells compared with NHM cells. CONCLUSIONS: These results suggest that increased levels of apoptosis might help overcome the DOX resistance effects of MRP/gamma-GCSh overexpression in SV40 TAg-transformed Met-5A cells.
PMID: 9788569, UI: 99002618
Department of Pharmacology, Chemotherapy and Medical Toxicology E. Trabucchi, University of Milan, Milano, Italy.
It is well known that the dicarboximide fungicides, vinclozolin and iprodione, induce lipid peroxidation by means of oxygen activation in fungi, but their action on mammalian cells is not yet clear. We therefore investigated the effect of 1- and 24-h treatments with vinclozolin at concentrations of 25, 50, 100 microg/ml and iprodione at concentration of 62.5, 125, 250 microg/ml on malonaldehyde and free radical production and on reduced glutathione levels in the human HepG2 hepatoma cell line. The concentrations were chosen on the basis of neutral red cytotoxicity assays. One-hour treatment with the different concentrations of either vinclozolin or iprodione increased both malonaldehyde and free radical content, and decreased reduced glutathione levels, whereas 24-h treatment decreased malonaldehyde content and free radical production, and increased reduced glutathione concentration. These results suggest that the mammalian cells respond to the initial oxidative damage caused by the two dicarboximide fungicides by means of a characteristic adaptative phenomenon within 24 h. This hypothesis is supported by the antagonized effects caused by treatment with the two dicarboximide fungicides and buthionine sulfoximine 0.5 mM, a specific and irreversible inhibitor of reduced glutathione synthesis. The data confirm that the two dicarboximide fungicides maintain their specific action in mammalian cells, although this action is masked by adaptation.
PMID: 9772096, UI: 98443094
Department of Haematology, University Hospital of Wales, Cardiff, UK.
Hepatic veno-occlusive disease (VOD) of the liver is a common complication following high-dose cytotoxic therapy for bone marrow transplantation (BMT). The major pathological changes are seen in centrilobular (zone 3) hepatocytes and adjacent endothelium. Glutathione (GSH) becomes depleted following chemotherapy and experimental evidence suggests reduced levels predispose to centrilobular hepatocyte and endothelial cell injury. Animal studies have shown that glutamine infusions can maintain GSH levels and protect against free radical injury. We have prospectively studied the effect of glutamine supplementation during BMT. Thirty-four patients undergoing BMT were randomised to receive either glycl-L-glutamine (n = 18) or an isonitrogenous mixture of non-essential amino acids (n = 16). Glutamine was shown to significantly preserve protein C (days +4 and +7, P < 0.05) and albumin levels (days 0 and +4, P < 0.02). Markers of thrombin and plasmin generation (thrombin-antithrombin, prothrombin fragment F1+2 and plasmin-antiplasmin levels) were not significantly changed between the two groups. These findings suggest that glutamine preserves hepatic function but does not alter thrombin or plasmin generation during BMT. Previous studies have shown reductions in protein C, albumin, factor X and factor VII levels post BMT. Falling protein C levels have been shown to be predictive of severe VOD. These data suggest a role for glutamine in the protection of hepatic function following BMT.
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PMID: 9720743, UI: 98385697
Department of Toxicology, Faculty of Pharmacy, Ankara University, Tandogan-Ankara, Turkey.
The levels of reduced glutathione (GSH) and lipid peroxidation (LP) of breast tumor and surrounding tumor free (normal) tissues of 39 breast cancer female patients with infiltrating ductal carcinoma and the relationship between these two parameters were investigated. Large interindividual variations in the levels of GSH and LP were found in both tumor and normal tissues. The mean GSH levels of tumors were significantly higher than those of normal tissues. This tendency did not change with the stage and grade (excluding grade 1) of the malignancy, menopausal status and chemotherapy treatment. No correlation was found between GSH level and stage or grade of malignancy (p > 0.05). However, although more than half of the tumor samples (23/39, 59%) had higher LP levels than their corresponding normal tissues, no significant difference was noted between the mean LP levels of tumor and normal tissues. This tendency did not change with the stage and grade of the malignancy, and menopausal status and chemotherapy treatment. No relationship was observed between the LP level and stage or grade of malignancy (p > 0.05). Overall, no association existed between the levels of GSH and LP in tumors (p > 0.05). These results reveal that the GSH, but not LP, could be a marker of breast malignancy and that the increase in GSH level is not sufficient to lower the LP level in human breast tumors.
PMID: 9717527, UI: 98383262
Department of Biological Sciences, Rutgers University, Newark, NJ 07102, USA.
Human ovarian tumors (derived from A2780 cells), growing as subcutaneous xenografts in immunodeficient mice, develop melphalan-resistant cells after a single treatment of the tumor-bearing animal with the drug [Caffrey, Zhang and Frenkel, submitted for publication]. Treatment of the animals with selenite by i.p. injection prevented the development of primary resistance to melphalan as well as cross-resistance to cisplatin. Selenite treatment also prevented the melphalan-induced increase in the cellular level of glutathione. In contrast, selenite administered s.c. or in drinking water had relatively little effect on the development of resistance. The results in this animal model suggest that selenite may be clinically useful in preventing the development of drug resistance during chemotherapy of cancer.
PMID: 9713502, UI: 98379124
Laboratoires de Genetique Moleculaire et Hormonologie, CHU de Pontchaillou, Rennes, France.
In medullary carcinoma of the thyroid (MTC), multidrug resistance (MDR) remains the major obstacle to effective chemotherapy. In this work MDR was investigated in TT cells, a human MTC cell line. We studied the effect of an efficient MDR agent (SDZ PSC 833) on doxorubicin (DOX)-induced cytotoxicity in TT cells cultured in monolayers. The toxicity was evaluated with four tests: MTT test, lacticode-hydrogenase and glutathione assays, and neutral red uptake. PSC 833 (3 microM) partially reversed the resistance to DOX in vitro after a 48-hour coincubation, followed by a 24 hour-post incubation. Under these conditions, PSC 833 was not toxic at the concentration used. Our results suggest that PSC 833 has the potential to reverse the MDR phenotype in MTC cells.
PMID: 9713490, UI: 98379112
Division of Medical Oncology, S. Salvatore Hospital, Pesaro, Italy.
Local extension prevents curative resection in more than two-thirds of gastric cancer patients. Unfortunately, resectability is one of the main prognostic factors in these patients, and survival is longer when tumours are completely removed. Preoperative chemotherapy is an attractive concept for obtaining curative resection. Thirty-two locally advanced unresectable gastric cancer patients were enrolled in five Italian Group for the Study of Digestive Tract Cancer (GISCAD) centres. For 16 patients, surgical unresectability was based on computerized tomography scan evaluation of tumour size (four patients) and invasion of adjacent structures (12 patients), whereas in another 16 patients locally advanced disease was confirmed by laparotomy. They received weekly administration of cisplatin 40 mg m(-2), 5-fluorouracil 500 mg m(-2), epidoxorubicin 35 mg m(-2), 6S-stereoisomer of leucovorin 250 mg m(-2) and glutathione 1.5 g m(-2). From the day after to the day before each chemotherapy administration, filgrastim was administered by subcutaneous injection at a dose of 5 microg kg(-1). One cycle of therapy consisted of eight weekly treatments. Fifteen of 32 patients (47%) responded to chemotherapy, whereas 13 (41 %) had stable disease and four (12%) progressed on therapy. Of the 15 responding patients, 13 were completely resected after chemotherapy and two of them had a complete pathological response. Two clinically responding patients were found unresectable at operation because of peritoneal seeding. At a median follow-up from the start of treatment of 24 months (range 11-39 months), 10 of 13 resected patients are alive and eight are relapse free. Three patients died after 11, 12, and 14 months respectively. Toxicity was acceptable: side-effects consisted mainly of grade II National Cancer Institute common toxicity criteria (NCICTC) leucopenia and thrombocytopenia in ten patients. Neither treatment-related death nor surgical complications in patients undergoing surgery were observed. This weekly intensive regimen enabled resection in half of previously inoperable tumours with a moderate toxicity. It can be offered to patients with locally advanced unresectable gastric cancer to obtain curative resection.
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PMID: 9703289, UI: 98366849
Department of Pharmacology, Pomeranian Academy of Medicine, Szczecin, Poland.
A clinical study was undertaken to evaluate the influence of a preparation containing selenium and vitamins with antioxidant properties (Protecton Zellaktiv from Smith Kline Naturarznei-Germany) on: (a) concentration of Se in serum and hair, (b) activity of glutathione peroxidase (GSH-Px), and (c) concentration of malondialdehyde (MDA) in serum, before and during supplementation. Women undergoing chemotherapy for ovarian cancer received selenium during three months at a daily dose of 200 micrograms. The results were compared with controls not receiving selenium supplementation. Administration of selenium significantly increased the serum and hair concentrations of selenium in the study group. After three months of supplementation the activity of GSH-Px was significantly higher in the study group. After one month of supplementation a difference in the concentration of MDA between the study and control groups was found. On the basis of the present results the administration of selenium in patients with ovarian cancer undergoing multi-drug chemotherapy is recommended.
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PMID: 9699224, UI: 98364380
Department of Medicine, University of Louisville, School of Medicine, KY 40202, USA.
Cardiac oxidative injury is a major limiting factor for clinical application of Adriamycin (ADR) in cancer chemotherapy. ADR depresses some antioxidant systems, thereby further enhancing the cardiotoxicity. Previous studies have shown that ADR inhibits the overall synthesis of DNA, RNA, and protein. It was presumed that the depressed antioxidant activity resulted from the inhibited gene expression. However, there were no experimental data to demonstrate the relationship between the change in antioxidant activities and that in their gene expression. Therefore, the present study was undertaken to examine the effects of ADR on the activities and mRNA abundances of antioxidants in mouse heart. FVB mice (7 weeks old) were treated with ADR (15 mg/kg) by a single i.p. injection. Four days after the treatment, cardiac antioxidant activities and mRNA abundances were measured. The results showed that ADR increased the levels of mRNAs for Cu,Zn-superoxide dismutase (Cu,Zn-SOD), catalase, glutathione peroxidase (GSHpx), and gamma-glutamylcysteine synthetase (gamma-GCS). On the other hand, ADR increased the activities of catalase and gamma-GCS, and slightly decreased total glutathione concentrations in the heart. Cu,Zn-superoxide dismutase, Mn-superoxide dismutase, and glutathione peroxidase activities were not changed significantly. In addition, ADR increased both mRNA and protein levels of metallothionein in the heart. The data demonstrate that up-regulation of antioxidant gene expression occurred in response to ADR in the mouse heart, although the antioxidant activities were not all increased.
PMID: 9698092, UI: 98361558
Biochemistry Department, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
Acrolein is a highly reactive and cytotoxic by-product released during activation of oxazaphosphorine (OAP) anticancer alkylating agents. Previously, we demonstrated that transfected human aldehyde dehydrogenase (ALDH, EC 1.2.1.3) isozymes (class 1 or 3) protect V79/SD1 cells from mafosfamide (MAF) cytotoxicity, but protection from 4-hydroperoxy-cyclophosphamide (4-hpCPA) was weaker. Acrolein, an ALDH inhibitor, may be detoxified by conjugation with the nucleophilic thiol 2-mercaptoethanesulfonate (MESNA), which is released from MAF but not from 4-hpCPA. We examined the effect of acrolein or acrolein/thiol conjugates on ALDH activity in vitro. We found that both ALDH isozymes were inhibited by acrolein, with IC50 values of 35 and 144 microM for ALDH-1 or ALDH-3, respectively. Both isozymes were partially protected by NAD+ cofactor, being at least five-fold more sensitive to acrolein if added before cofactor. In contrast, thiol conjugates of acrolein did not inhibit ALDH-3 activity, but were substrates only for ALDH-1. Further, acrolein was shown to be oxidized by ALDH-3, but not by ALDH-1. The effect of acrolein on ALDH-mediated resistance to OAP agents in intact cells was also examined. In control cells (without ALDH expression), acrolein and 4-hpCPA rapidly depleted intracellular GSH levels, whereas the effect of MAF was much less. Depletion of GSH by preincubation of V79/SD1 cells with a low concentration of acrolein (2 microM) before MAF exposure caused a two-fold reduction in ALDH-mediated resistance. Conversely, protection from 4-hpCPA cytotoxicity was enhanced by the addition of thiols (GSH, 2-mercaptoethanesulfonate, or N-acetylcysteine) during the drug exposure. These results suggest 1) that thiol content is an important determinant of the OAP resistance conferred by ALDH isoenzymes; and 2) a new mechanism whereby thiol modulation could increase the therapeutic index of OAP chemotherapy.
PMID: 9698086, UI: 98361552
[Article in Hungarian]
Semmelweis OTE II., Belklinika, Budapest.
Some human malignant tumours respond poorly to initial chemotherapy, indicating that they possess intrinsic resistance. On the other hand, in a significant portion of tumours after early promising results of therapy, the patients relapse, metastases appear, and acquired resistance to chemotherapy develops. The broad spectrum-resistance against chemotherapy is called multidrug resistance (MDR), and due to its clinical significance, studying of proteins responsible for multidrug resistance has become one of the most active research areas in biomedicine. There are several molecular mechanisms responsible for multidrug resistance. A group of filogenetically conservative plasmamembrane proteins actively extrudes different toxic compounds, xenobiotics, and also cytotoxic drugs from drug-resistant cells by using the energy of ATP. The clinically and biochemically most thoroughly characterized member of these proteins is the P-glycoprotein, which pumps hydrophobic drugs of natural origin and different chemical structure out of the cells. The recently cloned multidrug resistance associated protein (MRP) has also a broad substrate specificity, thus resembling P-glycoprotein. However, besides hydrophobic compounds, organic anions, glucuronide and glutathione conjugates are also excellent substrates of the MRP. The basic and clinically relevant properties of proteins causing multidrug resistance and the state of the art of current diagnostic approaches are summarized in this literature review. The different malignancies are characterized from the point of view of their multidrug resistance and recent clinical and biochemical data concerning therapeutic approaches for reversal of multidrug resistance are also presented.
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PMID: 9679612, UI: 98344555
Department of Cell Biology, School of Medicine, University of Virginia, Charlottesville 22908, USA.
gamma-Glutamyl transpeptidase (GGT) is found throughout the plant and animal kingdoms. It is a cell surface glycoprotein that cleaves gamma-glutamyl amide bonds. The most abundant physiologic substrates for the enzyme are glutathione and glutathione-conjugated compounds. GGT initiates the cleavage of extracellular glutathione into its constituent amino acids which can then be transported into the cell. It also catalyzes the initial step in the conversion of glutathione-conjugated compounds to mercapturic acids. GGT is expressed at high levels in many human tumors and in many carcinogen-induced tumors in animals. These observations have lead an increased focus on the role of the enzyme in the development and treatment of tumors. This chapter begins with an overview of the structure and function of GGT in normal tissues. A summary of its expression in neoplastic tissues and the ways in which GGT effects the response of tumors to chemotherapy follows. The chapter concludes with a discussion of strategies for using GGT to activate and target chemotherapy drugs to tumors as a means of improving treatment for common human malignancies.
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PMID: 9679564, UI: 98344507
Fourth Department of Internal Medicine, Sapporo Medical University School of Medicine, Japan.
In order to directly prove the involvement of GST-pi in drug resistance, it's antisense gene was transduced into human colorectal cancer cell line which has been shown to express high level of GST-pi and the sensitivity of this cell line to anticancer drugs were assessed. The transfectant showed higher sensitivity to adriamycin (3.3-fold), Cisplatnum (2.3-fold), Melphalan (2.2-fold), Etoposode (2.2-fold) than the parental cell, while the sensitivity to vincristine, mitomicin C, 5-fluorouracil was unchanged by transfection. When the transfectant and parental cells were innoculated in nude mice and treated with adriamycin, a significant suppression of tumor growth was observed with the transfectant as compared to the parental cell. On the basis of this observation, we then transduced sense GST-pi gene into human bone marrow stem cells (CD34+ cells) to protect them from toxicity of anticancer drug. The gene transduced CD34+ cells formed more CFU-GM than nontransduced CD34+ cell in the presence of adriamycin (30 ng/ml). Thus, the autotransplantation of GST-pi gene transduced cell into cancer patients to protect the bone marrow from subsequent highdose chemotherapy is considered to be a new strategy for cancer gene therapy.
PMID: 9679563, UI: 98344506
Department of Experimental Medicine, McGill University, Montreal, QC, Canada.
Notwithstanding ongoing progress in anticancer therapeutics development, the persistent problem remains to selectively target tumors while sparing normal tissues. This is confounding largely because the differences between normal and tumor cells are often subtle and part of a gradient, where a gene product may be more or less expressed in tumor compared with the host normal tissue, but seldom expressed (or turned off) in tumors. The role of glutathione (GSH) and related enzymes in cellular resistance to xenobiotics, including chemotherapy is well established. This study is among those attempting to modulate GSH to therapeutic advantage. The authors briefly describe the experience with the gamma-glutamylcysteine synthetase inhibitor buthionine sulfoximine, and then in greater detail outline recent evidence for a potentially more selective approach using the cysteine prodrug L-2-oxothiazolidine-4-carboxylate. This has led to a detailed study of the activating enzyme 5-oxo-L-prolinase, including enzymatic and immunocharacterization, as well as in vitro study of the effect of its modulators on anticancer drug toxicity. Using high affinity antibodies the authors have generated interesting information on the distribution of this enzyme in tumor versus normal human tissues. Finally, the authors have been studying the potential for modulating gap junctions as a part of anti-cancer therapeutics, since they transport GSH between cells and are generally deficient in tumor cells. Preliminary studies suggest that gap junction induction may dramatically deplete GSH concentration in tumor cells and sensitize them to a variety of treatments.
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PMID: 9679560, UI: 98344503
Terrapin Technologies, San Francisco, CA 94080, USA.
The use of cytotoxic chemotherapy for cancer therapy has been very successful in the treatment and often cure of patients with particular neoplasms, such as testicular carcinomas and some lymphomas. In addition, the use of adjuvant chemotherapy in patients whose primary tumor has been surgically removed contributes significantly to cure rates in some of the more common malignancies such as breast carcinoma and colon cancer. Nonetheless, for most patients with metastatic malignancies, current antineoplastic drugs provide only brief remissions with few or no long term cures. In addition, the side effects of therapy lead to substantial morbidity in nearly all patients. Insights derived from model system studies on two glutathione based lead compounds, TER286 and TER199, suggest new clinical strategies and raise interesting basic research questions regarding the cell biology foundations of cancer chemotherapy.
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PMID: 9679557, UI: 98344500
Department of Otolaryngology Head and Neck Surgery and Pathology, Georgetown University, Washington, DC, USA.
We examined the correlation between response to platinum-based chemotherapy and expression of glutathione S-transferase (GST), gamma-GGT (both by immunohistochemistry) and gamma-GCS (by in situ hybridization) in 51 patients with head and neck cancer, who received a total of 56 courses of chemotherapy. The overall response rate for the 56 chemotherapy treatment courses was 48%. The overall response rate (CR, PR) for patients with low GST scores was 88% (21 of 24), while among the patients with high GST scores, the overall response rate was 19% (6 of 32, P = 0.001). Patients with a low GST score were 4.7 times more likely to respond to chemotherapy than patients with high GST scores. GST scores corresponded to response in 84% of cases. Among 33 patients treated with chemotherapy for relapsed disease, the overall response rate for patients with low GST score was 70% (7 of 10), while among the patients with high GST scores, the overall response rate was 8.7% (2 of 23), P < 0.001). In contrast, both gamma-GCS and gamma-GGT showed a range of expression in these samples, but there was no significant correlation with treatment response. We conclude that GST expression correlates well with response to platinum based chemotherapy in head and neck cancer.
PMID: 9679554, UI: 98344497
Section of Experimental Oncology, Ospedale S. Salvatore, Pesaro, Italy.
AIMS AND BACKGROUND: The study was performed to assess the feasibility and activity of an intensive chemotherapeutic regimen as adjuvant treatment for patients with resected gastric cancer at high risk of recurrence (pT(2)N(1-2); pT(3-4)N(any) M0). PATIENTS AND METHODS: Starting 21 to 28 days after potentially curative surgery for primary gastric cancer, 25 patients received 8 weekly cycles of cisplatin 40 mg/m2, 5-fluorouracil 500 mg/m2, epidoxorubicin 35 mg/m2, 6S-stereoisomer of leucovorin at a dose of 250 mg/m2, and glutathione at a dose of 1.5 g/m2. From the day after to the day before each cycle of chemotherapy, filgrastim was administered by subcutaneous injection at a dose of 5 microg/kg. RESULTS: After a median follow-up of 33 months, 80% of the patients were alive and disease-free. Five patients had relapsed: three in the liver, one in the peritoneum and one in the lymph nodes. Toxicity was mild: five patients experienced WHO grade III toxicity (three leukopenia, two thrombocytopenia); no toxic deaths occurred. CONCLUSION: Intensive weekly chemotherapy is a feasible postoperative treatment option for patients with resected gastric cancer at high risk of relapse. These data, together with recent results in advanced disease, make this approach of interest for the development of new programs of adjuvant therapy in this setting.
Publication Types:
PMID: 9678619, UI: 98341759
Department of Obstetrics and Gynecology, Tottori University School of Medicine, Yonago, Japan.
Cellular detoxification, such as that mediated by the glutathione (GSH) system, is involved in the metabolism of various cytotoxic agents. Little is known, however, about the clinical relevance of cellular detoxification in chemoresistance. To elucidate the relevance of the GSH system to the resistance to chemotherapy observed in patients with ovarian cancer, we assayed the expression of mRNA encoded by the multidrug resistance-associated protein (MRP) and gamma-glutamyl cysteine synthetase (gamma-GCS) genes, as well as the level of GSH protein in 32 patients with epithelial ovarian cancer after chemotherapy. Tumors of 14 of the 32 patients responded to chemotherapy, whereas 18 did not. The levels of MRP and gamma-GCS transcripts in tumors from nonresponders were each about 2-fold higher than in responders. In contrast, the level of GSH did not differ between the two groups. We observed coordinated expression of gamma-GCS mRNA and GSH protein levels, and between gamma-GCS and MRP in nonresponders, but not in responders. Expression of MRP-encoded mRNA did not correlate to GSH level, however, in either group. These results suggest that gamma-GCS may up-regulate GSH and MRP expression in tumors unresponsive to chemotherapeutic agents, and that the GSH system may be involved in the mechanism of chemoresistance in ovarian cancer.
PMID: 9676849, UI: 98339471
Department of Biochemistry, Medical College of Wisconsin, Milwaukee, Wisconsin, 53226, USA.
gamma-Glutamylcysteine synthetase (gamma-GCS) catalyzes the ATP-dependent ligation of L-glutamate and L-cysteine to form L-gamma-glutamyl-L-cysteine; this is the first and rate-limiting step in glutathione biosynthesis. Inhibitors of gamma-GCS such as buthionine sulfoximine are widely used as tools for elucidating glutathione metabolism in vivo and as pharmacological agents for reversing glutathione-based resistance to chemotherapy and radiation therapy in certain cancers. Although gamma-GCS is readily isolated from rat kidneys, future drug design efforts are better based on structure-activity relationships established with the human enzyme. We report here the coexpression in Escherichia coli BL21(DE3) of the human gamma-GCS catalytic (heavy) subunit and regulatory (light) subunit using pET-3d and pET-9d vectors, respectively. Intracellular assembly of the holoenzyme occurred without difficulty, and levels of expression were acceptable (approximately 32 mg holoenzyme/100 g cells). Recombinant human gamma-GCS was purified to homogeneity in an overall yield of 45% by ammonium sulfate fractionation followed by sequential chromatography on Q-Sepharose ion-exchange, Superdex 200 gel filtration and ATP-affinity resins. Trace amounts of E. coli gamma-GCS were removed by immunoaffinity chromatography. The specific activity of the isolated enzyme was >1500 units/mg, comparable to the best preparations from rat kidney. The Km values for L-glutamate, L-cysteine, L-gamma-aminobutyrate (an L-cysteine surrogate), and ATP are 1.8, 0.1, 1.3, and 0.4 mM, respectively. Recombinant human gamma-GCS, like native rat gamma-GCS, is feedback inhibited by glutathione and is potently inhibited by buthionine sulfoximine and cystamine. Copyright 1998 Academic Press.
PMID: 9675072, UI: 98342274
Department of Pathology and Biology of Diseases, Graduate School of Medicine, Kyoto University, Japan.
An iron chelate, ferric nitrilotriacetate (Fe-NTA), induces renal proximal tubular damage, a consequence of iron-catalysed Fenton-like reactions, that finally leads to a high incidence of renal cell carcinoma (RCC) in rodents. Glutathione S-transferase (GST) is a family of enzymes that play an important role in detoxification of hydrophobic and electrophilic molecules, and has been associated with putative preneoplastic foci of rat hepatocarcinogenesis and chemotherapy-resistance of human cancers. Our previous study revealed an induction of pi-class glutathione S-transferase (Yp) mRNA in the kidney 3 h after administration of Fe-NTA. In the present study, expression of GST isozymes were further investigated in the Fe-NTA-induced RCCs of rats which are characterized by (1) high incidence of metastasis and invasion, (2) high incidence of tumour-associated mortality, and (3) possible involvement of reactive oxygen species in carcinogenesis. In the Fe-NTA-induced RCCs, the levels of alpha-class GST (Ya) mRNA and proteins were markedly decreased with no apparent change in the copy number of the gene. In contrast, GST-Yp mRNA and proteins were significantly increased in the RCCs while the total GST enzymatic activity was decreased. Immunohistochemical analysis revealed intense staining of GST-Yp not only in the primary RCCs and its metastatic sites, but also in their non-tumorous part of proximal tubules. The contrastive expression of GST isozymes in this renal carcinogenesis model suggests an alteration of its transcription mechanisms and warrants further investigation of this particular detoxifying enzyme from the viewpoint of reactive oxygen species-induced carcinogenesis.
PMID: 9635880, UI: 98297803
Department of Surgical Oncology, University of Illinois at Chicago, 60612, USA.
We hypothesized that unexplained increases in nucleoside triphosphates (NTP) observed by 31P magnetic resonance spectroscopy (MRS) after treatment of tumours by DNA-damaging agents were related to chemotherapy-induced up-regulation of the bcl-2 gene and DNA damage prevention and repair processes. To test this hypothesis, we treated HT-29 cells with 10(-4) M nitrogen mustard (HN2) and performed sequential perchloric acid extractions in replicate over 0-18 h. By reference to an internal standard (methylene diphosphonic acid), absolute changes in 31P-detectable high-energy phosphates in these extracts were determined and correlated with changes in bcl-2 protein levels, cell viability, cell cycle, apoptosis and total cellular glutathione (GSH) (an important defence against DNA damage from alkylating agents). After HN2 administration, bcl-2 protein levels in the HT-29 cell line rose at 2 h. Cell viability declined to 25% within 18 h, but apoptosis measured using fluorescence techniques remained in the 1-4% range. Increased cell division was noted at 4 h. Two high-energy interconvertible phosphates, NTP (P < or = 0.006) and phosphocreatine (PCr) (P < or = 0.0002), increased at 2 h concurrently with increased levels of bcl-2 protein and glutathione. This study demonstrates that bcl-2 and glutathione are up-regulated by HN2 and links this to a previously unexplained 31P MRS phenomenon: increased NTP after chemotherapy.
PMID: 9652754, UI: 98314862
[Article in Chinese]
Tongji Hospital of Tongji Medical University, Wuhan.
OBJECTIVE: To study the relationship between the expression of glutathione S-transferase-pi (GST-pi) in operative specimens and chemoresistance in patients with ovarian cancer. METHODS: The expression of GST-pi in 87 epithelial ovarian cancer tissues and 30 normal ovarian epithelial tissues was determined with labelled streptavidin biotin method (LSAB). All the patients had not received chemotherapy before operation. We used Chi-Square and Cox-Mantel test to analyze the relativity between the expression of GST-pi and clinical pathological data, chemotherapeutic response, prognosis in patients with ovarian cancer. RESULTS: (1) 59 (67.8%) of 87 ovarian cancer tissue were demonstrated to be positive expression with GST-pi, but all 30 normal ovarian epithelial tissue were negative. (2) There was no direct correlation between the expression of GST-pi and clinical pathological data. (3) 43 (43/59) of GST-pi positive cases were chemoresistant, while only 3 (3/28) of GST-pi negative ones were chemoresistant. (4) The difference in the chemotherapeutic response between the two groups was obviously significant (P < 0.005). The survival period of the patients with GST-pi positive expression was also obviously shorter than that of those with GST-pi negative expression (P = 0.004). CONCLUSION: These results strongly suggest that GST-pi expression in epithelial ovarian cancer tissues is closely related to chemoresistance clinically and it may be served as a useful marker to predict the prognosis of patients.
PMID: 9639737, UI: 98303864
Department of Clinical Cytology and Pathology, Malmo General Hospital, Lund University, Sweden.
Malignant mesotheliomas show a highly variable aggressiveness, but it is difficult to predict the outcome in the individual case at the time of diagnosis. Glutathione S-transferases are detoxification enzymes that have been correlated with the prognosis in some tumours. We have therefore assessed the value of GST expression as a prognostic parameter in mesotheliomas. The reactivities to GST-pi, -alpha and -mu antibodies were studied in histological sections from altogether 88 cases. Most of them showed distinct cytoplasmic reactivity to one or more of the GST antibodies tested. This high prevalence is in good agreement with the low responsiveness of mesotheliomas to chemotherapy. However, there was no prognostic value in detecting GST immunoreactivity, and it gave no information of value for distinguishing between neoplastic and reactive mesothelium.
PMID: 9637272, UI: 98299342
Department of Neurosurgery, Nagasaki University School of Medicine, Japan.
Glioblastoma is one of the most malignant of all neoplasms, and often shows resistance to chemotherapy and radiation therapy. Ionizing radiation activates transcriptional factors, such as nuclear factor kappa-B (NF-kappa B). Previously we found that glutathione (GSH) synthesis is induced by cytokines mediated by NF-kappa B (Urata et al. J. Biol. Chem., 1996). Here, we present direct evidence that NF-kappa B activated by ionizing radiation induces the expression of gamma-glutamylcysteine synthetase (gamma-GCS), the rate limiting enzyme of GSH synthesis, using T98G human glioblastoma cells. T98G cells have approximately 14-times the level of intracellular GSH of NB9 cells, radiation-sensitive neuroblastoma cells. In T98G cells, 30-Gy of ionizing radiation was required for the activation of NF-kappa B on an electrophoretic mobility shift assay and the induction of gamma-GCS mRNA on Northern blots and a nuclear run-on assay. However, when T98G cells were treated with buthionine sulfoximine, 3-Gy of ionizing radiation stimulated the DNA-binding activity of NF-kappa B and the expression of gamma-GCS. We constructed chimeric genes containing various regions of gamma-GCS promoter gene and the coding region for Luciferase. T98G cells transiently transfected with a plasmid containing the gamma-GCS promoter-luciferase construct showed increased luciferase activity when treated with ionizing radiation. The luciferase activity stimulated by ionizing radiation was found in the gamma-GCS promoter containing the NF-kappa B binding site, whereas not in that containing its mutated site. These results suggest that GSH synthesis is upregulated by ionizing radiation mediated by NF-kappa B and a high concentration of GSH in T98G cells causes downregulation of the NF-kappa B-DNA binding activity in response to ionizing radiation. The irresponsiveness of the intracellular signal transduction cascade to irradiation may be a factor in the resistance of T98G cells to radiation therapy.
PMID: 9626582, UI: 98289884
Department of Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan.
We investigated the utility of examining biological markers to predict chemoresponse and survival. The subjects consisted of 39 unresectable gastric cancer patients treated with a combination of 5-fluorouracil and cis-platinum. The expression of p53, bcl-2, thymidylate synthase (TS), glutathione S-transferase pi (GST-pi), and vascular endothelial growth factor (VEGF) in the formalin-fixed biopsy samples of primary tumors before chemotherapy was examined immunohistochemically. The positive rate for VEGF, bcl-2, TS, p53, and GST-pi was 51, 10, 46, 38, and 69%, respectively. VEGF-positive cases showed a higher response rate than did negative cases (11 of 20 versus 2 of 19 cases; P = 0.0057). The cases that were negative for p53, TS, bcl-2, and GST-pi were more likely to respond to chemotherapy than the cases that were positive for these markers. The 10 cases having 4 or 5 favorable phenotypes (VEGF positive, p53 negative, bcl-2 negative, TS negative, and GST-pi negative) survived longer than the remaining 29 cases (P = 0.0069). Multivariate analysis revealed that the number of favorable phenotypes (> or = 4 versus < or = 3) had a greater impact on survival than performance status (0 versus 1 or 2), age (> 60 years versus < or = 60 years), macroscopic type (scirrhous versus nonscirrhous), histological type (intestinal versus diffuse), or tumor extent (locally advanced versus metastatic). Immunohistochemical examination of biological markers in biopsy samples may be useful in predicting the clinical outcome of unresectable gastric cancer patients treated with 5-fluorouracil and cis-platinum.
Publication Types:
PMID: 9626464, UI: 98289766
Department of Oncology, Haukeland University Hospital, Bergen, Norway.
PURPOSE: Elevated cellular glutathione has been associated with resistance to cancer chemotherapy. Treatment with the aromatase inhibitor aminoglutethimide increases the concentration of gamma-glutamyl transpeptidase (gamma-GT) in breast cancer patients. This enzyme catalyzes the first step in the degradation of extracellular glutathione, and the products formed may act as precursors for intracellular glutathione synthesis. METHODS: Plasma and red-blood-cell glutathione levels were determined in 26 patients suffering from advanced breast cancer before and during treatment with aminoglutethimide (n = 16) or the steroidal aromatase inhibitors exemestane or formestane (n = 10) and in 5 cancer patients receiving dexamethasone. RESULTS: Pretreatment values for gamma-GT in the total patient group (n = 31) correlated negatively with the level of reduced (P < 0.0001), oxidized (P < 0.025), and total glutathione (P < 0.005) in plasma. Plasma gamma-GT levels increased by a mean value of 249% during treatment with aminoglutethimide. The concentration of reduced and oxidized glutathione in plasma decreased to 42.7% (P < 0.0005) and 80.6% (P < 0.005) of their pretreatment levels, respectively. This fall in reduced plasma glutathione correlated negatively with the increase in gamma-GT (P < 0.001). The ratio of oxidized to reduced glutathione increased by 88.9% (P < 0.005), and this increase correlated positively with the increase in gamma-GT (P < 0.005). Treatment with the steroidal aromatase inhibitors (exemestane and formestane) or dexamethasone did not influence the plasma thiol status. CONCLUSIONS: We conclude that aminoglutethimide influences plasma glutathione disposition by mechanisms not related to estrogen suppression or due to glucocorticoids given in concert.
PMID: 9619757, UI: 98281056
Department of Melanoma/Sarcoma, The University of Texas, M. D. Anderson Cancer Center, Houston 77030, USA.
The combination of cisplatin-based chemotherapy with interleukin-2 (IL-2) and interferon, referred to as biochemotherapy, has shown encouraging results in patients with advanced melanoma. Toxicity is high, however and no objective parameters exist to distinguish between patients who are likely to respond and those who are not. The purpose of this pilot study was to determine whether in vitro cisplatin-induced damage to the glutathione S-transferase-pi (GST-pi) gene in peripheral blood mononuclear cells (PBMCs) before therapy correlated with the histological response in melanoma patients with local-regional metastases who received concurrent biochemotherapy before definitive surgery. Before therapy, PBMCs from 16 patients were exposed to cisplatin at concentrations of 25, 50 or 100 microM for 3 h and the extent of damage to the GST-pi gene was quantitated by polymerase chain reaction (PCR). Patients were subsequently treated on a biochemotherapy regimen consisting of cisplatin 20 mg/m2 intravenously (i.v.) on days 1-4, vinblastine 1.5 mg/m2 i.v. on days 1-4, dacarbazine 800 mg/m2 i.v. on day 1, IL-2 9 MIU/m2 per day i.v. by continuous infusion on days 1-4 (total of 96 h), and interferon alpha2a 5 MU/m2 subcutaneously on days 1-5. The 16 patients were categorized into two groups: major responders (n = 7) and non-major responders (n = 9). Although we observed a wide interpatient variation, a statistically significant correlation existed between the histological response and the degree of DNA damage caused in the PBMCs at all three cisplatin concentrations tested (P = 0.024 for 25 microM; P = 0.036 for 50 microM; P = 0.007 for 100 microM). Our pilot study suggests that determination of in vitro cisplatin-induced DNA damage using a gene-specific PCR assay may be useful in predicting the histological response to biochemotherapy.
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PMID: 9610867, UI: 98272423
Department of Haematology, University Hospital of Wales, College of Medicine, Cardiff, UK.
Hepatic veno-occlusive disease (VOD) of the liver is a common complication following high-dose cytotoxic therapy for bone marrow transplantation (BMT). Liver injury is believed to occur following free radical damage to endothelial cells of the sinusoids and small hepatic veins. Glutathione the main antioxidant of the cytosol becomes depleted following chemotherapy. Animal studies have shown that glutamine infusions can maintain glutathione levels and protect against free radical injury. We present two cases of established VOD successfully treated with intravenous glutamine (as dipeptide) and oral vitamin E. Although both cases have possible confounding factors we believe that these give support to the notion that glutamine/vitamin E may have a role in the prophylaxis and treatment of VOD. Further formal trials are indicated.
PMID: 9603409, UI: 98264572
Institut Territorial de Recherches Medicales Louis Malarde, Papeete, Tahiti, French Polynesia.
The full-length cDNA sequence encoding Brugia malayi L3 paramyosin has been isolated by immunoscreening a cDNA library with a mouse antiserum raised against Wuchereria bancrofti L3 infective larvae. A recombinant truncated form of paramyosin was expressed as a glutathione S-transferase fusion protein and used to evaluate humoral responses of adults from a W. bancrofti-endemic area in French Polynesia according to their parasitological status. Immunoglobulin G4 (IgG4) preferentially bound to paramyosin in W. bancrofti-parasitized individuals, in contrast to unparasitized individuals, who harbored neither microfilaria nor Og4C3 adult worm circulating antigen. Reduction of the anti-paramyosin IgG4 titer following combined chemotherapy with diethylcarbamazine and ivermectin was significantly correlated with a reduction in the adult worm burden. This indicates that the presence of paramyosin-reactive IgG4 is associated with the presence of parasites and that reduction can be used as an immunological marker for W. bancrofti clearance.
PMID: 9596759, UI: 98261538
Department of Cancer Chemotherapy, Faculty of Medicine, Kagoshima University, Japan.
The mechanism for cisplatin resistance in cisplatin-resistant KCP-4 cells was studied. Although multidrug resistance-associated protein (MRP) was not detected in KCP-4 cells, the cells were more resistant to heavy metals than multidrug-resistant C-A120 cells that overexpressed MRP. KCP-4 cells expressed metallothionein, but it was scarcely involved in cisplatin resistance in these cells. KCP-4 cells did not express canalicular multispecific organic anion transporter (cMOAT). The glutathione (GSH) level was 4.7-fold higher in KCP-4 cells than in KB-3-1 cells. When the GSH level in KCP-4 cells was decreased by treating the cells with buthionine sulfoximine and nitrofurantoin, the accumulation of and sensitivity to cisplatin in the cells were increased. C-A120 cells were only 3.0-fold more resistant to cisplatin than KB-3-1 cells and this resistance was not affected by the increased glutathione level. The accumulation of platinum in C-A120 and KCP-4 cells was 68.5 and 20.4% of that in KB-3-1 cells, respectively, while the intracellular levels of antimony potassium tartrate in C-A120 and KCP-4 cells were 13.2 and 9.9% of that in KB-3-1 cells, respectively. The ATP-dependent efflux of antimony was enhanced in both C-A120 and KCP-4 cells. These results, taken together, suggest an efflux pump for heavy metals different from MRP and cMOAT is involved in cisplatin resistance in KCP-4 cells.
PMID: 9597004, UI: 98259292
Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas, USA. sawasthi@utmb.edu
Dinitrophenyl S-glutathione (DNP-SG) ATPase is a 38 kDa membrane protein expressed in erythrocytes and other tissues. Although stimulation of ATP hydrolysis catalyzed by DNP-SG ATPase has been demonstrated in the presence of several structurally unrelated amphiphilic ions, structural and functional properties of this protein have not been well-defined. In the present study, we have developed an improved protocol for the purification of DNP-SG ATPase and investigated its kinetic and substrate-binding properties. The purification procedure was based on highly specific elution of the 38 kDa protein from DNP-SG affinity resin in the presence of ATP. The protein could not be eluted using either ADP or adenosine-5'-[beta,gamma-methylene]triphosphate (methylene-ATP), a nonhydrolyzable analogue of ATP. Doxorubicin (DOX), a weakly basic anthracycline chemotherapy agent, was found to be the preferred activator for stimulation of ATP hydrolysis by the enzyme. ATP binding to the enzyme was demonstrated using 8-azido-ATP photoaffinity labeling and binding of trinitrophenyl (TNP)-ATP, a fluorescent analogue of ATP. The photoaffinity labeling of DNP-SG ATPase (38 kDa) was saturable with respect to 8-azido ATP (Kd = 2 microM), indicating that the enzyme was capable of specific and saturable binding to ATP. DNP-SG binding was evident from the purification procedure itself and was also demonstrable by quenching of tryptophan fluorescence. Results of quenching of tryptophan fluorescence as well as radioactive isotope-binding studies indicated that DOX was bound to the purified protein as well.
PMID: 9548754, UI: 98215648
McGill Center for Translational Research in Cancer, Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
5-Oxo-L-prolinase (5-OPase) is an enzyme of the gamma-glutamyl cycle involved in the synthesis and metabolism of glutathione (GSH), which is known to protect cells from the cytotoxic effects of chemotherapy and radiation. Previous studies on rats have shown that administration of the cysteine prodrug L-2-oxothiazolidine-4-carboxylate, a 5-oxo-L-proline analogue that is metabolized by 5-OPase, preferentially increases the GSH content of normal tissues while paradoxically decreasing it in the tumor and results in an enhanced in vivo tumor response to the anticancer drug melphalan. These observations initiated the present study of 5-OPase in experimental models and clinical specimens to investigate the potential role of this enzyme in the selective modulation of GSH in normal and tumor tissues. First, 5-OPase activity was measured in tissues of tumor-bearing rats, in the peripheral mononuclear cells of normal human subjects, and in surgically resected tumor and the adjacent normal tissues from patients. We found that the activity of 5-OPase in human kidney, liver, and lung is significantly lower than that found in rats. Second, we have raised a polyclonal IgG anti-5-OPase antibody by immunizing rabbits with purified 5-OPase from rat kidney. This antibody has very high affinity (shown by immunoprecipitation) and specificity (shown by Western blot) and cross-reacts with human 5-OPase (shown by Western blot and immunohistochemistry). It was then used to examine the distribution of 5-OPase in paired normal and neoplastic human specimens using Western blot and immunohistochemistry. Examination of paired normal and neoplastic tissues of stomach and lung revealed a significantly lower level of 5-OPase in tumor tissues than in the paired normal tissues. In colon tissues, there is no significant difference in 5-OPase level between the normal and tumor tissues. These findings could have implications for both carcinogenesis and therapy.
PMID: 9516961, UI: 98177605
Department of Surgery, Division of Urology, Taichung Veterans General Hospital, Taiwan, ROC.
We evaluated the possible correlation between intracellular glutathione (GSH) and drug sensitivity of urothelial cancer. Tissue GSH content of surgical specimens from 20 patients with urothelial cancer was assayed with high performance liquid chromatography (HPLC). GSH levels of cancer tissue (7.887 +/- 6.176 microM/mg protein) were significantly higher than GSH levels of normal mucosa (1.345 +/- 1.252 microM/mg). All patients having measurable lesions were then treated with methotrexate, epirubicin and cisplatin (MEC). These patients were classified into three groups according to clinical response criteria. GSH content in cancer tissue from four patients with complete response was 0.804 +/- 1.183 microM/mg protein. However, the cancer cells from patients with partial response and non-response contained a significantly higher level of GSH (6.295 +/- 2.459 (n = 8) and 12.955 +/- 6.141 microM/mg protein (n = 8), respectively). Intracellular glutathione content may play an important role in intrinsic resistance of urothelial cancer to MEC chemotherapy. It might be potentially used to predict drug sensitivity in urothelial cancer patients before starting chemotherapy.
PMID: 9570366, UI: 98230292
Departement de Pharmacotoxicologie et Pharmacogenetique (URA-147 CNRS), Institut Gustave-Roussy, Villejuif, France.
The purpose of this study was to find out whether the glutathione (GSH), in red blood cells could predict the response to neoadjuvant chemotherapy cisplatin/5-fluorouracil (CDDP/5-FU) in patients with head and neck squamous cell carcinoma (HNSCC). Three courses of induction chemotherapy with CDDP/5-FU were administered and followed by surgery and radiotherapy or radiotherapy alone, in 51 patients with HNSCC. GSH was measured by spectrophotometry in red blood cell before any treatment (Sample 1: S1), after each course of chemotherapy (S2, S3, S4). Our results showed that GSH was the same at diagnosis in patients with complete or partial response (OR) compared to those with stable or progressive disease (NR). With regard to evolution of the GSH during the 3 courses of CT a significant difference was found between courses (S2: 5.06 +/- 0.35 vs S4 = 3.61 +/- 0.4 mumol/g haemoglobin, p < 0.05). When we separated our patients into OR and NR, a significant difference was found over the 3 courses of chemotherapy for GSH content. Non responder patients showed decreased GSH content at the end of the treatment, (S2: 5 +/- 0.5 vs S4: 2.2 +/- 0.4 mumol/g haemoglobin, p < 0.05) while OR were stable. In conclusion, red blood cell GSH seems to have no early predictive value for chemoresponse to neoadjuvant chemotherapy CDDP/5-FU in HNSCC.
PMID: 9568091, UI: 98229511
First Department of Surgery, Kurume University, School of Medicine, Japan.
OBJECTIVE: The objective of this study was to determine whether oral glutamine supplements can protect lymphocyte and gut barrier function in patients with advanced esophageal cancer undergoing radiochemotherapy. SUMMARY BACKGROUND DATA: Glutamine supplements improved protein metabolism in tumor bearing rats who underwent chemotherapy and reduced the toxicity of chemotherapy through an enhancement of glutathione production in rats. METHODS: Thirteen patients with esophageal cancer were randomly placed in either a control or a glutamine group. Glutamine was administered orally (30 g/day) at the start of radiochemotherapy and for the subsequent 28 days. All patients underwent mediastinal irradiation and chemotherapy consisting of 5-fluorouracil and cisplatin. The lymphocyte count was determined, and blast formation was assessed after stimulation with phytohemagglutinin and concanavalin A. Gut barrier function was assessed by measuring the total amount of phenolsulfonphthalein excreted in the urine after the oral administration of phenolsulfonphthalein. RESULTS: Glutamine supplements prevented a reduction in the lymphocyte count (control: 567 +/- 96/mm3 vs. glutamine: 1007 +/- 151, p < 0.05), and blast formation of lymphocyte (phytohemagglutinin, control: 19478 +/- 2121 dpm vs. glutamine: 33860 +/- 1433, p < 0.01, concanavalin A, control: 19177 +/- 1897 dpm vs. glutamine: 29473 +/- 2302, p < 0.01), and amount of phenolsulfonphthalein excretion in the urine was greater with control than with glutamine group (control: 15.4 +/- 2.4% vs. glutamine: 7.4 +/- 1.2, p < 0.05) 7 days after the initiation of radiochemotherapy. CONCLUSIONS: Oral glutamine supplementation protects lymphocytes and attenuates gut permeability in patients with esophageal cancer during radiochemotherapy.
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PMID: 9563534, UI: 98222998
Department of Urology, Erasmus University Hospital, Rotterdam, The Netherlands.
Chemotherapy is the principal strategy to systemically challenge metastasized cancers of genitourinary origin. Unfortunately, the efficacy of chemotherapy is often hampered by multidrug resistance, the resistance to a variety of structurally and functionally distinct cytotoxic agents. Multidrug resistance can be either intrinsic or acquired, and can be caused by several mechanisms. The so-called classical multidrug resistance, mediated by the MDR1 gene product P-glycoprotein, has been held mainly responsible for inferring the multidrug resistance phenotype on urologic malignancies. However, several other multidrug resistance pathways have been identified. Multidrug resistance can be caused by the membrane-bound multidrug-resistance-associated protein, the detoxifying glutathione metabolism, the antiapoptotic protein BCL2, and changes in levels or activity of the topoisomerase enzymes. Strategies to overcome multidrug resistance of genitourinary tumors have arisen from the better understanding of the biologic and molecular mechanisms of multidrug resistance, and have been studied in experimental and clinical settings. However, attempts to modulate multidrug resistance in clinical renal cell, bladder, prostate, and testicular cancer have not been very rewarding so far, despite the optimism that had arisen from experimental data. Nevertheless, application of novel therapies to reverse multidrug resistance and to increase efficacy of chemotherapy for urologic cancers should be further pursued, within the setting of controlled clinical trials, to improve on current strategies.
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PMID: 9535594, UI: 98195272
Department of Neurosurgery, Nara Medical University, Kashihara, Japan.
To cast light on the mechanisms of drug-resistance, experimental brain tumors were immunohistochemically evaluated for expression of glutathione S-transferase (GST)-alpha, mu, pi, p-glycoprotein and apoptosis-related factors, such as bcl-2 and p53, as well as by the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labelling (TUNEL) method. Rat brain tumors induced by means of prenatal exposure to ethylnitrosourea (ENU) were treated with 1-(4-amino-2-methyl-5-pyrimidinyl)methyl-3-(2-chloroethyl)-3-nitrosourea hydrochloride (ACNU) and/or vincristine. Tumors more than 2 mm in size were considered to be drug resistant. The expression of GST-mu was strongly positive in ACNU-treated brain tumors, while p-glycoprotein was overexpressed in vincristine-treated brain tumors. Neither p53 nor bcl-2 expression directly correlated with apoptosis identified by TUNEL method, but tumors lacking apoptotic cells always demonstrated the expression of either GST-mu or p-glycoprotein. These results indicate that tumors resistant to chemotherapy might not be susceptible to induction of apoptosis, and therefore that mechanisms of drug resistance are related to programmed cell death in brain tumors.
PMID: 9525810, UI: 98184724
Laboratory of Virology, Regina Elena Institute for Cancer Research, Rome, Italy. venuti@crs.ifo.it
Antibody response to HPV16 E7 oncoprotein may represent a marker of cervical cancer. A HPV16 GST-E7 fusion protein was used in a Western Blot assay to analyse the HPV16 E7 antibody response in 30 patients before and after treatment for cervical carcinoma (stage IIB or IIIB). Patients were treated with three courses of cisplatin/bleomycin therapy followed by surgery, or with surgery alone. Thirteen out of 30 patients had serum antibodies to HPV16 E7 antigen. Three months after chemotherapy little or no change in antibody titre was detected. In contrast, after surgery, a significant decrease in antibody titre was observed in 9/10 patients. In two cases the titre declined to zero 3 and 9 months after treatment, respectively. These results confirm the usefulness of studying anti-HPV16 E7 antibody profile in cervical cancer patients and suggest that the serum response correlates with tumour burden.
PMID: 9515768, UI: 98175521
[Record supplied by publisher]
Concomitant Endometrial Hyperplasia in Patients with Endometrial Carcinoma Fatih Gucer, Olaf Reich, Karl Tamussino, Armin A. Bader, Doris Pieber, Wolfgang Scholl, Josef Haas, and Edgar Petru Decline in Incidence of Endometrial Cancer Following Increase in Prescriptions for Opposed Conjugated Estrogens in a Prepaid Health Plan Harry K. Ziel, William D. Finkle, and Sander Greenland Treatment for Fertility and Risk of Ovarian Tumors of Borderline Malignancy Fabio Parazzini, Eva Negri, Carlo La Vecchia, Simona Moroni, Anna Polatti, Francesca Chiaffarino, and Elena Ricci Immunohistochemical Expression of Thymidine Phosphorylase in Human Endometrial Cancer Ritsuto Fujiwaki, Kohkichi Hata, Kohji Iida, Mikio Koike, and Kohji Miyazaki Palliative Benefit of External-Beam Radiation in the Management of Platinum Refractory Epithelial Ovarian Carcinoma Daphna Gelblum, Borys Mychalczak, Lois Almadrones, David Spriggs, and Richard Barakat Virilizing Ovarian Tumor of Low Malignant Potential Associated with Antecedent Tamoxifen Use for Breast Cancer Daniel V. Surbek, Irene Hoesli, Joachim Torhorst, Alfonso C. Almendral, Athanassios Dellas, and Wolfgang Holzgreve Value of Glutathione S-Transferase pi and the Oncogene Products c-Jun, c-Fos, c-H-Ras, and c-Myc as a Prognostic Indicator in Endometrial Carcinomas Yoshihito Yokoyama, Morio Sagara, Shigemi Sato, and Yoshiharu Saito Prevalence, Risk Factors, and Accuracy of Cytologic