Current Medicinal Chemistry - Volume 19, Issue 12, 2012

Immune suppression induced by chemotherapeutic agents (chemotherapy, CT) and ionizing irradiation (radiotherapy, RT) has often been the cause for a contraindication to combine “classical” tumor therapies with immune therapy (IT). As a single treatment, IT achieved less success as expected. During the last years it has become more and more evident that besides a timely (CT and RT) and locally (RT) restricted immune suppression, a specific activation of the immune system against the therapy-modified tumor is achievable. In addition, IT has been shown to be more beneficial when combined with other therapies, since the immune systems seems not to be capable to deal with big tumor masses, but rather with small tumor burden, recurrent upcoming tumors and metastases. In this special issue about “Modulation of the immune system by ionizing irradiation and chemotherapeutic agents” attention is given to how CT and RT contribute to activation of innate and adaptive immune responses as well as to blocking of immune suppression. A special focus is set on modulation of the tumor microenvironment, especially on direct and indirect activation of natural killer (NK) and dendritic cells (DCs) against the tumor as well as on general immune modulating properties of RT and/or CT. Based on the array of subsumed preclinical data, concepts are presented how optimized combination schemes of “classical” tumor therapies with immune therapies could appear in the near future. The immune modulating properties of radiotherapy with ionizing irradiation became evident in the 19th century. Inflammation in joints was temporarily ameliorated after local RT with low doses. Dr. Rodel and colleagues summarise how endothelial cells, mononuclear and polymorphonuclear immune cells are influenced by low dose RT. The current knowledge suggests that most of the radiation-induced immune modulations display discontinuous dose dependencies, shared with “non-targeted“ effects. In many cases, doses in the range of 0.3-0.7 Gy are connected with the strongest anti-inflammatory action of low dose RT. The complexity of the interaction between ionizing radiation and the immune system arises therein, that a higher single dose of RT (2.0 Gy as representative standard single dose in anti-tumor therapy) does not lead to anti-inflammation but rather to specific immune activation under certain microenvironmental conditions....

During the last decade, a multitude of experimental evidence has accumulated showing that low-dose radiation therapy (single dose 0.5-1 Gy) functionally modulates a variety of inflammatory processes and cellular compounds including endothelial (EC), mononuclear (PBMC) and polymorphonuclear (PMN) cells, respectively. These modulations comprise a hampered leukocyte adhesion to EC, induction of apoptosis, a reduced activity of the inducible nitric oxide synthase, and a lowered oxidative burst in macrophages. Moreover, irradiation with a single dose between 0.5-0.7 Gy has been shown to induce the expression of X-chromosome linked inhibitor of apoptosis and transforming growth factor beta 1, to reduce the expression of E-selectin and L-selectin from EC and PBMC, and to hamper secretion of Interleukin-1, or chemokine CCL20 from macrophages and PMN. Notably, a common feature of most of these responses is that they display discontinuous or biphasic dose dependencies, shared with “non-targeted” effects of low-dose irradiation exposure like the bystander response and hyper-radiosensitivity. Thus, the purpose of the present review is to discuss recent developments in the understanding of low-dose irradiation immune modulating properties with special emphasis on discontinuous dose response relationships.

Although cancer progression is primarily driven by the expansion of tumor cells, the tumor microenvironment and anti-tumor immunity also play important roles. Herein, we consider how tumors can become established by escaping immune surveillance and also how cancer cells can be rendered visible to the immune system by standard therapies such as radiotherapy or chemotherapy, either alone or in combination with additional immune stimulators. Although local radiotherapy results in DNA damage (targeted effects), it is also capable of inducing immunogenic forms of tumor cell death which are associated with a release of immune activating danger signals (non-targeted effects), such as necrosis. Necrotic tumor cells may result from continued exposure to death stimuli and/or an impaired phosphatidylserine (PS) dependent clearance of the dying tumor cells. In such circumstances, mature dendritic cells take up tumor antigen and mediate the induction of adaptive and innate anti-tumor immunity. Locally-triggered, systemic immune activation can also lead to a spontaneous regression of tumors or metastases that are outside the radiation field - an effect which is termed abscopal. Preclinical studies have demonstrated that combining radiotherapy with immune stimulation can induce anti-tumor immunity. Given that it takes time for immunity to develop following exposure to immunogenic tumor cells, we propose practical combination therapies that should be considered as a basis for future research and clinical practice. It is essential that radiation oncologists become more aware of the importance of the immune system to the success of cancer therapy.

Together with surgery and chemotherapy, ionizing irradiation is one of the key therapeutic approaches to treat cancer. More than 50 percent of all cancer patients will receive radiotherapeutic intervention at some stage of their disease. The more precise instrumentation for delivery of radiotherapy and the emphasis on hypofractionation technologies have drastically improved loco-regional tumor control within the last decades. However, the appearance of distant metastases often requires additional systemic treatment modalities such as chemotherapy. High dose chemotherapy is generally considered as immunosuppressive and can cause severe adverse effects. Therefore, we want to elucidate the effects of ionizing irradiation on the immune system and provide immunological treatment strategies which are induced by the host's stress response. Similar to other stressors, ionizing irradiation is known to enhance the synthesis of a variety of immune-stimulatory and -modulating molecules such as heat shock proteins (HSP), high mobility group box 1 (HMGB1) and survivin. Herein, we focus on HSP that exhibit an unusual cell membrane localization and release mechanism in tumor cells. These tumor-specific characteristics render HSP as ideal targets for therapeutic interventions. Depending on their intra/membrane and extracellular localization HSP have the ability to protect tumor cells from stress-induced lethal damage by interfering with antiapoptotic pathways or to elicit anti-cancer immunity.

The crosstalk of natural killer (NK) and dendritic cells (DCs) plays an important role in the induction of the tumor-specific immune response against cancer. During the last decade, our advanced understanding of the immune system led to the development of new therapeutic strategies in the field of immunotherapy and cellular immunology. However, these immunotherapeutic concepts have not been as successful as initially expected because of their inability to counteract cancer-induced immunosuppressive pathways. Some of the major difficulties of effective cellular immunotherapy are the highly immunosuppressive factors induced by tumor cells themselves or by their microenvironment. Therefore, one major challenge in immunotherapy is the question: “How to enforce NK cell & DC action under immunosuppressive conditions?” This review focuses on the current knowledge on the tumor microenvironment, the crosstalk of NK cells and DCs, as well as their deregulation in the complex interplay with the immunosuppressive tumor microenvironment. We further discuss possible strategies to minimize the negative impact of the tumor microenvironment on the immune system.

In recent years, the effects of cancer chemotherapy and radiotherapy (CT/RT) regimens as they apply to the immune system have been explored. NK cells represent the main cytotoxic arm of the innate immune system, and their functionality is vital to establishing an effective anti tumor immune response. This review examines current CT/RT interventions in light of their effects on NK cell functionality. The effects of CT/RT on the expression of the various ligands for activating and inhibitory NK cell receptors are discussed. Expression of ligands for the activating NKG2D receptor is enhanced by cell stress; accordingly there are numerous reports of their higher expression in cells exposed to various CT/RT agents. In contrast, some agents have been reported to cause ligand shedding, which can serve to inhibit NK cell activity. Reported effects of CT/RT on tumor expression of ligands for the activating Natural Cytotoxicity Receptors, and of HLA class I ligands for NK cell inhibitory receptors are also noted. Additionally, we describe reports concerning the direct effects of CT/RT on NK cell function. Many treatments adversely affect NK cell function directly, but observations made through in vitro systems may differ from those obtained utilizing clinical samples. The effects of CT/RT on both direct NK cell cytotoxicity and on NK cell-mediated Antibody Dependent Cellular Cytotoxicity are explored. Taken together, CT/RT affects NK cell anti-tumor immunity from multiple angles. The interplay is complex, and future work is needed to achieve the optimal synergy between CT/RT and innate as well as adaptive immunity in the treatment of cancer.

Since 1948, when Farber et al. introduced aminopterin, the first chemotherapeutic agent, more than 100 such agents have come into use. Initially, antitumor chemotherapies were thought to produce only antiproliferative or cytotoxic effects on dividing tumor cells as it was often associated with the damage to healthy tissues and the development of resistant tumor clones. However, that view has been changing as a consequence of recent demonstrations that several antineoplastic drugs, even at low doses, have antiangiogenic and sometimes immunomodulating effects. In addition, new studies indicate that lowering the dose of conventional cytotoxic agents and combining chemotherapy with other modalities may not only decrease the toxicity of conventional chemotherapy, but also up-regulate the efficacy of different anticancer therapies. Giving chemotherapy in this manner has several potential advantages, including impediment of the onset of mutation-dependent mechanisms of acquired drug resistance and increase in the efficacy and durability of combinatorial therapeutic modalities. Certain “immunogenic” forms of cancer chemotherapy may cause indirect activation of immune cells due to the accessibility of tumor antigens and certain “danger” signals. Furthermore, new findings indicate that several chemotherapeutic agents can directly activate immune cells when used in ultra low noncytotoxic concentrations, the new phenomenon that was termed chemoimmunomodulation. The goal of this review is to analyze the immune modulating properties of antineoplastic chemotherapeutic agents and present new evidence of the immunostimulating potentials of several agents used in low and ultra low nontoxic doses. Therapeutic potentials of combined chemo-immunotherapeutic regimens have been extensively reviewed in a variety of recent publications and will not be discussed.

Dose-limiting toxicity to healthy tissues is among the major hurdles in anticancer treatment along with intrinsic or acquired multi-drug resistance. Development of small molecule inhibitors (SMI) specific for antiapoptotic Bcl-2 proteins is a novel approach in a way that these antagonists are aimed to interfere with specific protein-protein interactions unlike conventional chemo-/radiotherapies. SMIs of antiapoptotic Bcl-2 proteins are assumed to compete with proapoptotic Bcl-2s to occupy BH3 docking grooves on the surfaces of antiapoptotic family members. Instead of directly initiating cell death, these inhibitors are intended to decrease apoptotic threshold in tumor cells that were already primed to death. In this regard, antiapoptotic Bcl-2 protein SMIs have the advantage of lower normal tissue toxicity relative to conventional anticancer therapies that interfere with general mechanisms including DNA synthesis, mitosis and tyrosine kinase activity. Besides, Bcl-2 antagonists were shown to potentiate efficacies of established drugs in several hematological malignancies and solid tumors which render them promising candidates for combination anticancer therapy. Utilizing these SMIs in such a way may prove to decrease the patient drug load by diminishing the required chemo-/radiotherapy dose. This review summarizes and compares BH3 mimetics on the basis of specificity, mode of action and efficacy, as well as providing remarks on their therapeutical potential and routes of development in near future.

Src family of protein tyrosine kinases (SFKs) plays key roles in the regulation of signal transductions in cellular processes. However, hyper-activated SFKs lead to uncontrolled cell proliferation and cancers. Src-targeted compounds were developed to block the cell proliferation signal transductions for cancer therapy. Src kinase domain inhibitors were designed, synthesized and evaluated as anticancer agents, while the patents applied at the same time. Great progress has been made in the Src kinase inhibitor area. Herein, some predominant patents about Src kinase inhibitors of the recent years are reviewed.

The blood-brain barrier (BBB) is a protective fence between the central nervous system and the systemic circulation, and is essential for maintaining the normal homeostasis of the central nervous system. BBB breakdown is instigated in many neurological disorders such as Alzheimer's disease and multiple sclerosis. Recent literature has advanced the knowledge on the physiology and pathophysiology of BBB breakdown, including the attribution of detrimental inducers and signalling transduction cascades. Natural products, such as flavonoids, phenolic compounds, terpenes, alkaloids, lipids and phthalides have been reported to attenuate many neurological diseases by modulating the signalling transduction cascades associated with BBB breakdown. Understanding the activities of these natural products through the molecular mechanisms associated with BBB breakdown will offer considerable scope in the discovery and development of novel agents for preventing BBB breakdown and thus, the progression of neurological disorders.

New-generation antidepressants are a heterogeneous class of drugs used in the treatment of depression and related disorders. This review deals with the first new-generation antidepressant class to enter the pharmaceutical market, i.e., selective serotonin reuptake inhibitors (SSRIs), which are still the most prescribed and widely used ones. Their common characteristics are the comparable clinical efficacy, good tolerability and relative safety in comparison to “first generation antidepressants”, i.e. classic tricyclic antidepressants and monoamine oxidase inhibitors. This class of drugs includes fluoxetine, citalopram, paroxetine, sertraline, fluvoxamine and, since 2011, vilazodone. In this review, the main pharmacodynamic and pharmacokinetic properties of the six commercially available SSRIs are described, focusing on side and toxic effects, chemical-clinical correlations, interactions with other drugs, the role of therapeutic drug monitoring (TDM) and related bioanalytical methodologies.

Radiation exposure leads to an increased risk for cancer and, possibly, additional ill-defined non-cancer risk, including atherosclerotic, cardiovascular, cerebro-vascular and neurodegenerative effects. Studies of brain irradiation in animals and humans provide evidence of apoptosis, neuro-inflammation, loss of oligo-dendrocytes precursors and myelin sheaths, and irreversible damage to the neural stem compartment with long-term impairment of adult neurogenesis. With the present paper we aim to present a comprehensive review on brain effects of radiation exposure, with a special focus on its impact on cognitive processes and psychological functions, as well as on their possible role in the pathophysiology of different psychiatric disorders.

Despite advances in cancer treatment, a large number of patients eventually develop metastatic disease that is generally incurable. Systemic chemotherapy remains the standard treatment for these patients. Several chemotherapeutic combinations have proven effective in the management of cancer. Paradoxically, although the purpose of polychemotherapy is to improve the prognosis and prolong the survival of patients, it often carries considerable toxicity that causes substantial adverse symptoms. For this reason, a major goal of cancer research is to improve the effectiveness of these cytotoxic agents and reduce their adverse effects. Gene transfer has been proposed as a new strategy to enhance the efficacy of anti-tumor drugs in the treatment of intractable or metastatic cancers. In fact, the association of gene therapy and drugs (combined therapy) has been reported to increase the anti-proliferative effect of classical treatments in lung, bladder, pancreatic, colorectal and breast cancers, among others. Various especially promising therapies have been proposed in this context, including the use of suicide genes, antisense oligonucleotides, ribozymes and RNA interference. In this chapter, we review recent progress in the development of novel anti-cancer strategies that associate cytotoxic agents with gene transfer to enhance their antitumor effect.

Angiogenesis plays a pivotal role in many pathological processes including chronic liver diseases. Various factors, such as renin-angiotensin-aldosterone system (RAAS), insulin resistance (IR), and reactive oxygen species (ROS) contribute reciprocally to promote angiogenesis. Blockade of RAAS by angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II (AngII) receptor blocker (ARB) markedly attenuates liver fibrosis and hepatocellular carcinoma (HCC) along with suppression of angiogenesis, IR, and ROS. Aldosterone (Ald), a downstream component of AngII, is also involved in these processes, and a selective Ald blocker (SAB) significantly suppressed the progression of chronic liver diseases. The IR status itself has shown to directly accelerate the progression of chronic liver diseases whereas inhibition of ROS by iron chelator suppressed it through augmentation and inhibition of neovascularization. The combination therapy of ACE-I/ARB/SAB with other clinically used agents, such as interferon, imatinib mesylate, vitamin K, iron chelator, and branched-chain amino acids (BCAA) exerted more potent inhibitory effects on the development of liver fibrosis and HCC than the treatment using a single agent alone. Collectively, the anti-angiogenic treatment targeting RAAS, IR, ROS with clinically available agents may become a new therapeutic strategy against the progression of chronic liver diseases.