BackgroundL-Leucovorin (l-LV; 5-formyltetrahydrofolate, folinic acid) is a precursor for 5,10-methylenetetrahydrofolate (5,10-CH2-THF), which is important for the potentiation of the antitumor activity of 5-fluorouracil (5FU). LV is also used to rescue antifolate toxicity. LV is commonly administered as a racemic mixture of its l-LV and d-LV stereoisomers. We compared dl-LV with l-LV and investigated whether d-LV would interfere with the activity of l-LV.MethodsUsing radioactive substrates, we characterized the transport properties of l-LV and d-LV, and compared the efficacy of l-LV with d-LV to potentiate 5FU-mediated thymidylate synthase (TS) inhibition. Using proliferation assays, we investigated their potential to protect cancer cells from cytotoxicity of the antifolates methotrexate, pemetrexed (Alimta), raltitrexed (Tomudex) and pralatrexate (Folotyn).Resultsl-LV displayed an 8-fold and 3.5-fold higher substrate affinity than d-LV for the reduced folate carrier (RFC/SLC19A1) and proton coupled folate transporter (PCFT/SLC46A1), respectively. In selected colon cancer cell lines, the greatest enhanced efficacy of 5FU was observed for l-LV (2-fold) followed by the racemic mixture, whereas d-LV was ineffective. The cytotoxicity of antifolates in lymphoma and various solid tumor cell lines could be protected very efficiently by l-LV but not by d-LV. This protective effect of l-LV was dependent on cellular RFC expression as corroborated in RFC/PCFT-knockout and RFC/PCFT-transfected cells. Assessment of TS activity in situ showed that TS inhibition by 5FU could be enhanced by l-LV and dl-LV and only partially by d-LV. However, protection from inhibition by various antifolates was solely achieved by l-LV and dl-LV.ConclusionIn general l-LV acts similar to the dl-LV formulations, however disparate effects were observed when d-LV and l-LV were used in combination, conceivably by d-LV affecting (anti)folate transport and intracellular metabolism.

Supplementary Data from Trifluorothymidine Resistance Is Associated with Decreased Thymidine Kinase and Equilibrative Nucleoside Transporter Expression or Increased Secretory Phospholipase A2

Supplementary Appendix and Figure 1 from Expression Microarray Analysis and Oligo Array Comparative Genomic Hybridization of Acquired Gemcitabine Resistance in Mouse Colon Reveals Selection for Chromosomal Aberrations

Background Expression of proton-coupled folate transporter (PCFT) is associated with survival of mesothelioma patients treated with pemetrexed, and is reduced by hypoxia, prompting studies to elucidate their correlation. Methods Modulation of glycolytic gene expression was evaluated by PCR arrays in tumour cells and primary cultures growing under hypoxia, in spheroids and after PCFT silencing. Inhibitors of lactate dehydrogenase (LDH-A) were tested in vitro and in vivo. LDH-A expression was determined in tissue microarrays of radically resected malignant pleural mesothelioma (MPM, N = 33) and diffuse peritoneal mesothelioma (DMPM, N = 56) patients. Results Overexpression of hypoxia marker CAIX was associated with low PCFT expression and decreased MPM cell growth inhibition by pemetrexed. Through integration of PCR arrays in hypoxic cells and spheroids and following PCFT silencing, we identified the upregulation of LDH-A, which correlated with shorter survival of MPM and DMPM patients. Novel LDH-A inhibitors enhanced spheroid disintegration and displayed synergistic effects with pemetrexed in MPM and gemcitabine in DMPM cells. Studies with bioluminescent hypoxic orthotopic and subcutaneous DMPM athymic-mice models revealed the marked antitumour activity of the LDH-A inhibitor NHI-Glc-2, alone or combined with gemcitabine. Conclusions This study provides novel insights into hypoxia/PCFT-dependent chemoresistance, unravelling the potential prognostic value of LDH-A, and demonstrating the preclinical activity of LDH-A inhibitors.

RX-3117 is a novel cytidine analog showing encouraging results in ongoing Phase 2a studies with gemcitabine-resistant pancreatic ductal adenocarcinoma and advanced urothelial bladder cancer. Cellular uptake of RX-3117 is mediated by the equilibrative nucleoside transporter 1 (hENT1). RX-3117 is activated by uridine-cytidine kinase-2 (UCK2) and is not a substrate for cytidine deaminase (CDA), and shows a good oral bioavailability. In an earlier study accumulation of RX-3117 nucleotides was associated with sensitivity to the drug. RX-3117 is incorporated into RNA and DNA and inhibits DNA methyltransferase 1 (DNMT1). RX-3117 is active against gemcitabine-resistant non-small cell lung cancer (NSCLC) cell lines. In this study we aimed to elucidate potential resistance mechanisms against RX-3117. For that purpose the NSCLC cell lines H460, A549 and SW1573 (including its gemcitabine resistant variant SW-G) were exposed to increasing concentrations of RX-3117. For A549 and SW1573 two variants were obtained: A549/RX1, A549/RX2, SW1573/RX1 and SW1573/RX2. Resistance varied from 10 (H460; SW-G) to >100-fold for the other cell lines. Resistance was stable except for H460 cells. Cross-resistance in the same range was observed for the cytidine analogs ethynyl-cytidine (ETC), cyclopentenylcytosine (CPEC) and aza-cytidine (aza-CR), which are all activated by UCK2; no cross-resistance was observed for gemcitabine and aza-deoxycytidine which are activated by deoxycytidine kinase. No change was observed in the expression of DNMT1, while expression of ribonucleotide reductase 1 was decreased. However, analysis of UCK2 at the enzyme activity level, protein and gene expression did not reveal a decrease in UCK2 while for ETC, aza-CR and CPEC resistance was reported to be mediated by a UCK2 deficiency. No change was found in the other activating enzymes UMP-kinase, CMP-kinase and NME1/NDKA. Despite this lack of change, accumulation of RX-3117 and RX-3117 nucleotides (mono-, di- and triphosphate) was 2-5-fold lower in the resistant cells after incubation with 10 or 100 μM RX-3117 for 4-24 hr. No evidence for accumulation of RX-3117 deoxynucleotides was found in both the parent and the resistant cell lines. Since no change in hENT1 was found, cell lines were further investigated by using RNA-seq, and western blotting focusing on nucleoside/nucleotide degradation enzymes. CDA was decreased in resistant cells, but the cytosolic pyrimidine nucleotidase NT5C3 was increased in the resistant cell lines as well as DCTPP1, which can degrade deoxynucleoside triphosphates. Moreover several DNA repair enzymes SAMHD1, MTH1 and TDP1 were increased. However, inhibition of MTH1 and DCTPP1 did not increase sensitivity to RX-3117. In conclusion, induction of resistance to the novel cytidine analog RX-3117 led to a decreased accumulation of RX-3117 ribonucleotides, which might be associated with an increased degradation.Citation Format: Godefridus J. Peters, Dzjemma Sarkisjan, Btissame El Hassouni, Richard J. Honeywell, Joris R. Julsing, Beatrice Balboni, Daniel J. De Klerk, Safet Zekanovic, Kees Smid, Elisa Giovannetti, Young B. Lee, Deog J. Kim. Unusual mechanism of resistance to the novel cytidine analog fluorocyclopentenylcytosine (RX-3117) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1267.

Many patients with Crohn’s disease (CD) and ulcerative colitis (UC) who have a high 6-methylmercaptopurine/6-thioguanine (6-MMP/6-TGN) ratio receive allopurinol 100 mg in addition to thiopurines to optimize metabolite concentrations. However, some patients do not tolerate allopurinol at this dosage. The aim of this study was to determine the intra-patient effect of reducing the allopurinol dosage from 100 to 50 mg, in terms of metabolite concentrations, enzyme activities, efficacy, and tolerability. A prospective non-inferiority one-way crossover study was performed. CD and UC patients with stable disease using a thiopurine and allopurinol 100 mg were switched to 50 mg for 1 month. Primary outcomes were thiopurine metabolite concentrations. Secondary outcomes were enzyme activities of xanthine oxidase, thiopurine methyltransferase and hypoxanthine-guanine phosphoribosyltransferase, disease activity, and tolerability. Twenty-two patients were included. Treatment with allopurinol 50 mg compared with 100 mg resulted in a significant decrease in mean 6-TGN levels (761 to 625 pmol/8 × 108 RBC; p = 0.005) and a significant increase in mean 6-MMP levels (451 to 665 pmol/8 × 108 RBC; p = 0.01). However, the mean metabolite concentrations were still therapeutic. Enzyme activities, disease activity scores, and patient experiences did not alter significantly. Generally, UC patients were more positive about their improved treatment than CD patients. Combination therapy with 50 mg allopurinol led to a decrease of 6-TGN levels compared with 100 mg allopurinol. Disease activity, side effects, and patient experience, however, were similar between allopurinol 100 and 50 mg. UC patients seem to benefit and prefer lower doses whereas the contrary is seen in CD patients. EudraCT trial registry - number 2016-001638-84

Abstract RX-3117 (Fluorocyclopentenylcytosine; FCPEC) is an orally bioavailable novel cytidine analog which is currently being evaluated in a Phase I clinical study. Downregulation of DNA methyltransferase 1 (DNMT1) by RX-3117 was shown in various cell lines with different histological backgrounds. In the present study we determined the effect of RX-3117 on DNMT1 at the DNA, RNA, protein and enzyme activity, and reactivation of suppressed target genes, including p16INK4A, methylguanine methyltransferase (MGMT) and the proton coupled folate transporter (PCFT). In the moderately sensitive non-small cell lung cancer (NSCLC) cell lines such as A549 and SW1573, 5-50 μM RX-3117 downregulated DNMT1 protein expression by 5-20% after 24 hr exposure and >90% after 48 hr. DNMT1 mRNA was not affected after 24 hr exposure but was affected moderately after 48 hr. In the sensitive ovarian cancer cell line A2780, protein down regulation was already observed after 24 hr at 1 μM RX-3117. DNMT1 activity was inhibited by 1 μM RX-3117 by 32% which was similar to the percent inhibition with 5 μM of the reference compound 5-aza-2’-deoxycytidine (DAC, 31%). In A549 cells 5 μM RX-3117 decreased overall methylation of DNA (detected by an antibody against 5-methylcytosine) by 25% after 48 hr exposure, while 5 μM DAC only inhibited 9%. For several genes known to be affected by methylation, we evaluated their protein expression and activity. In A549 and SW1573 cells a 24 hr exposure to 5 μM RX-3117 increased the expression of the cell cycle protein p16INK4A and of the DNA repair enzyme MGMT. For PCFT we evaluated its functional activity in CCRF-CEM leukemic cells which have a highly methylated PCFT promoter and in CEM-MTX cells which are deficient for the reduced folate carrier (RFC). PCFT is a specific folate transporter responsible for uptake of folic acid and the folate analogs methotrexate (MTX) and pemetrexed. Incubation of both CEM and CEM-MTX cells with either 29.6 μM RX-3117 or DAC as a positive control markedly increased PCFT mediated transport of MTX. This was more pronounced in CEM-MTX cells, 10-11-fold increase for both RX-3117 and DAC, compared to a 4-fold increase in CEM cells. In conclusion, the down-regulation of DNMT1 by RX-3117 was accompanied by a decrease in DNMT1 protein expression and enzyme activity, resulting in up-regulation of proteins of MGMT, PCFT, and the tumor suppressor gene p16INK4A. These data underline DNMT1 inhibition as a novel mechanism of RX-3117. Citation Format: Godefridus J. Peters, Dzjemma Sarkisjan, Joris J. Julsing, Ahmed Hassan, Kees Smid, Ietje Kathmann, Young Lee, Deog J. Kim. Inhibition of DNA methyltransferase by RX-3117 (fluorocyclopentenylcytosine) leads to upregulation of hypomethylated targets. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4725.

Fluorocyclopentenylcytosine (RX-3117) is an orally available cytidine analog, currently in Phase I clinical trial. RX-3117 has promising antitumor activity in various human tumor xenografts including gemcitabine resistant tumors. RX-3117 is activated by uridine-cytidine kinase (UCK). Since UCK exists in two forms, UCK1 and UCK2, we investigated which form is responsible for RX-3117 phosphorylation. For that purpose we transfected A549 and SW1573 cell lines with UCK-siRNAs. Transfection of UCK1-siRNA efficiently downregulated UCK1-mRNA, but not UCK2-mRNA expression, and did not affect sensitivity to RX-3117. However, transfection of UCK2-siRNA completely downregulated UCK2-mRNA and protein and protected both A549 and SW1573 against RX-3117. UCK enzyme activity in two panels of tumor cell lines and xenograft cells correlated only with UCK2-mRNA expression (r = 0.803 and 0.915, respectively), but not with UCK1-mRNA. Moreover, accumulation of RX-3117 nucleotides correlated with UCK2 expression. In conclusion, RX-3117 is activated by UCK2 which may be used to select patients potentially sensitive to RX-3117.

Tioguanine (TG) may be indicated in case of intolerance of or resistance to conventional thiopurines in the treatment of inflammatory bowel diseases (IBD). The aim of our study was to evaluate the intrapatient variability in the TG metabolizing enzymes: hypoxanthine-guanine phosphoribosyl transferase (HGPRT), thiopurine S-methyl transferase and xanthine oxidase. We performed a pharmacokinetic study of TG after oral and intravenous administration in IBD patients in remission. The enzyme activities were determined at baseline and one week after the initiation of TG in red blood cells, peripheral blood mononuclear cells (PBMC) or plasma. From the results we conclude that HGPRT activity in erythrocytes decreases following the initiation of TG therapy, which may imply that HGPRT is a rate limiting enzyme in TG metabolism. Moreover, little intrapatient variability in enzyme activities was observed except for HGPRT activity in PBMC. These data may have implications in regard of future therapeutic drug monitoring.

Abstract Fluorocyclopentenylcytosine (RX-3117) is an orally bioavailable novel cytidine analog, currently being tested in a Phase I clinical trial. RX-3117 shows promising antitumor activity in various human tumor xenografts including patient derived xenografts resistant to gemcitabine. Initial characterization of RX-3117 indicates that this compound is incorporated into both RNA and DNA, and downregulates DNA methyltransferase I (DNMT1). RX-3117 is not deaminated by cytidine deaminase, an enzyme that limits the efficacy of most cytidine analogs due to extensive deamination. Our studies also demonstrate that RX-3117 is taken up by the equilibrative nucleoside transporter and is activated by uridine-cytidine kinase (UCK), since co-administration of uridine or cytidine protects cells against cytotoxicity of RX-3117, and inhibits RX-3117 phosphorylation in enzyme activity assays. Since UCK exists in two forms, UCK1 and UCK2, we investigated which form is responsible for RX-3117 phosphorylation by transfecting two non-small cell lung cancer cell lines, A549 and SW1573 with siRNA directed against either UCK1 or UCK2 to determine whether downregulation would protect cells against RX-3117. UCK1-siRNA and UCK2-siRNA efficiently downregulated the expression of UCK1 and UCK2, respectively, in both cell lines, up to at least 72 hr after transfection. Exposure of UCK1-siRNA transfected cells to IC50 concentrations of RX-3117 did not affect the sensitivity of either A549 or SW1573 cells; however, transfection of UCK2-siRNA completely protected both A549 and SW1573 from the cytotoxic effects of RX-3117. In order to further investigate the role of UCK2, we tested the sensitivity of transfected cells to ethynylcytidine (ETC), a known substrate for UCK2. UCK2-siRNA transfection protected cells against ETC, but transfection with UCK1-siRNA did not. In order to explore whether we can use UCK2 expression in tumors as a predictive biomarker, we measured UCK enzyme activity, using radioactively labelled RX-3117 and the natural substrate uridine in 6 tumor cell lines to determine whether the enzyme activity correlates with UCK1 or UCK2 mRNA expression. UCK2 mRNA expression was significantly (p<0.001) correlated with enzyme activity measured with both uridine (r = 0.828) and RX-3117 (r = 0.803) but not for UCK1 (r = -0.721 and -0.585, respectively). Phosphorylation of RX-3117 in intact cells was significantly correlated with UCK2 expression (r = 0.936), but not with UCK1 (R = -0.620). In conclusion, RX-3117 is activated by UCK2 which may be used to select patients potentially sensitive to RX-3117. Citation Format: Godefridus J. Peters, Joris R. Julsing, Kees Smid, Daniel De Klerk, Dzjemma Sarkisjan, Mi Y. Yang, Young B. Lee, Deog J. Kim. Fluorocyclopentenylcytosine (RX-3117) is activated by uridine-cytidine kinase 2, a potential biomarker. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2622. doi:10.1158/1538-7445.AM2015-2622

Abstract Background: 5FU is widely used and inhibits thymidylate synthase (TS); LV given in combination with 5FU enhances TS inhibition. TS levels and inhibition are associated with survival in advanced disease. The large variation in response between patients indicates that more mechanisms may be important. To make better treatment decisions, several additional biomarkers, next to TS, such as 5FU activation, breakdown and incorporation into RNA have been investigated. Several studies on global molecular profiling for 5FU activity have been performed on model systems and patients, showing that loss of 18p11-32, which harbors the TS gene, was associated with better survival. Aim: Identification of new potential mechanisms of action and potential biomarkers of 5FU with or without LV treatment using in-depth proteomics analysis of patient CRC tissues. Methods: Patients received approximately 48 hours before resection, a test dose of 5FU (500 mg/m2) (n = 5), 5FU with LV (500 mg/m2) (n = 7) or no test dose (n = 7). For proteomics analysis, samples of CRC resection material were lysed in SDS sample buffer, fractionated by 1D gel electrophoresis, followed by in-gel digestion and nano-liquid chromatography coupled to tandem mass spectrometry (QExactive). The MaxQuant tool was used for protein identification and quantification by spectral counting. Results: Our CRC proteome analysis identified a total of 6880 proteins and 874 with altered abundance (p< 0.05) upon treatments. Our results indicate that 5FU induces upregulation of proteins associated with the extracellular matrix, membrane vesicles, stress and immune responses and downregulates mitochondrial proteins, peroxisomes and (most profoundly) ribosomal proteins. Patients who received 5FU-LV also displayed upregulation of extracellular matrix and vesicle/granule proteins in addition to cell adhesion proteins, an extensive downregulation of ribosomal proteins and downregulation of mitochondrial and ubiquitin proteins. In addition, there is an upregulation of the GO-term ‘Extracellular region part’ in both 5FU and 5FU/LV treated patients, compared to controls. Top upregulated proteins were isoform NELF-D of negative elongation factor C (NELFCD), AMP deaminase 3 (AMPD) and myeloblastin (PRTN3), while top downregulated were neudesin (NENF), antigen KI-67 (MKI67) and HERC4. Conclusions: Proteome analysis revealed strong changes in the CRC proteome upon 48 hrs of 5FU +/- LV treatment, with regulated proteins involved in stress and immune responses, vesicular transport, protein synthesis and metabolism. A number of proteins were not yet associated to 5FU actions. These proteins when correlated in a larger cohort to clinical outcome may function as biomarkers for future treatment decision. Citation Format: Kees Smid, Erik Meijer, Thang V. Pham, Inge de Reus, Sander R. Piersma, Godefridus J. Peters, Connie R. Jimenez. Proteomics analysis of the effect of fluorouracil (5FU) and 5FU/leucovorin (LV) on colorectal cancer (CRC) in patients. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 572. doi:10.1158/1538-7445.AM2015-572

2',2'-Difluoro-2'-deoxycytidine (dFdC, gemcitabine) is a cytidine analogue active against several solid tumor types, such as ovarian, pancreatic and non-small cell lung cancer. The compound has a complex mechanism of action. Because of the structural similarity of one metabolite of dFdC, dFdUMP, with the natural substrate for thymidylate synthase (TS) dUMP, we investigated whether dFdC and its deamination product 2',2'-difluoro-2'-deoxyuridine (dFdU) would inhibit TS. This study was performed using two solid tumor cell lines: the human ovarian carcinoma cell line A2780 and its dFdC-resistant variant AG6000. The specific TS inhibitor Raltitrexed (RTX) was included as a positive control. Using the in situ TS activity assay measuring the intracellular conversion of [5-H-3]-2'-deoxyuridine or [5-H-3]-2'-deoxycytidine to dTMP and tritiated water, it was observed that dFdC and dFdU inhibited TS. In A2780 cells after a 4 h exposure to 1 mu M dFdC tritium release was inhibited by 50% but did not increase after 24 h, Inhibition was also observed following dFdU at 100 mu M. No effect was observed in the dFdC-resistant cell line AG6000; in this cell line only RTX had an inhibitory effect on TS activity. In the A2780 cell line RTX inhibited TS in a time dependent manner. In addition, DNA specific compounds such as 2'-C-cyano-2'-deoxy-1-beta-D-arabino-pentafuranosylcytosine and aphidicoline were utilized to exclude DNA inhibition mediated down regulation of the thymidine kinase.Inhibition of the enzyme resulted in a relative increase of mis-incorporation of [5-H-3]-2'-deoxyuridine into DNA. In an attempt to elucidate the mechanism of in situ TS inhibition the ternary complex formation and possible inhibition in cellular extracts of A2780 cells, before and after exposure to dFdC, were determined. With the applied methods no proof for formation of a stable complex was found. In simultaneously performed experiments with 5FU such a complex formation could be demonstrated. However, using purified TS it was demonstrated that dFdUMP and not dFdCMP competitively inhibited TS with a Ki of 130 mu M, without ternary complex formation. In conclusion, in this paper we reveal a new target of dFdC: thymidylate synthase. (C) 2014 Elsevier Ltd. All rights reserved.

We aimed to determine whether the multidrug-resistance-proteins MRP4 (ABCC4) and MRP5 (ABCC5) confer resistance to the antimetabolites cytarabine (Ara-C), gemcitabine (GEM), and the L-nucleoside analog troxacitabine. For this purpose we used HEK293 and the transfected HEK/MRP4 (59-fold increased MRP4) or HEK/MRP5i (991-fold increased MRP5) as model systems and tested the cells for drug sensitivity using a proliferation test. Drug accumulation was performed by using radioactive Ara-C, and for GEM and troxacitabine with HPLC with tandem-MS or UV detection. At 4-hr exposure HEK/MRP4 cells were 2-4-fold resistant to troxacitabine, ara-C and 9-(2-phosphonylmethoxyethyl)adenine (PMEA), and HEK/MRP5i to ara-C and PMEA, but none to GEM. The inhibitors probenecid and indomethacin reversed resistance. After 4-hr exposure ara-C-nucleotides were 2-3-fold lower in MRP4/5 cells, in which they decreased more rapidly after washing with drug-free medium (DFM). Trocacitabine accumulation was similar in the 3 cell lines, but after the DFM period troxacitabine decreased 2-4-fold faster in MRP4/5 cells. Troxacitabine-nucleotides were about 25% lower in MRP4/5 cells and decreased rapidly in MRP4, but not in MRP5 cells. Accumulation of GEM-nucleotides was higher in the MRP4/5 cells. In conclusion: MRP4 and MRP5 overexpression confer resistance to troxacitabine and ara-C, but not to GEM, which was associated with a rapid decline of the ara-C and troxacitabine-nucleotides in HEK/MRP4-5 cells.

A novel cytidine analog fluorocyclopentenylcytosine (RX-3117; TV-1360) was characterized for its cytotoxicity in a 59-cell line panel and further characterized for cytotoxicity, metabolism and mechanism of action in 15 additional cancer cell lines, including gemcitabine-resistant variants. In both panels sensitivity varied 75-fold (IC50: 0.4- > 30 μM RX-3117). RX-3117 showed a different sensitivity profile compared to cyclopentenyl-cytosine (CPEC) and azacytidine, substrates for uridine-cytidine-kinase (UCK). Dipyridamole, an inhibitor of the equilibrative-nucleoside-transporter protected against RX-3117. Uridine and cytidine protected against RX-3117, but deoxycytidine (substrate for deoxycytidine-kinase [dCK]) not, although it protected against gemcitabine, demonstrating that RX-3117 is a substrate for UCK and not for dCK. UCK activity was abundant in all cell lines, including the gemcitabine-resistant variants. RX-3117 was a very poor substrate for cytidine deaminase (66,000-fold less than gemcitabine). RX-3117 was rapidly metabolised to its nucleotides predominantly the triphosphate, which was highest in the most sensitive cells (U937, A2780) and lowest in the least sensitive (CCRF-CEM). RX-3117 did not significantly affect cytidine and uridine nucleotide pools. Incorporation of RX-3117 into RNA and DNA was higher in sensitive A2780 and low in insensitive SW1573 cells. In sensitive U937 cells 1 μM RX-3117 resulted in 90 % inhibition of RNA synthesis but 100 μM RX-3117 was required in A2780 and CCRF-CEM cells. RX-3117 at IC50 values did not affect the integrity of RNA. DNA synthesis was completely inhibited in sensitive U937 cells at 1 μM, but in other cells even higher concentrations only resulted in a partial inhibition. At IC50 values RX-3117 downregulated the expression of DNA methyltransferase. In conclusion, RX-3117 showed a completely different sensitivity profile compared to gemcitabine and CPEC, its uptake is transporter dependent and is activated by UCK. RX-3117 is incorporated into RNA and DNA, did not affect RNA integrity, depleted DNA methyltransferase and inhibited RNA and DNA synthesis. Nucleotide formation is related with sensitivity.

Cytarabine (ara-C) and gemcitabine (dFdC) are commonly used anticancer drugs, which depend on the equilibrative (ENT) and concentrative-nucleoside-transporters to enter the cell. To bypass transport-related drug resistance, lipophilic derivatives elacytarabine (CP-4055), ara-C-5'elaidic-acid-ester, and CP-4126, (CO 1.01) gemcitabine-5'elaidic-acid-ester, were investigated for the entry into the cell, distribution, metabolism and retention. The leukemic CEM-cell-line and its deoxycytidine-kinase deficient variant (CEM/dCK-) were exposed for 30 and 60 min to the radiolabeled drugs; followed by culture in drug-free medium in order to determine drug retention in the cell. The cellular fractions were analyzed with thin-layer-chromatography and HPLC. Elacytarabine and CP-4126 were converted to the parent compounds both inside and outside the cell (35-45%). The ENT-inhibitor dipyridamole did not affect their uptake or retention. Inside the cell Elacytarabine and CP-4126 predominantly localized in the membrane and cytosolic fraction, leading to a long retention after removal of the medium. In contrast, in cells exposed to the parent drugs ara-C and dFdC, intracellular drug concentration increased during exposure but decreased to undetectable levels after drug removal. In the dCK- cell line, no metabolism was observed. The concentrations of ara-CTP and dFdCTP reached a peak at the end of the incubation with the drugs, and decreased after drug removal; peak levels of dFdCTP were 35 times higher than ara-CTP and was retained better. In contrast, after exposure to elacytarabine or CP-4126, ara-CTP and dFdCTP levels continued to increase not only during exposure but also during 120 min after removal of the elacytarabine and CP-4126. Levels of ara-CTP and dFdCTP were higher than after exposure to the parent drugs. In conclusion, the lipophilic derivatives elacytarabine and CP-4126 showed a nucleoside-transporter independent uptake, with long retention of the active nucleotides. These lipophilic nucleoside analogues are new chemical entities suitable for novel clinical applications.

Abstract Cytidine analogs play an important role in the treatment of various types of cancer, both solid tumors and leukemia. A novel cytidine analog fluorocyclopentenylcytosine (RX-3117) was characterized for its cytotoxic effects, its metabolism and its mechanism of action in a panel of 9 solid tumor and leukemic cell lines, as well as 6 variants resistant to gemcitabine, cytarabine and other pyrimidine analogs. Sensitivity in the parent cell lines after 72 hr exposure varied 75 fold with IC50 values from 0.4 to 30 µM RX-3117. The human equilibrative nucleoside transporter mediates transport of RX-3117, since its inhibition protected cells. Uridine and cytidine also protected cells against RX-3117, indicating that activation of RX-3117 is dependent on phosphorylation catalyzed by uridine-cytidine kinase (UCK), which was abundant in all tested cell lines, including the gemcitabine resistant variants. Deoxycytidine did not protect cells against RX-3117. RX-3117 was a very poor substrate for cytidine deaminase (66,000-fold less than gemcitabine). After its uptake in cells, RX-3117 was rapidly metabolised to its nucleotides with the triphosphate being the most prominent form (90% of all nucleotides), while synthesis of the nucleotides was highest in the most sensitive cell lines (U937 and A2780 cells) and lowest in the least sensitive cells (CCRF CEM cells). No difference in nucleotide formation was observed between the SW1573 and its gemcitabine resistant variant SW1573/G. In the AG6000 cells, the dCK- variant of A2780 and resistant to gemcitabine and RX-3117, a normal monophosphate level was found, but no di-and triphosphates were formed, explaining its resistance. Similarly incorporation of RX-3117 into RNA and DNA was higher in the sensitive A2780 and low in the insensitive SW1573 cells, with no difference between the gemcitabine sensitive and resistant variants. The effect of RX-3117 on synthesis of RNA and DNA was quite different; in the sensitive U937 cells 10 µM RX-3117 inhibited RNA synthesis 90%, while in A2780 and CCRF-CEM cells 100 µM RX-3117 was required for 90% inhibition of RNA synthesis. The effect on DNA synthesis was quite different. 1 µM RX-3117 completely inhibited DNA synthesis in the sensitive U937 cells, 80-90% inhibition was achieved with 10 µM in both CCRF CEM variants and with 100 µM in SW1573/G and AG6000, but in A2780 and SW1573 cells 100 µM only resulted in a partial or no inhibition, respectively. In conclusion, RX-3117 showed a completely different sensitivity profile compared to other cytidine analogs. Its uptake is transporter dependent; it is not activated by dCK, but by UCK. RX-3117 is incorporated into RNA and DNA; RX-3117 hardly affected RNA synthesis at IC50 values, but inhibited DNA synthesis. Its metabolism to nucleotides is related with its sensitivity, possibly because they directly inhibit the target presumably DNA methyltransferase. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1770. doi:1538-7445.AM2012-1770

Thiopurines are crucial in the treatment of inflammatory bowel disease. The phenotype of pivotal metabolic enzymes determines whether thioguanine nucleotides (6-TGN) are generated in clinically sufficiently high levels. The first step in activation of thiopurine prodrugs to 6-TGN is catalysis by hypoxanthine-guanine phosphoribosyltransferase (HGPRT). Often, patients exhibit a clinically unfavorable metabolism, leading to discontinuation of conventional thiopurine therapy. The combination of allopurinol and low-dose thiopurine therapy may optimize this variant metabolism, presumably by affecting enzyme activities. We performed a prospective pharmacodynamic study to determine the effect of combination therapy on the activity of HGPRT. The activity of HGPRT and 6-TGN concentrations was measured in red blood cells during thiopurine monotherapy and after 4 weeks of combination therapy. The activity of HGPRT was also measured after 12 weeks of combination therapy. From the results, we conclude that combination therapy increases the activity of HGPRT and subsequently 6-TGN concentrations.

Abstract Pemetrexed improves the effect of platinum-compounds against MPM, but biomarkers of response and novel effective combinations are warranted. The present study evaluated the 1) correlation between expression and polymorphisms of pemetrexed's key target TS and outcome of MPM patients treated upfront with carboplatin/pemetrexed, and 2) pharmacological interaction of new targeted compounds (gefitinib, erlotinib, sorafenib, vandetanib, and enzastaurin) with carboplatin-pemetrexed in MPM cell lines. Analysis of TS TSER-2R/3R, mRNA and protein expression was performed by PCR and immunohistochemistry (using H-score) in tumors from 99 patients. The role of TS and other molecular determinants in the interaction of carboplatin, pemetrexed with new targeted compounds was investigated in the H2052, H2452, H28 and MSTO-211H cells. Drug interaction was studied using MTT and SRB assays and evaluated with combination index method. EGFR, Akt and Erk phosphorylation, as well as VEGF secretion, were analyzed with ELISA, whereas RT-PCR and western blot were performed to assess modulation of the expression of TS, E2F-1 and genes involved in DNA repair (ERCC1 and XPD). A significant correlation between low TS protein expression and response (odd ratio, 4.2; p=0.023), longer PFS (8vs6 months; hazard ratio [HR]:0.60: p=0.023), or OS (18vs9 months; HR:0.59; p=0.029) was found when patients were categorized according to median H-score. Similarly, patients with TS mRNA below the median had longer PFS and OS (p<0.001). The higher tertile of TS mRNA expression also correlated with higher risk of progressive disease (OR:2.5; p=0.044). At multivariate analysis, TS mRNA level and H-score confirmed their independent prognostic role for PFS and OS. No correlations were observed for TSER polymorphisms. Vandetanib emerged as the targeted compound with the most potent cell growth inhibitory effects, and interacted synergistically with carboplatin and pemetrexed in all cell lines, increasing apoptotic indices. Pemetrexed enhanced EGFR phosphorylation, but reduced Akt phosphorylation and ERCC1 and XPD expression. Conversely, vandetanib significantly downregulated EGFR, Erk and Akt phosphorylation, as well as E2F-1 and TS expression (eg, H28 cells had 4.8-fold TS mRNA decrease). In conclusion, low TS protein and mRNA levels were associated to response, longer PFS and OS. Furthermore, vandetanib improved pemetrexed-carboplatin activity against MPM cells, through modulation of critical molecular mechanisms, such as EGFR-Akt phosphorylation and TS expression. These data support further prospective trials for the validation of the prognostic/predictive role of TS in patients treated with pemetrexed-based regimens, as well as future studies on the integration of vandetanib in the treatment of MPM. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 5041. doi:10.1158/1538-7445.AM2011-5041

Prodrugs can have the advantage over parent drugs in increased activation and cellular uptake. The multidrug ETC-L-FdUrd and the duplex drug ETC-FdUrd are composed of two different monophosphate-nucleosides, 5-fluoro-2'deoxyuridine (FdUrd) and ethynylcytidine (ETC), coupled via a glycerolipid or phosphodiester, respectively. The aim of the study was to determine cytotoxicity levels and mode of drug cleavage. Moreover, we determined whether a liposomal formulation of ETC-L-FdUrd would improve cytotoxic activity and/or cleavage. Drug effects/cleavage were studied with standard radioactivity assays, HPLC and LC-MS/MS in FM3A/0 mammary cancer cells and their FdUrd resistant variants FM3A/TK(-). ETC-FdUrd was active (IC(50) of 2.2 and 79 nM) in FM3A/0 and TK(-) cells, respectively. ETC-L-FdUrd was less active (IC(50): 7 nM in FM3A/0 vs 4500 nM in FM3A/TK(-)). Although the liposomal formulation was less active than ETC-L-FdUrd in FM3A/0 cells (IC(50):19.3 nM), resistance due to thymidine kinase (TK) deficiency was greatly reduced. The prodrugs inhibited thymidylate synthase (TS) in FM3A/0 cells (80-90%), but to a lower extent in FM3A/TK(-) (10-50%). FdUMP was hardly detected in FM3A/TK(-) cells. Inhibition of the transporters and nucleotidases/phosphatases resulted in a reduction of cytotoxicity of ETC-FdUrd, indicating that this drug was cleaved outside the cells to the monophosphates, which was verified by the presence of FdUrd and ETC in the medium. ETC-L-FdUrd and the liposomal formulation were neither affected by transporter nor nucleotidase/phosphatase inhibition, indicating circumvention of active transporters. In vivo, ETC-FdUrd and ETC-L-FdURd were orally active. ETC nucleotides accumulated in both tumor and liver tissues. These formulations seem to be effective when a lipophilic linker is used combined with a liposomal formulation.

to patients were collected between January, 2001 and December, 2009.Each IBD patient was linked to the Dutch nationwide pathology archive (PALGA) to verify the IBD diagnosis and to determine whether a patient had developed NMSC.Cox proportional hazard regression analysis was used to calculate the risk of NMSC in patients with and without thiopurine use, adjusted for type of IBD, gender, age and duration of IBD.Results: A total of 2887 patients with a confirmed IBD diagnosis were included in this study.Of these, 819 patients (28%) used thiopurines.No statistically significant differences were found for type of IBD, gender, age and extent of IBD between thiopurine users and non-users.Disease duration was significantly shorter in users compared to non-users (34 months (SD 45) versus 38 months (SD 48), p=0.03).Eighty-six patients (3%) developed NMSC during 18,727 person years of follow-up.Of these patients, 24 (28%) had used thiopurines.Mean age at NMSC diagnosis was 64 years (SD 12) in thiopurine users compared to 63 years (SD 13) in nonusers (p=0.68).Increasing age and duration of IBD were associated with a higher risk of developing NMSC (adjusted hazard ratio (HR) 1.06, 95% Confidence Interval (CI) 1.04-1.08 and adjusted HR 1.007, 95% CI 1.002-1.011,respectively).A diagnosis of ulcerative colitis and female gender were associated with a decreased risk of NMSC (adjusted HR 0.62, 95% CI 0.40-0.98)and adjusted HR 0.47, 95% CI 0.30-0.74).Thiopurine use was not associated with an increased risk of developing NMSC (adjusted HR 0.85, 95% CI 0.51-1.41).Conclusion: In contrast to transplant recipients, thiopurine use in IBD patients is not associated with an increased risk of developing NMSC.