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Activation of cyclophosphamide in mouse limb bud cultures using a reconstituted cytochrome P-450 system.

Purified phenobarbital-induced rat liver cytochrome P-450 was incorporated in a reconstituted system containing NADPH-cytochrome P-450 reductase, dilauroyl phosphatidyl choline and sodium cholate. This system was added to organ cultures of limb buds from mouse embryos on day 11 of gestation. Cyclophosphamide (100 micrograms per ml) was used as a "pre-teratogen" and activation was initiated by adding an NADPH-regenerating system. Due to extensive purification, toxicity of the enzyme preparations and residual solubilisation detergents could be greatly reduced. A reconstituted system containing 10-100 pmol cytochrome P-450 per ml without cyclophosphamide caused no noticeable interference with limb development. The same assay containing cyclophosphamide, however, resulted in a pronounced impairment of cartilage differentiation and in the formation of clearly abnormal structures, especially at the paw skeleton. The activity of the reconstituted system declined under the experimental conditions used, but some activating capacity towards cyclophosphamide was still demonstrable after about 2 h of incubation.

Animals↗

[The evaluation of the cyclophosphamide sensitivity of human tumours by determining the incorporation of tritiated uridine and thymidine into the nucleic acids of human tumor cells in vitro in presence of 4-hydroxycyclophosphamide (author's transl)].

A new in vitro assay for screening the sensitivity of human tumour cells against Cyclophosphamide has been developed. While biologically activated Cyclophosphamide was unsuitable because of unpurities in the material, synthetic 4-Hydroxycyclophosphamide was shown to inhibit the incorporation of tritiated uridine and thymidine into the nucleic acids of human tumour cells in vitro. 29 tumours including 14 mammarial carcinomas, 8 ovarial carcinomas and 7 other malignant tumours were tested. While 12 tumours showed a significant and 5 only a slight inhibition of the 3H-uridine incorporation in vitro. 12 tumours showed no effect. Histologically none-differentiated tumours were more sensitive against 4-Hydroxycyclophosphamide as compared with the more differentiated ones. First observations point to 4-Hydroperoxycyclophosphamide instead of 4-Hydroxycyclophosphamide as a more suitable form of activated Cyclophosphamid for the in vitro assay of Cyclophosphamide sensitiveness because of the higher stability and better availability of this compound.

Antineoplastic Agents↗

Formation, toxicity and inactivation of acrolein during biotransformation of cyclophosphamide as studied in freshly isolated cells from rat liver and kidney.

In the present study the formation and the effects of cyclophosphamide-derived acrolein were investigated using isolated cells from rat liver and kidney, with particular regard to the protective action of low molecular weight thiols against cellular toxicity. The results may be summarized as follows: Cyclophosphamide (CTX)-mediated toxicity to isolated cells is dependent on cytochrome P-450 activity; Loss of viability in cells incubated with cyclophosphamide is preceded by a depletion of cellular GSH; Stimulation of cellular GSH synthesis or the presence of low molecular weight thiols in the incubation medium protects against cyclophosphamide-induced toxicity; Acrolein is probably formed extracellularly as well as intracellularly and can be detoxified by thiol compounds, forming a thiochemiacetal or a thioether.

Acrolein↗

Cyclophosphamide treatment of female non-obese diabetic mice causes enhanced expression of inducible nitric oxide synthase and interferon-gamma, but not of interleukin-4.

In pancreatic lesions of non-obese diabetic (NOD) mice the expression of inducible nitric oxide synthase (iNOS) and of the cytokines interferon-gamma and interleukin-4 were studied. Strong iNOS expression as determined at the level of transcription, translation and of enzyme activity was associated with destructive insulitis as seen 8-10 days after cyclophosphamide treatment of 70- to 80-day-old female NOD mice. Immunohistochemistry showed iNOS associated with infiltrating macrophages but not in endocrine cells. The enhancement of iNOS after cyclophosphamide correlated with an increase of T-helper type 1 (Th1) associated interferon-gamma expression while T-helper type 2 (Th2) associated interleukin-4 was the dominant cytokine prior to cyclophosphamide and after diabetes onset. We conclude that insulitis in young NOD mice is carried by Th2 cells while cyclophosphamide enhanced insulitis is determined by Th1 cells. Macrophages show two different functional states in insulitis; strong iNOS expression in macrophages is associated with destructive insulitis.

Amino Acid Oxidoreductases↗

Effect of renal insufficiency on the pharmacokinetics of cyclophosphamide and some of its metabolites.

Cyclophosphamide pharmacokinetics were studied in seven patients with moderate to severe renal insufficiency (creatinine clearances 0-51 ml . min-1), and compared with a matched control group of patients with normal renal function. The mean half-life of cyclophosphamide following intravenous administration in the normal group was 8.21 +/- 2.33 (SD) h whilst that in renal failure was 10.15 +/- 1.80 h: these were significantly different. The total body clearance in the normal control group was 58.6 +/- 10.9 ml . kg-1h-1 which was significantly larger than in renal failure where it was 48.8 +/- 10.9 ml . kg-1h-1. Vd beta, Vdss and Vc were not significantly different between the two groups. A linear relationship exists between beta, the first order disposition rate constant and endogenous creatinine clearance since this drug shows a relatively small degree of compartmentalisation. The plasma half-life of phosphoramide mustard, a cytotoxic metabolite of cyclophosphamide, shows a parallel and significant increase in renal failure with the parent compound. The t1/2 in normal patients was 8.33 +/- 2.0 h, whilst in the renal failure group it was 13.37 +/- 4.23 h. Total alkylating activity as measured by the nitrobenzyl-pyridine reaction showed a significant increase in renal failure. This data suggests that in pharmacokinetic terms it may not be necessary to alter the dose of cyclophosphamide until there is severe renal impairment. Further studies correlating the efficacy and toxicity of the drug with its pharmacokinetics in renal failure are necessary.

Aged↗

Effect of body weight on the pharmacokinetics of cyclophosphamide in breast cancer patients.

Cyclophosphamide pharmacokinetics have been studied in 16 female patients with advanced breast cancer. The group included 7 patients who were greater than 20%, less than or equal to 30% over ideal body weight and 5 patients who were greater than 30% over ideal body weight. Cyclophosphamide plasma elimination half-lives ranged between 152 and 984 min (mean 457 min), the apparent volume of distribution between 19.1 and 62.3 1 (mean 36.1 1), and plasma clearance between 25.9 and 166.6 ml/min (mean 69.5 ml/min). There was a significant positive correlation (r = 0.624, P = 0.010) between body weight and plasma elimination half-life, and a significant negative correlation between body weight and cyclophosphamide clearance when normalized to body surface area (r = 0.578, P = 0.019) or normalized to ideal body weight (r = 0.531, P = 0.0345). The apparent volume of distribution did not correlate with body weight. The results show that cyclophosphamide disposition is altered in patients with increased body weight.

Administration, Oral↗

Dose-toxicity relationship of carboplatin in combination with cyclophosphamide in ovarian cancer patients.

A study was undertaken to examine the relationships between carboplatin's pharmacokinetic parameters and the myelotoxicity associated with its administration in combination with cyclophosphamide. An additional aim of the study was to test the applicability of the method proposed by Calvert et al. for calculation of the carboplatin dose to be used in the combination regimen. A total of 24 previously untreated ovarian cancer patients were given a combination of 250-500 mg/m2 carboplatin and 500 mg/m2 cyclophosphamide every 4 weeks for 4 months. The pharmacokinetics of carboplatin and the associated myelotoxicity were investigated in 64 courses. The results showed a significant correlation (r = 0.89) between the AUC calculated for carboplatin and that predicted according to Calvert's formula [carboplatin dose in milligrams = AUC (glomerular filtration rate +25)]. We conclude that the model is a useful guide in the calculation of the carboplatin dose to be given in combination with cyclophosphamide, and it enables a more precise prediction of the carboplatin exposure than does the conventional calculation, which is based on milligrams of drug per square meter of body surface. The AUC for carboplatin was a reliable predictor of the myelotoxicity as measured by the relative decrease in thrombocyte count. However, the relationship between AUC and myelotoxicity changed during the treatment because of increasing bone marrow toxicity. Despite this finding, dose calculation based on carboplatin's AUC appears to provide an improvement in the clinical use of the drug, and the method also seems to be fully applicable in combination chemotherapy with cyclophosphamide.

Antineoplastic Combined Chemotherapy Protocols↗

Kidney biopsy prior to cyclophosphamide therapy in primary nephrotic syndrome.

The study includes 30 children, 10 each with minimal change nephropathy (MCNS), diffuse mesangial proliferative glomerulonephritis (MesPGN) and focal segmental glomerulosclerosis (FSGS). Indications for kidney biopsy were: steroid resistance in 12 cases, and frequent relapses on maintenance steroid therapy in 18 cases. A 2-year remission was achieved by cyclophosphamide therapy in 6 patients with FSGS, 8 patients with MCNS and 8 patients with MesPGN. In terms of initial response to corticosteroids, only 3 of 8 patients with early steroid resistance responded to cyclophosphamide therapy compared with 3 of 4 with late steroid resistance and 16 of 18 with frequent relapses on maintenance steroid therapy. Response to cyclophosphamide therapy correlates better with the initial corticosteroid response than renal histopathology. A kidney biopsy prior to administration of cyclophosphamide is not essential in patients who respond to initial corticosteroid therapy.

Adolescent↗

Effect of irradiation, cyclophosphamide, and etoposide (VP-16) on number of peripheral blood and peritoneal leukocytes in mice under normal conditions and during acute inflammatory reaction.

In order to develop a suitable model for studying the role of granulocytes and monocytes in resistance against pathogenic microorganisms, we investigated the effect of irradiation and cytostatic treatment (cyclophosphamide and VP-16) on the number of both peripheral blood and peritoneal leukocytes in male Swiss mice. Irradiation and cyclophosphamide treatment severely decreased the number of both granulocytes and monocytes in peripheral blood, whereas VP-16 only lowered the number of blood monocytes to a significant degree and had little effect on the number of blood granulocytes or lymphocytes. When normal mice were injected intraperitoneally with newborn calf serum (NBCS) the number of peritoneal granulocytes rose about 100-fold within 6 h. In irradiated and cyclophosphamide-treated mice, this influx of granulocytes into the peritoneal cavity was virtually eliminated, as was the concomitant increase in the number of blood granulocytes; in VP-16-treated mice, on the other hand, the number of peripheral blood and peritoneal granulocytes increased to the same degree as in normal mice. An increase in the number of peripheral blood monocytes and peritoneal macrophages occurred 24-48 h after injection of NBCS in normal mice. This increase was significantly impaired by irradiation as well as by treatment with cyclophosphamide or VP-16.

Animals↗

Cyclophosphamide therapy of medulloblastoma: from the laboratory to the clinic and back again (and again and again).

Medulloblastoma, the most common malignancy of childhood, was originally shown to be sensitive to cyclophosphamide in 1981. We have used combined laboratory and clinical investigations to demonstrate the synergy of cyclophosphamide and vincristine in the treatment of this tumor, the therapeutic gain associated with escalation of the dosage of cyclophosphamide, the consequence of and mechanisms underlying resistance of medulloblastoma to cyclophosphamide, the emerging importance of the neuraxis as a site of relapse of medulloblastoma, and newer approaches, including intrathecal 4-hydroperoxycyclophosphamide and busulfan, to treat neuraxis disease. These studies serve as a paradigm for laboratory-clinical translational research.

Animals↗

Studies of lung infections caused by Pseudomonas aeruginosa in mice treated with cyclophosphamide.

An experimental Pseudomonas aeruginosa lung infection was induced by aerosol exposure in mice which had been pretreated with cyclophosphamide. A single dose of 200 mg/kg cyclophosphamide resulted in leukopenia which lasted for three days. At the lowest PMN levels, the mice were exposed to aerosols containing varying doses of bacteria. The survival time of the mice and the number of viable bacteria in their lungs were determined. A dramatic rise in the viable counts of Pseudomonas organisms was found between 18 and 24 hours after infection. Mice which had not been pretreated with cyclophosphamide remained healthy and did not show any lung lesions. The number and phagocytic function of the alveolar macrophages remained unaltered after cyclophosphamide treatment. Thus, PMNs seem to play an important role in the lung's early defence mechanisms against Pseudomonas aeruginosa. This animal model could be of use in evaluating additional therapies for lung infections caused by Pseudomonas aeruginosa.

Animals↗

5-Hydroxyindoleacetic acid excretion following combination chemotherapy with cyclophosphamide, epirubicin and 5-fluorouracil plus ondansetron compared to ondansetron alone.

The aim of the work was to evaluate the impact of cyclophosphamide and ondansetron on serotonin metabolism measured by urinary 5-hydroxyindoleacetic acid (5-HIAA) excretion. The pattern of urinary 5-HIAA excretion was analysed within 24 h following cyclophosphamide, epirubicin and 5-fluorouracil (FEC) chemotherapy (n = 14), ondansetron as single agent (n = 31), and in a control group (n = 62). 5-HIAA was measured by a fluorescence/polarisation immunoassay. Both FEC and ondansetron alone induced a significantly higher 5-HIAA increase following the first 12 h after drug administration when compared to the control group. The comparison of quantitative variables of 5-HIAA excretion between FEC and ondansetron failed to reveal any statistical differences. Cyclophosphamide-based chemotherapy is associated with only minor increases of 5-HIAA excretion. Analysis of 5-HIAA excretion does not help in the description of the pathophysiology of cyclophosphamide-induced emesis. In contrast to experimental data, serotonin 3 receptor antagonism with ondansetron induces an increase of 5-HIAA excretion in humans.

Adult↗

A murine plasmacytoma MOPC 104E resistant to cyclophosphamide is resistant to immunotherapy.

A murine plasmacytoma MOPC 104E (MOPC) is highly sensitive to chemotherapeutic agents such as cyclophosphamide and mitomycin C as well as to immunotherapy (OK-432-combined adoptive immunotherapy using interleukin-2-cultured killer cells). In the present study, we prepared cyclophosphamide-resistant MOPC cells (MOPC-CPA/R) by serial in vivo passage of tumor cells following cyclophosphamide treatment. The in vivo sensitivity of MOPC-CPA/R to mitomycin C or to immunotherapy (OK-432-combined adoptive immunotherapy) was significantly decreased compared to the parent MOPC. In vitro experiments showed that MOPC-CPA/R were more resistant (five-fold) to lysis by cultured immune spleen cells than MOPC. Inhibition of the lytic activity of cultured immune spleen cells against MOPC was significantly increased (P less than 0.05) by the addition of unlabeled MOPC compared to unlabeled MOPC-CPA/R. These results suggest that MOPC-CPA/R express weaker antigenicity than MOPC. However, the transfer of immune spleen cells cultured with tumor extract derived from MOPC-CPA/R significantly prolonged the survival of MOPC-CPA/R-inoculated mice. Thus, by repeated cyclophosphamide treatment, tumor cells with low-antigenicity were selected. These tumor cells had lower sensitivity to another chemotherapeutic agent and immunotherapy. Such an immunological response may play an important role in cancer therapy.

Animals↗

Investigations on the influence of cyclophosphamide, gold sodium thiomalate and D-penicillamine on nystatin oedema and adjuvant arthritis.

Cyclophosphamide (5 or 10 mg/kg p.o.) and Gold sodium thiomalate (0 or 40 mg/kg i.m.) inhibit after repeated administrations (5 days) all the phases of Nystatin edema, whereas a single administration is ineffective. D-Penicillamine (25 or 100 mg/kg p.9.) inhibits the early phases of Nystatin edema after a single administration whereas repeated administrations are almost ineffective. An early treatment with Cyclophosphamide (2.5 mg/kg p.o.) simply delays the appearance of the secondary lesions of adjuvant arthritis but inhibit the development of the primary lesions. A late treatment with Cyclophosphamide as both the types of treatment with Gold sodium thiomalate (10 mg/kg i.m.) are effective against primary and secondary lesions. The only effect of D-Penicillamine (50 mg/kg p.o.) in adjuvant arthritis is a significant increase of the intensity of secondary lesions during the late treatment. It is suggested that the anti-inflammatory activity of Cyclophosphamide does not depend exclusively upon its immunosuppressant activity and that D-Penicillamine is effective on some cell population committed in the inflammatory reactions.

Animals↗

The influence of in vivo pretreatment of cyclophosphamide on phagocytic activity of mouse macrophages in vitro.

The action of cyclophosphamide on phagocytosis by macrophages from mouse peritoneal exudate cultured in vitro was studied. The mice were pretreated with cyclophosphamide administered for seven days. The experiments were carried out in the presence of serum (with or without complement) from untreated animals or without serum. A significantly increased phagocytic activity was shown in experiments without serum and when decomplemented serum was used. No significant variation was found when macrophages from treated mice were tested with serum with complement from untreated animals. It is tentatively assumed that low dosage administration in vivo of cyclophosphamide does not affect macrophage phagocytic activity while several findings suggest an inhibitory effect of cyclophosphamide on T and B lymphocytes.

Animals↗

Pharmacokinetics of intravenous etoposide in patients with breast cancer: influence of dose escalation and cyclophosphamide and doxorubicin coadministration.

This study investigates the impact of dose escalation and of doxorubicin and cyclophosphamide coadministration on the pharmacokinetics of etoposide (ETO). Pharmacokinetics of ETO were analyzed in seven patients with breast cancer receiving 3-4 cycles of conventional-dose (CD) and one final course of high-dose (HD) chemotherapy including ETO (450 mg/m(2) and 2100 mg/m(2), respectively, fractionated over 3 consecutive days). ETO was given as monoinfusion apart from day 1 of CD, where cyclophosphamide and doxorubicin were coadministered. Plasma samples obtained on day 1 and day 2 of CD- and HD-therapy, respectively, were analyzed for ETO by HPLC. Data from a total of 25 cycles of CD- and 7 cycles of HD-therapy are given as means +/- SD for CD-day 1, CD-day 2, HD-day 1 and HD-day 2, respectively. Following administration of 210+/-29, 278+/-41, 1143+/-79 and 1143+/-79 mg ETO, the AUC (0-24 h, normalized to 150 mg/m(2)) was 123+/-23, 113+/-22, 92+/-11 and 100+/-22 microgxh/ml. The AUC and CL of single-agent ETO were not significantly different between CD (day 2) and both days of HD ETO. However, we observed a modest but significant difference for AUC and CL between day 1 of CD (coadministration of doxorubicin and cyclophosphamide) and day 2 of CD (ETO monoinfusion), the AUC and CL being 9% higher (see above) and 10% lower (21.1 vs. 23.3 ml/minxm(2)) ( P<0.05), respectively, on day 1. The fraction of unbound ETO was similar on all occasions (range: 5.5%-6.6%). Interpatient variability for AUC and CL during CD-therapy was moderate with coefficients of variation (CV) of 17%-20%, while intraindividual variability was comparatively high and almost in the same range (CV of 13%-16%). Pharmacokinetics of etoposide were not significantly altered following fivefold dose escalation in the same patients. A 10% decrease in systemic clearance of etoposide was observed during doxorubicin and cyclophosphamide coadministration, which could result from drug interactions affecting renal and/or metabolic elimination of etoposide. The magnitude of the decrease, however, is unlikely to be of clinical significance.

Adult↗

Extremely high exposures in an obese patient receiving high-dose cyclophosphamide, thiotepa and carboplatin.

An obese 53-year-old woman (height 167 cm, weight 130 kg) with metastatic breast cancer received high-dose chemotherapy comprising cyclophosphamide, thiotepa and carboplatin (CTC). The cyclophosphamide (1 g/m(2) per day) and thiotepa (80 mg/m(2) per day) doses were based on body surface area (BSA) calculated using total body weight (TBW). The daily carboplatin dose was calculated based on the Calvert formula, using a target area under the plasma concentration-time curve (AUC) value of 3.25 mg.min/ml and applying the Cockcroft-Gault equation to estimate the glomerular filtration rate. The patient received the three agents as short infusions over four consecutive days. For therapeutic drug monitoring (TDM), blood samples were collected on day 1. Thiotepa and its main metabolite tepa, ultrafilterable platinum, cyclophosphamide and its activated metabolite 4-hydroxycyclophosphamide were determined. Individual pharmacokinetics were assessed using Bayesian analysis. Exposure to the individual compounds was determined by calculating the AUC. Exposures to 4-hydroxycyclophosphamide, the combination of thiotepa/tepa and carboplatin were 94%, 117% and 71% higher than the median respective exposures in a non-obese population of patients ( n=24) receiving similar doses. Because high AUCs of 4-hydroxycyclophosphamide, thiotepa/tepa and carboplatin correlate with increased toxicity, the treatment risk in this obese patient was significantly increased. Therefore doses were adapted on the 3rd day of the course. It is concluded that cyclophosphamide and thiotepa in obese patients should not be dosed on the basis of BSA incorporating TBW since the patient will be overexposed. Moreover, applying the Cockcroft-Gault equation to obese patients leads to an overprediction of creatinine clearance and, when used in the Calvert equation, consequently to a carboplatin dose that is too high. Obese patients represent a unique group of patients in which TDM is extremely valuable in optimizing dosing, particularly in high-dose chemotherapy.

Antineoplastic Combined Chemotherapy Protocols↗

Phase I/II trial of human recombinant granulocyte-colony-stimulating factor (filgrastim) and escalating doses of cyclophosphamide, mitoxantrone, and 5-FU in the treatment of advanced breast cancer.

PURPOSE: We performed a phase I/II dose-escalation trial of cyclophosphamide, mitoxantrone, and 5-fluorouracil (CNF) in combination with human recombinant granulocyte-colony-stimulating factor (G-CSF, filgrastim) in patients with advanced breast cancer. The objectives of this trial were (1) to gain experience with filgrastim given to patients with advanced breast cancer and receiving standard-dose CNF, and (2) to determine the maximum tolerated dose of CNF that could be given with filgrastim support by incremental dose escalation of two components of the CNF regimen, cyclophosphamide and mitoxantrone. METHODS: Four patients who had received prior therapy for advanced disease received standard-dose CNF with filgrastim support. Sequentially enrolled patients who had received no prior chemotherapy for advanced disease were treated with standard-dose CNF without filgrastim (5 patients), standard-dose CNF with filgrastim (15 patients), or were entered into sequential cohorts of 3-6 patients to be treated with increasing doses of CNF with filgrastim support (29 patients). RESULTS: The maximum tolerated doses that could be given with filgrastim support were 1500 mg/ml cyclophosphamide, 20 mg/m2 mitoxantrone, and 500 mg/m2 5-FU. Overall, 7 complete (14%) and 13 partial responses (26%) were observed. Despite the use of filgrastim, repeated cycles of CNF at doses of 2000 mg/m2 cyclophosphamide, 25 mg/m2 mitoxantrone, and 500 mg/m2 5-FU could not be given because of neutropenia and thrombopenia. Among 18 patients with bidimensionally measurable disease there were 3 complete (17%) and 5 partial (28%) responses. The median progression-free survival of all patients was 236 days (34 weeks). CONCLUSION: The use of filgrastim allows CNF to be given at approximately twice the dose intensity of "standard"-dose CNF. Because nonhematopoietic toxicity was not dose-limiting, further dose escalation of this regimen might be possible with more effective hematopoietic support. The response rate and survival of patients treated in this study were within the range expected with standard-dose chemotherapy.

Adult↗