Comparative Study of Doxorubicin, Mitoxantrone, and Epirubicin in Combination with ICRF-187 (ADR-529) in a Chronic Cardiotoxicity Animal Model'

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ICANCERRESEARCH52, 194-201,January 1, 19921 Comparative Study of Doxorubicin, Mitoxantrone, and Epirubicin in Combination with ICRF-187 (ADR-529) in a Chronic Cardiotoxicity Animal Model'

Patricia M. Alderton, Janet Gross, and Michael D. Green2 Department ofMedical Oncology, Royal Melbourne Hospital, Parkville, Victoria, 3050 [P. M. A., M. D. G.J, and Department ofPathology, University of Melbourne, Parkville, Victoria, 3052 Ii. G.J,Australia

ABSTRACF superoxide dismutase, catalase, glutathione peroxidase, and reduced glutathione, are intrinsically very low, rendering the In this study doxorubicin,epirubicin,and mitoxantronewerecompared heart very susceptible to free radical attack (10, 11). By com for their cardiotoxic potential in a chronic mouse model in an effort to identify and compare their mechanism(s) of toxicity. In addition, the parison with doxorubicin, mitoxantrone has been shown to be cardioprotective ability of ICRF-187 t(Â±)-1,2-bis(3,5-dioxopiperazinyl-1- less susceptible to enzymatic activation to its free radical form yl)propanejwith each anticancer drug was evaluated in this model.The and inactive in stimulating oxygen free radical production or antioxidant capacity (superoxide dismutase, reduced glutathione, cata lipid peroxidation (12â€”15).This study is designed to determine lase, and glutathione peroxidase) was assessed following drug treatment. whether similar mechanisms of action apply to anthracene Five-week-old BALB/c mice received weekly i.p. injections of each diones and anthracyclines. drug or the drug and ICRF-187 over a 3-month period. ICRF-187 was Another approach to abrogating doxorubicin cardiotoxicity administered 30 mm prior to the anticancer drug. The hearts were has been the use of a cardioprotective agent, ICRF-187 (ADR examined by electron and light microscopy to assess subcellular changes, 529),@ administered just prior to doxorubicin (16, 17). ICRF and the cardiac and hepatic antioxidant levels were measured concur 187 may protect against cardiac damage by preventing the rently. Chronic treatment with these drugs or each combinedwith ICRF 187 did not change the antioxidant levels relative to the control values. induction of oxygen free radicals by doxorubicin (18, 19). In However,all three drugs causedcardiacdamageduringchronicexposure. contrast to its cardioprotective role ICRF-187 acts synergisti Both epirubicin and mitoxantrone caused less severe damage than doxo cally with respect to the cytotoxicity of doxorubicin, actually rubicin, and epirubicin was the least cardiotoxic of the three. ICRF-187 enhancing its antitumor activity (20, 21). These observations was cardioprotectivefor epirubicinand doxorubicinbut not for mitoxant lead to the proposal that the antitumor activity of doxorubicin rone. These results suggest epirubicin acts by a mechanism similar to can be separated from its cardiotoxic action, and these two that of doxorubicin that is probably mediated by oxygen-free radicals, actions may occur by different mechanisms. ICRF-187 is able whilemitoxantroneacts bya differentmechanismto cause cardiotoxicity. to block one mechanism and enhance the other. This work was undertaken to extend previous observations INTRODUCTION (18) about the effect of the combination of cardiotoxic drugs and ICRF-187 on the cardiac antioxidant capacity. In this Doxorubicin is one of the most effective chemotherapeutic particular study three anticancer drugs (doxorubicin, epirubicin, drugs used for cancer treatment, but its usefulness is compro and mitoxantrone) are compared with respect to their effect on mised by the development of chronic dose-dependent cardi cardiac morphology and antioxidant capacity in a chronic otoxicity. One approach to overcoming doxorubicin cardiotox mouse model of cardiotoxicity. The potential cardioprotective icity is to develop structural analogues which retain the anti ability of ICRF-187 when coadministered with each drug is cancer activity but are less or not cardiotoxic. Two of the most evaluated. promising drugs that have been developed include epirubicin, an epimer of doxorubicin, and mitoxantrone, an anthracenedione. MATERIALS AND METHODS Epirubicin has been reported to be less cardiotoxic than its Doxorubicin hydrochloride, epirubicin hydrochloride, and ICRF-l87 parent drug, doxorubicin, and has comparable antitumor activ (ADR-529) were obtained from Farmitalia-Carlo (Milan, Italy). Mi ity (1â€”3).Mitoxantrone was initially described as noncardi toxantrone hydrochloride (Novantrone) was purchased from Lederle otoxic in animal models (4, 5) with an antitumor activity similar Laboratories Division, Cynamid Australia (New South Wales, Aus to that ofdoxorubicin (6),but morerecentstudieshavereported tralia). All other chemicals were obtained from the sources detailed that mitoxantrone is cardiotoxic (7â€”9).Hence these drugs were previously (18). chosen for investigation to assess their cardiotoxic potential Experimental Animals. Female BALB/c mice were obtained from the and to contribute to an understanding of the biochemical mech Walter and Eliza Hall Institute's Breeding Laboratories (Melbourne, anisms involved in cardiotoxicity. Australia) at 5 weeks of age and then used in the experiments. Mice There is growing evidence in the literature that implicates were housed in plastic cages and fed a laboratory diet and water ad libitum. Mice wererandomlydividedinto eighttreatmentgroups,each oxygen free radicals as a primary mechanism in doxorubicin containing four mice which received (a) 0.9% NaCl solution, (b) ICRF cardiotoxicity. Doxorubicin can be reduced by cellular flavoen 187, (c) doxorubicin, (d) doxorubicin and ICRF-187, (e) epirubicin, zymes to a semiquinone free radical. This drug radical is pos (1) epirubicinandICRF-187,(g)mitoxantrone,and(h)mitoxantrone tulated to give rise to oxygen free radicals that can initiate and ICRF-187. The same treatment protocol utilized to develop a cellular damage if they overwhelm the antioxidant defense model for chronic doxorubicin cardiotoxicity was used (18). Briefly, mechanisms. The cardiac antioxidant defenses, which include each mouse, depending on the treatment group, received weekly i.p. injections over a 12-week period ofeither 0.9% NaC1 solution or ICRF Received 6/7/91; accepted 10/18/91. 187 (12.5 mg/kg) 30 mm prior to a 0.9% NaC1 solution, doxorubicin The costs of publication of this article were defrayed in part by the payment (1 mg/kg), epirubicin (1 mg/kg), or mitoxantrone (0.2 mg/kg) injection. of page charges. This article must therefore be hereby marked advertisement in accordancewith 18 U.S.C. Section 1734solelyto indicatethis fact. The totalcumulative doses receivedwere 12mg/kg for both doxorubicin I This study was supported by a grant from the Anticancer Council of Victoria.

2 To whom requests for reprints should be addressed, at Department of Medical 3 The abbreviations used are: ICRF-l87 or ADR-529, (Â±)-l,2-bis(3,5-dioxo Oncology, c/o Post Office, Royal Melbourne Hospital, Victoria, 3050, Australia. piperazinyl-l-yl)propane. 194

Downloaded from cancerres.aacrjournals.org on September 24, 2021. © 1992 American Association for Cancer Research. CARDIOTOXICITYOF DOXORUBICIN, MITOXANTRONE, AND EPIRUBICIN and epirubicin, 2.4 mg/kg for mitoxantrone, and 150 mg/kg for ICRF the Z-bands. In comparison, doxorubicin induced more pro 187. A lower dose of mitoxantrone than of doxorubicin was used, since nounced disorientation of the cristae associated with clearing mitoxantrone has been reported to be 5â€”7timesmore potent and toxic out of the matrix in some mitochondria. These degenerative than doxorubicin in humans (22) and in animal models (4â€”6).One mitochondrial changes caused by doxorubicin were associated week after the final injection cycle the mice were sacrificed, the hearts with the appearance of myelin figures. Furthermore, there was and livers were removed for antioxidant assays, and a portion of the heart was retained for electron microscopy.This study consisted of two marked disruption of the organized myofibrillar array, includ experiments in which a total of6 mice/treatment group (3/experiment) ing misalignment of the Z-bands and myofibrillar lysis, leading were examined by electron and light microscopy, and the cardiac to focal loss of banding in the myocytes following chronic antioxidant capacity was assessed. doxorubicin exposure. Doxorubicin also caused dilation of sarc Antioxidant Assays. The mouse livers and hearts were homogenized otubular and t-tubular systems, separation ofthe adjacent mem and centrifuged to obtain a 100,000 xg supernatant fraction following branes of the intercalated disc, and swelling of the peri a modification of the procedure detailed by Doroshow et aL (10), as nuclear area, changes which were absent with epirubicin treat described previously (18). Aliquots of the tissue homogenate super ment. Neither epirubicin nor doxorubicin affected the mor natants were stored at â€”70Cuntil analysis. However, reduced gluta phology of the endothelial cells. The morphological changes thione is subject to oxidation during long-term storage, and therefore were scored as grade 1 for epirubicin and grade 3 for its concentration was determined within 3 days of sample preparation. The reducedglutathione, superoxide dismutase, glutathione peroxidase, doxorubicin. and catalase assays were performed as specified before (18) using Mitoxantrone was cardiotoxic in this chronic mouse model, previously published methods. with the degree and severity of the morphological changes Electron and Light Microscopy. The interventricular septum was observed in the myocardium being classified as grade 2, mdi dissected from the heart immediately after death and cut into 1-mm3 cating the level of cardiotoxicity lies between epirubicin and piecesbefore fixation in 2% glutaraldehyde, 2% paraformaldehyde, and doxorubicin. The severity of subcellular changes was less 4% glucose in phosphate buffer. To prevent any deterioration in the marked in comparison to doxorubicin (compare Figs. 2A, 2B, heart tissue the whole procedure from death to removal of the heart and 3C). Mitoxantrone treatment induced mitochondrial swell and placement in the fixative was performed rapidly over a 1â€”2mm ing, partial clearing of the matrix in some mitochondria, and period. Standard postbuffering, osmication, and processing conditions the appearance of myelin figures. Vacuolation and swelling of for electron microscopy were followed. For light microscopy examina tion 1-gim sections were taken from the same epon-embedded blocks the cisternae of the sarcoplasmic reticulum and dilation of the used for electron microscopy and stained with toluidine blue 0. Speci t-tubular systems was also evident. Anthracenedione caused mens were examined blind with a Phillips electron microscope, and the slight myofibrillar lysis, but disruption of the band registry was degree of changes in myocardial and endothelial cells was assessed. The not apparent, unlike the effect of exposure to doxorubicin. As frequency and severity of cardiac damage in the myocardial cells were was observed for epirubicin, mitoxantrone did not affect the graded according to a scoring system described by Billingham et a!. morphology of the intercalated disc or the endothelial cells, or (23). The Billingham grade calculated for each treatment group repre cause swelling of the perinuclear zone. Although mitoxantrone sents the average of six animals, taking into account any animal treated hearts showed many ultrastructural changes similar to variability. Several heart specimens (up to eight) from each animal were those induced by doxorubicin, in comparison, a smaller pro assessed and averaged, and the final grade for each treatment group represents this value averaged between six animals. portion of the myocytes showed these alterations. In this study the cardioprotective role of ICRF-187 in com bination with each cardiotoxic drug was examined. ICRF-187 RESULTS was cardioprotective for most of the doxorubicin-induced Morphological Changes. To evaluate the cardiotoxic changes damage, with the remaining morphological changes present induced by the anthracyclines or mitoxantrone, the effect of being judged as grade 1, indicating that less than 5% of the these drugs in a chronic toxicity mouse model was examined. myocytes were affected. The subcellular changes were much Electron microscopy examination of the treated mouse hearts less severe in comparison to doxorubicin alone (compare Fig. was used to assess whether after chronic exposure to the drugs 2, A-C), showingminor mitochondrial swelling and a small with or without ICRF-187 they were cardioprotective or cardi degree of myofibrillar lysis but no disruption of the ordered otoxic, respectively. The results of this study, depicted in Figs. parallel array. The most pronounced toxicity change still pres 1â€”3,were consistent with our previous investigations (18), in ent following doxorubicin and ICRF-187 treatment was dilation that doxorubicin was cardiotoxic and caused typical anthracy of the tubular systems. ICRF-187 was totally protective for the dine-induced ultrastructural changes. Epirubicin and mitoxant epirubicin-induced changes, with the morphology being evalu rone were also cardiotoxic in this mouse model, although the ated as grade 0 (Fig. 3B). However, ICRF-187 was unable to degree of toxicity and the type of subcellular changes varied protect against mitoxantrone-induced damage or affect the between the drugs (Figs. 2, A and B, and 3, A and C). Control degree, severity, or type of subcellular changes observed (com and ICRF-187-treated mice hearts (Fig. 1, A and B) contained pare Fig. 3, C and D). The morphology following mitoxantrone intact mitochondria and an ordered array of myofibrils as and ICRF-187 treatment was classified as grade 2, and the indicated by the parallel alignment of the Z-bands. Slight dila changes were similar to those described for mitoxantrone alone. tion of the sacroplasmic reticulum cisternae was present follow The myocardia of the treated mice were also examined at the ing chronic exposure to ICRF-187 (Fig. 1B). light microscopy level to give an overall view ofthe distribution Chronic epirubicin exposure caused similar ultrastructural of cellular damage among individual myocytes and to indicate changes to doxorubicin, but these changes were much less severe the number of damaged myocytes involved. Control and ICRF (compare Figs. 2, A and B, and 3A). Electron microscopy 187-treated animals contain intact myocytes with no vacuoli examination revealed that epirubicin treatment caused mito zation evident (Fig. 1, C and D). Doxorubicin exposure caused chondrial swelling and minor disruption of the cristae, but very vacuolization and coalescence to form large vacuoles in individ little disorganization of the ordered myofibrillar array was ual myocytes, replacing the normal contractile components, apparent, although minor myofibrillar lysis was present near and the distortion of cross-striations in other myocytes (Fig. 195

CARDIOTOXICITYOF DOXORUBICIN, MITOxANTRONE, AND EPIRUBICIN

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Fig. 1. Electron and light micrographs of myocardium of control and ICRF-l87-treated mice.Mice receivedweeklyinjectionsof saline or ICRF-187 over a 12-week period. The cumu lative dose of ICRF-187 was 150 mg/kg. Light micrographs (C and D) were stained with tolui dine blue 0. A, control; B, ICRF-187; C, control; D, ICRF-187. A and B, x 10,000; C and D, x 40.

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4A). Pretreatment with ICRF-187 prevented the marked my The effect of doxorubicin, epirubicin, mitoxantrone, and the ocytic vacuolization induced by doxorubicin (Fig. 4B). Epirub combination of each drug with ICRF-187 on the cardiac and icin-treated hearts contained vacuolated myocytes scattered hepatic antioxidant capacity is shown in Fig. 5. None of the throughout the myocardium, and the vacuoles were very small cardiotoxic drugs or the drug combinations with ICRF-187 (Fig. 4C). The administration of epirubicin and ICRF-187 caused any significant change in any of the antioxidants ass protected against vacuolization of myocytes, resulting in mor essed when compared with the control value. This result is in phology similar to that of control or ICRF-187-treated mice. consensus with our previous work evaluating the effect of Mitoxantrone exposure induced a lower grade of damage com doxorubicin or doxorubicin and ICRF-187 on cardiac antioxi pared with doxorubicin, observed as pale myocytes containing dants (18). Thus, although electron and light micrographs of many small vacuoles (Fig. 4D). Pretreatment with ICRF-187 the treated hearts demonstrated morphological damage caused did not prevent the myocytic vacuolization caused by mitoxant by the cardiotoxic drugs, this was not accompanied by a depres rone, so that the pattern of damage was similar to that shown sion or elevation of cardiac antioxidant capacity. for mitoxantrone alone. Antioxidant Capacity. Antioxidant levels were assessed in the DISCUSSION hearts and livers of mice chronically treated with the drugs. The liver was used as a control because it appears not to be This investigation has considered the effect of three anti affected by anthracyclines to the same extent as the heart. The cancer drugs on cardiac subcellular structure, antioxidant ca antioxidant levels measured included catalase, superoxide dis pacity, and their interaction with ICRF-187. It was established mutase, and glutathione peroxidase activities and reduced glu that all three drugs were cardiotoxic in this chronic mouse tathione concentration. model to varying degrees. Epirubicin was found to be less 196

Fig. 2. Electron micrographs of myocar dium after ICRF-187 and doxorubicin treat ment.Micereceivedweeklyinjectionsofdox orubicin and/or ICRF-l87 over a 12-week period. 1CRF-187 was administered 30 mm prior to doxorubicin. Cumulative doses were 12 mg/kg for doxorubicin and 150 mg/kg for ICRF-187. A and B, doxorubicin. Mitochon dna contain disrupted cristae and there is some clearing out of the matrices. Separation and lysis of myofibrils results in marked disorgan ization of band registry (A). A loss of myofi brillar structural elements can be seen (B, ar rows). Swelling and vacuolization of the tubu lar systems are evident (s). There is prominent separation of the fascia adherens of inter calated discs(ID). Perinuclearswellingcan be seen around the nucleus (B). C, doxorubicin and ICRF-187. Generally, mitochondria and myofibrils are in good condition, but there is minor myofibrillar lysis, swelling of mitochon dna, and moderate dilation of t-tubular and sacrotubular systems (*) x 10,000.

cardiotoxic than doxorubicin, in agreement with previous find quite dangerous in light of these findings to administer mi ings (1â€”3).Mitoxantrone was evaluated as less cardiotoxic than toxantrone without monitoring for potential cardiotoxicity, doxorubicin because the ultrastructural changes were less severe especially if the patient has had prior doxorubicin treatment. when compared with doxorubicin, in agreement with recent The reason for the differences in cardiotoxicity of mitoxantrone reports in animals (7, 9) and in clinical trials (8, 24, 25). in animal models may be due to species specificity, the drug In this chronic toxicity mouse model the mitoxantrone-in dose, treatment protocol, the route of administration, the dif duced morphological changes were qualitatively similar to those ferent procedures used to evaluate cardiotoxicity, or any com induced by doxorubicin, as reported in another mouse study bination of these factors. (7), but differed from the observations in a rat model, where Neither the cardiotoxic drugs nor the drugs in conjunction not all the typical characteristics of anthracycline damage were with ICRF-187 caused any significant effect on the cardiac or identified (9). In the latter study mitoxantrone, while it was less hepatic antioxidant capacity of these mice after chronic expo cardiotoxic than doxorubicin, caused conspicuous mitochon sure. These results support the findings of a previous study in drial degenerative changes but no sarcotubular dilation or my which only doxorubicin was evaluated (18) and seem to discount ofibrillar disruption. In clinical trials mitoxantrone induced one possible theory for the mechanism of doxorubicin cardi subcellular changes similar to those induced by doxorubicin (8, otoxicity. This theory postulated that doxorubicin may depress 25). The observationthat mitoxantronewascardiotoxic sup the cardiac antioxidant levels, particularly glutathione peroxi ports the recent reports describing the use ofthis drug in clinical dase, while concomitantly increasing oxygen free radical pro trials (8) and discounts the initial premise that the drug was duction, thereby overwhelming the limited cardiac defense sys not cardiotoxic in animal models (4, 5). In fact it would be tem (10). Instead it seems more likely that doxorubicin and 197

@tS Fig. 3. Electron micrographs of myocar dium after ICRF-l87 and epirubicin or mi toxantrone treatment. Mice received weekly @--@â€˜@--@i:'-5- injections of the anticancer drug or the drug and ICRF-187 over a 12-week period. ICRF 187 was administered 30 mm prior to epirub icin or mitoxantrone. Cumulative doses were 12 mg/kg for epirubicin, 2.4 mg/kg for mi toxantrone, and 150 mg/kg for ICRF-187. A, @ epirubicin. There is mitochondrial swelling, A -- â€˜@ B some myofibrillar lysis, and slight dilation of the sacroplasmic reticulum (). B, epirubicin and ICRF-187. Normal morphology showing intact mitochondria and parallel myofibrillar array. C, mitoxantrone. There is mitochon drial swellingand disruption of cristae align @ ment. @,dilationof t-tubules and the cisternae \ -5 @@:/â€˜@ of the sacroplasmic reticulum. Arrows, slight myofibrillar lysis but no disorganization of the

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epirubicin cause cardiac damage by the induction ofoxygen free duced hydroxyl radical production by perfused rat hearts (19). radicals rather than a combined insult on the cellular antioxi It is possible, based on the structural similarities between the dant defenses. Furthermore mitoxantrone did not affect the two anthracyclines, that ICRF-187 prevents epirubicin-induced measured cardiac antioxidant capacity, so it does not appear to damage by a similar postulated mechanism. cause damage by an effect on the myocardial antioxidant The observation that ICRF-187 did not completely protect defenses. against doxorubicin-induced damage, although it did signifi The cardioprotective agent, ICRF-187, prevented cardiac cantly reduce the severity and incidence, is similar to the reports damage induced by epirubicin but not mitoxantrone, which by others (17, 29â€”32).In these studies ICRF-187 achieved suggests that epirubicin acts by a mechanism similar to that of almost complete protection, but some subjects did show slight doxorubicin, whereas mitoxantrone probably acts by a different morphological damage, evaluated as grade 1 or less based on mode of action. We have proposed, based on previous findings, the Billingham grading system (23), while doxorubicin cardiac that ICRF-187 is cardioprotective by preventing the induction lesions were scored as grade 2 or more. The cardioprotection of oxygen free radicals by doxorubicin, probably by complexing offered by ICRF-187 compared to doxorubicin alone was sta iron. Recent evidence has implicated iron as an essential com tistically significant in these cited investigations. In the current ponent in the generation of oxygen free radicals by doxorubicin work the cardiac damage was assessed as grade 1 for doxorub (26, 27). In support of this theory, Hasinoff (28) has shown icin and ICRF-187 and grade 3 for doxorubicin alone. that ICRF-1 87 or its hydrolysis product, ICRF-198, can remove The reason why epirubicin is less cardiotoxic than doxorub iron from a doxorubicin-iron complex. Furthermore, it has icin is unknown, but it may be related to its ability to generate been demonstrated that ICRF-187 prevented doxorubicin-in oxygen free radicals and/or its stimulation oflipid peroxidation. 198

CARDIOTOXICITYOF DOXORUBICIN, MITOXANTRONE, AND EPIRUBICIN

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)55 Fig. 4. Light micrographs of myocardium after doxorubicin, mitoxantrone, or epirubicin treatment. Mice received the drugs as de scribed in Figs. 2 and 3. 4, doxorubicin; large coalscent vacuoles contained in myocytes and distortion of cross-striations. B, doxorubicin and ICRF-187; C, epirubicin;some myocytes contain small vacuoles. D, mitoxantrone; pale myocytes containing small vacuoles. No dis .-- @@ ruption ofthe myofibrillarstructure.Toluidine [email protected] Â¶W@@ @. @@@ blue0 stain, x 40. . ,@S_ @4 @@@@ S... @â€˜ @--? -. .-@@Tf@4S@@S-?

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This concept is supported by studies using acute and chronic may be the fact that it has pharmacokinetic properties different models comparing these two drugs, which demonstrated that from those of doxorubicin (3). the hearts exhibited less oxidative stress, measured as endoge Although chemically distinct from anthracyclines, mitoxant nous lipid peroxidation and hydroperoxide-initiated chemilu rone contains quinone functional groups, which suggests that minescence, for epirubicin compared with doxorubicin (1, 33). it may function in a way similar to that of doxorubicin, causing However, other investigations have been unable to detect any cardiotoxicity by an oxygen free radical-mediated mechanism. difference in the ability of the two anthracyclines to generate However, the observation that ICRF-187 does not prevent drug superoxide anions (34) or promote lipid peroxidation (14). induced damage suggests that mitoxantrone acts by a mecha Although it must be noted that these later studies were under nism in the heart different from that of anthracyclines. This is taken using in vitro systems composed of hepatic microsomes supported by published evidence which has reported that mi and the drug or subcellular-free incubations of the drug and toxantrone is not activated to its drug free radical form by iron, Llesuy et a!. (1, 33) examined the heart's capacity for lipid cellular reductases (12), it is unable to generate oxygen free peroxidation after drug treatment, which may explain the dif radicals (12, 15), and it does not stimulate but actually inhibits ferences in observations. Alternatively, it has been postulated lipid peroxidation (13, 14). In contrast, doxorubicin is activated that doxorubicin may be cardiotoxic by affecting cardiac to a semiquinone radical by reductases, and it stimulates oxygen calcium concentration. In comparison to doxorubicin, epirubi free radical production and lipid peroxidation. These observa cm causes less pronounced inhibition of calcium turnover in tions collectively suggest that mitoxantrone does not act by a cultured heart cells (35) and less inhibition of the Na@/Ca2@ mechanism similar to that of anthracyclines. pump (36), which may explain its lower cardiotoxicity. Another However, mitoxantrone does generate a free radical signal by factor contributing to the reduced cardiotoxicity of epirubicin a mechanism different from that of anthracyclines (37, 38). 199

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Fig. 5. Antioxidantlevelsafterchronicexposureto the drugs as described in Figs. 1-3. A, glutathione peroxidase activity, B, superoxide dismutase activity; C, catalase activity, D, reduced glutathione concentra tion. Columns, mean for six animals bars, SD. SOD, 400 superoxide dismutase; GP, glutathione peroxidase; C GSH, reduced glutathione; ICRF, ICRF-187; DOX, I- doxorubicin;EPI, epirubicin;MIT, mitoxantrone. 300 I-.; a. 200 Ca 100 U C., 0 HEART LIVER HEART LIVER ORGAN ORGAN

Mitoxantrone is activated by peroxidases in an oxidative proc G. Cardiacmorphologicalandfunctionalchangesinducedby epirubicin chemotherapy. J. Clin. Oncol., 7: 947â€”958,1989. ess to a N-centered free radical, and it is not a substrate for the 3. Casazza, A. M. Experimental studies on new anthracyclines. In. M. Ogawa, cellular reductases which activate doxorubicin, thus explaining E. M. Muggia, and M. Rozencweig (eds.), Adriamycin: Its Expanding Role in Cancer Treatment, pp. 439-451. Amsterdam: Excerpta Medica, 1984. its previous inability to produce oxygen free radicals (12, 38, 4. Henderson, B. M., Dougherty, W. R., James, V. C., Tilley, L P., and Noble, 39). The mitoxantrone free radical reacts with hydroperoxy J. F. Safety assessment of a new anticancer compound, mitoxantrone, in fatty acids, thereby inhibiting lipid peroxidation in the propa beagledogs:Comparison with doxorubicin.I. Clinicalobservations.Cancer Treat.Rep.,66: 1139â€”1143,1982. gation stage (13). Also, mitoxantrone inhibits prostaglandin 5. Sparano, B. M., Gordon, G., Hall, C., Iatropoulos, M. J., and Noble, J. F. synthesis, probably by interfering with the regulatory processes Safetyassessment of a new anticancer compound, mitoxantrone, in beagle inherently dependent on hydroperoxy fatty acids (40, 41). The dogs: comparison with doxorubicin. II. Histologic and ultrastructural pa thology.Cancer Treat. Rep., 66: 1145â€”I158,1982. relevance of this mechanism to cardiotoxicity at present is still 6. Wallace, R. E., Murdock, K. C., Angler, R. B., and Durr, F. E. Activity of a unclear. Possibly the mitochondrial and tubular calcium levels novel anthracenedione,l,4-dihydroxy-5,8-bis@{@2-4(2-hydroxyethyl)amino@ ethyl@aminoJ@-9,10-anthracenedionedihydrochloride,against experimental are altered by a hydroperoxide-mediated process (41), thus tumors in mice. Cancer Res., 39: 1570â€”1574,1979. affecting mitochondrial function and excitation coupling for 7. Perkins, W. E., Schroeder, R. 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Downloaded from cancerres.aacrjournals.org on September 24, 2021. © 1992 American Association for Cancer Research. Comparative Study of Doxorubicin, Mitoxantrone, and Epirubicin in Combination with ICRF-187 (ADR-529) in a Chronic Cardiotoxicity Animal Model

Patricia M. Alderton, Janet Gross and Michael D. Green

Cancer Res 1992;52:194-201.

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