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Drug resistance parallels in cancer overexpression of drug resistance proteins

Drug resistance is not unique to epilepsy or indeed neurology. It may occur in other chronic conditions such as arthritis. Resistance has been studied most comprehensively in oncology. Laboratory studies show that resistance to anticancer drugs at a cellular level involves many mechanisms including reduced drug uptake, increased drug metabolism, alterations in intended drug targets, altered survival mechanisms, especially reduced induction of apoptosis and increased transport of anticancer drugs from the cell. Transport-based resistance mechanisms have been amongst the most intensively studied 18 . Many anticancer drugs are derived from natural product toxins. A number of innate host transporters have evolved to protect cells and organisms from such toxins by removing the toxins from cells or their environment. These transporters are widely distributed amongst living organisms and tend to share highly conserved amino acid and structural sequences. They possess the general ability to...

Cancer

Seizures in cancer patients may be due to several mechanisms (i) metabolic abnormalities (ii) chemotherapeutic agents (iii) vascular events including embolic events from non-bacterial thrombotic endocarditis (iv) radiation injury (v) tumour itself or direct invasion of the brain or leptomeninges and (vi) central nervous system opportunistic infections 63 and paraneoplastic disease.

Pgp in cancer

Cancer Multidrug Resistance

Drug resistance, either intrinsic or acquired, is a frequently encountered problem in the failure of antineoplastic agents. Pgp, an efflux pump that extrudes hydrophobic cytotoxic drugs from cancer cells, plays a key role in multidrug resistance (MDR) and may contribute to clinical drug resistance. Pgp is a 170 kDa cell-surface glycoprotein, encoded for by the MDR1 gene (Riordan & Ling 1985). The presence of MDR has been correlated with poor outcome in acute myeloid leukaemia, non-Hodgkin's lymphoma, acute lymphoblastic leukaemia and multiple myeloma (Arceci 1993, Fojo et al 1987, Goldstein et al 1990, Campos et al 1992). Many chemotherapeutic agents were also confirmed to be excellent substrates for the Pgp pump (Pastan & Gottesman 1987, Dorr et al 1987, Ford & Hait 1990, Epstein et al 1989, Herweijer et al 1990, Campos et al 1992). Many studies analysed the expression of Pgp in normal and malignant tissues and found that several tumours that showed high levels of expression of Pgp...

Associations and Seizures and Epilepsy

This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation.

The MDR phenomenon transporters involved

Chemotherapy is often ineffective in the treatment of cancer the tumour cells of a large number of patients are either inherently drug-resistant or a drug-resistant phenotype may develop during the treatment. It is generally accepted that in the majority of the cases the molecular basis of multidrug resistance (MDR) is the overexpression of the so-called multidrug transporters. Elevated expression of these proteins was found in drug-resistant tumour cells of patients as well as in cell lines exposed to selection by increasing concentration of cytotoxic compounds. At the time of writing, it is well established that there are three major multidrug transporter proteins contributing to the MDR phenotype P glycoprotein (Pgp also known as multidrug resistance protein MDR1 or ABCB1, according to the Gene Nomenclature Database (http the multidrug resistance-associated protein 1 (MRP1 ABCC1) and the breast cancer resistance protein (BCRP ABCG2). The multidrug transporters belong to the ATP...

Drug transport systems across the bloodbrain barrier drug resistance proteins

Many drugs have been shown to be actively removed from the brain by transport systems (some referred to as 'drug resistance' systems), and the relevant genes and transporter proteins have been identified. Genes for the latter include MDR1 (p-glycoprotein multiple drug resistance protein) and MRP1. Their importance has long been known in cancer therapy, but recent interest has focused on antiepileptic drugs. P-glycoprotein mediates the absorption of drugs such as phenytoin, phenobarbital, lamotrigine and felba-mate across the blood-brain barrier and over-expression may be one mechanism of drug resistance. While this is an obviously attractive idea, there is little evidence currently to support it. Another attractive postulate is that genetic variations in these drug-resistance proteins can affect concentrations of antiepileptics in the brain and thus their efficacy, and this is an area of active research. P-glycoprotein is also found in the gastrointestinal tract, but its effect on...

Vocabulary Builder

Steroid A group name for lipids that contain a hydrogenated cyclopentanoperhydrophenanthrene ring system. Some of the substances included in this group are progesterone, adrenocortical hormones, the gonadal hormones, cardiac aglycones, bile acids, sterols (such as cholesterol), toad poisons, saponins, and some of the carcinogenic hydrocarbons. eu

Pharmacokinetic interaction

Over the course of these trials, a new complication inherent in studies employing Pgp antagonists was recognized. When cyclosporin was used as the antagonist, the dose of the anticancer agent had to be reduced in order to avoid excess toxicity. Pharmacokinetic studies demonstrated that anticancer drug clearance was reduced, resulting in a prolonged terminal half-life, and an increased area under the concentration curve (AUC). If the dose of the anticancer agent was reduced, then the observed toxicity could be equalized to that observed for the anticancer agent in the absence of cyclosporin. Figure 1 represents a model of the AUC curves for anticancer agents with and without the addition of a Pgp antagonist. It was hoped that the AUCs would be more or less comparable, and efficacy would be FIG. 1. Model of AUC curves for anticancer agents. FIG. 1. Model of AUC curves for anticancer agents. improved (panels A and B). The cyclosporin analogue and more potent Pgp antagonist PSC 833 also...

Interpatient variability

As noted above, studies reporting PK from trials in which a reduced anticancer drug dose was required, suggested that there was the risk of reduced drug exposure. Since dose reductions are determined by defining maximal tolerated dose in conventional Phase I dose escalation schedules, there is no opportunity to individualize dosing. The well-known interindividual variation in P450 activity may result in interindividual variation in the pharmacokinetic interaction observed when a Pgp antagonist is combined with an anticancer drug (Thummel et al 1994). In our recently reported Phase I study of paclitaxel (Taxol) in combination with PSC 833, the maximum tolerated dose of paclitaxel was 17.5 mg m2 when administered over 96 h in combination with PSC 833 (Chico et al 2001). This dose was half that administered over 96 h without PSC 833 (Wilson et al 1994). However, in some patients, the reduced dose of paclitaxel administered with PSC 833 appeared to be insufficient, in that little bone...

Realistic expectations

TABLE 5 Expression of MDR1 in selected cell lines and cancer samples assayed by quantitative PCR method2 TABLE 5 Expression of MDR1 in selected cell lines and cancer samples assayed by quantitative PCR method2 Breast cancer samples analysed for MDR1 expression, it was observed that levels typically ranged up to 10-fold above the levels observed in the 'sensitive cells'. This type of expression could be expected to alter intracellular drug concentrations, but not to confer the tremendous degree of resistance observed in the in vitro selected models, or in the tumours of previously heavily pretreated cancer patients. Thus, overly high expectations led to the original home-run designs in the clinical trials, and ultimately to disappointment in the results obtained. More realistic expectations will lead to better trial design, and potentially, proof of concept for Pgp inhibition.

Clinical development of P glycoprotein modulators in oncology

The last two decades have witnessed dramatic advances into the mechanisms of drug resistance in cancer. The identification of P glycoprotein (Pgp) as a specific mechanism led to the initial hope and expectation that it would be possible to modulate this and increase sensitivity to drug therapy. Clinical trials using first- and second-generation Pgp modulators did establish proof of principle that in some settings, clinical drug resistance could be overcome with the addition of a Pgp modulator for example, clinical resistance to paclitaxel, a Pgp substrate, in women with ovarian cancer was shown to be overcome in approximately 20 with the addition of PSC 833, a highly effective Pgp modulator. However, evolutionary and adaptive redundancy in resistance mechanisms have tempered clinical results, even with very effective second- and third-generation modulators. The lessons from oncology establish sound methodology for the evaluation of Pgp modulators for safety, tolerability...

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Elude organ failure, ischaemia hypoxia, electrolyte and endocrine disturbance, drugs and drug withdrawal, cancer and systemic disease affecting the CNS 10 , The underlying cause may be reversible, although provoked seizures do heighten the risk of later (spontaneous) seizures. Typically, reversible brain insults do not result in parenchymal damage. By contrast, when cortical damage follows the insult, the risk of subsequent symptomatic seizures increases. Chronic seizures that follow brain insults are categorized as remote symptomatic.

Treatment And Outcome

The patient underwent a right temporal lobectomy. Pathological examination of the resected tissue was consistent with hippocampal sclerosis. During the year that elapsed after our initial meeting, her father was diagnosed with Alzheimer's disease, her mother developed breast cancer, and a close male friend was diagnosed with testicular cancer.

Monitoring Patients May Be More Important Than Their Laboratory

The patient's past medical history was significant for diabetes mellitus, mild congestive heart failure following three-vessel coronary artery bypass graft surgery 4 years previously, chronic obstructive pulmonary disease, depression, rheumatoid arthritis and colostomy for resected colon cancer. Medications included phenytoin as above, insulin (Humulin 70 30) 20 units subcutaneously in the morning and 10 units in the evening, clopidogrel 75 mg day, amitriptyline 25 mg day at bedtime and sertraline 100 mg day in two divided doses. Her only known allergy was to penicillin. She had a previous history of smoking, no history of alcohol or drug abuse and a strong family history of diabetes and coronary artery disease in middle age.

Entitled to Respect A National Survey of Teens Attitudes and Behaviors About Epilepsy and Acceptance Executive Summary

Summary Entitled to Respect A National Survey of Teens' Attitudes and Behaviors About Epilepsy and Acceptance Executive Summary summarizes the results of a survey of teens' attitudes and behaviors about epilepsy. The survey consisted of a questionnaire that was distributed to teens throughout the United States by 20 affiliates of the Epilepsy Foundation from March through July 2001 in schools selected by the affiliates. The questionnaire asked about respondents' (1) demographics (2) awareness of epilepsy (3) knowledge of epilepsy (4) perceived stigmas associated with epilepsy and (5) awareness of muscular dystrophy, human immunodeficiency virus infection acquired immunodeficiency syndrome, arthritis, diabetes, breast cancer, and Parkinson's Disease. Results are based on 19,441 usable questionnaires. Thirty-six percent of the respondents felt that kids with epilepsy are likely to get picked on or bullied more than other kids. Only 25 percent felt this is unlikely to happen. Thirty-one...

Evidence for overexpression of drug resistance proteins in human epilepsy

The study of fixed material cannot determine whether the proteins detected are functionally active. Absence or inhibition of MDR1 and MRP1 can lead to excessive cerebrospinal fluid penetration of a range of molecules 32,36 , and overexpression is associated with resistance to anticancer treatment in some neurological malignancies 52 . Given the known transport capacity of MDR1 in

Biological Based Therapies

Herbal therapy employs an individual herb or a mixture of herbs for healing purposes. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals such as magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and the use of bee pollen to treat autoimmune and inflammatory diseases.

Manipulative and Body Based Methods

Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.

Gene expression profiling of epothilone Aresistant cells

A major obstacle to the effective treatment of cancer is the intrinsic or acquired resistance to chemotherapeutic agents. One form of drug resistance, known as multidrug resistance (MDR), is a phenomenon whereby cells that acquire resistance to certain cytotoxic drugs generally demonstrate cross-resistance to other, sometimes structurally and functionally unrelated drugs. Several mechanisms that mediate MDR have been identified. P glycoprotein (Pgp) is a known mediator of MDR. However, failure to completely sensitize some drug resistant tumours to chemotherapy using Pgp-reversing agents suggests the existence of multiple mechanisms of cancer drug resistance. Selecting resistant cells to non-Pgp substrates would reveal novel mechanisms of resistance. exhibit cytotoxic activity (Bollag et al 1995). Epothilones, like Taxol, have the ability to arrest cells in mitosis, bind directly to tubulin and microtubules, cause formation of bundles of intracellular microtubules in non-mitotic cells...

P glycoprotein and the mechanism of multidrug resistance

The human P glycoprotein (Pgp MDR1) is an ATP-driven transporter for hydrophobic drugs and causes multidrug resistance in cancer. Our knowledge related to the mechanistic details of the ATP hydrolytic cycle of MDR1 has recently significantly progressed due to studies on the formation of a catalytic intermediate (occluded nucleotide state). According to the most accepted current model, both catalytic sites in MDR1 are active and ATP is hydrolysed alternatively within the two sites. ATP hydrolysis at one site triggers conformational changes within the protein resulting in drug transport, while hydrolysis of a second ATP molecule (at the other site) is required for resetting the initial ('high-affinity binding') conformation. The two active sites act in a cooperative manner and experiments support a model where the two ATP binding cassette (ABC) domains form a coupled catalytic machinery. Although no high resolution structure is available as yet, some relevant structural...

Inflammatory and immunological diseases of the nervous system

Paraneoplastic disorders can cause seizures. Epilepsia partialis continua (EPC) can occur as a paraneoplastic phenomenon. This is usually in the context of a paraneo-plastic 'cortical encephalomyelitis' due to various tumours (notably small cell lung cancer and breast carcinoma). The MRI scan can show non-specific T2 signal changes. Seizures also occur in limbic encephalitis of paraneoplastic origin often associated with memory loss, psychiatric and behavioural changes.

Drug resistance in epilepsy human epilepsy

The basis of drug resistance in human epilepsy is not understood. Parallels with resistance in cancer suggest that drug resistance proteins may have a role. To examine this possibility, we have studied human brain tissue containing pathologies capable of causing refractory epilepsy. Using immunohistochemistry for P glycoprotein (Pgp) and multidrug resistance-associated protein 1 (MRP1), we examined both pathological tissue and control tissue. We demonstrate expression of Pgp and MRP1 in glia from cases of malformation of cortical development studied both before and after the onset of epilepsy, as well as in cases of hippocampal sclerosis and dysembryoplastic neuroepithelial tumours. In one particular type of malformation, we also demonstrate that dysplastic neurons express MRP1. The pattern of immunolabelling suggests overexpression is concentrated particularly around vessels in most of the pathologies. The timing shows that expression may be constitutive in some...

Use of Pgp modulators in oncology

Some of the earliest modulators (first generation) were agents that were in clinical use and were found to have a general mild Pgp modulating ability. Examples are verapamil, cyclosporin and tamoxifen. The advantages with these agents were the general familiarity with longer-term use and knowledge of chronic toxicity. Limitations were the lack of specificity of action, poor therapeutic ratio and possibility of pharmacokinetic interaction with other drugs (particularly with agents such as cyclosporin). These agents were subsequently combined in different schedules with cyclical chemotherapy to see if the anticancer effect of chemotherapy could be enhanced.

Expression and activity in vivo

Resistance Epileptic

The human MDR1 gene encodes an integral membrane protein, P glycoprotein (Pgp), whose function is the energy dependent export of substances from the inside of cells, and from membranes, to the outside. Its physiological role is the protection of cells from toxic substances or metabolites. Many drugs that have been developed for the treatment of human diseases are substrates of Pgp. Because of that, the degree of expression and the functionality of the MDR1 gene product can directly affect the therapeutic effectiveness of such agents. This is of particular importance in cancer therapy where high expression and activity of MDR1 causes cancer cells to become refractory to the treatment with many agents, all of which are Pgp substrates. MDR1 is also expressed on different non-malignant cells in various organs, e.g. in the intestine and at the blood brain barrier. Modulation of MDR1 expression in these normal cell types can also influence the activity and bioavailability of...

Drug resistance caused by multidrug resistanceassociated proteins

Department of Ophthalmogenetics, The Netherlands Ophthalmic Research Institute, Meibergdreef47, 1105 BA, Amsterdam and Divisioon oof Molecular Biology, The Netherlands Cancer lnstitute,Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands Abstract. Three types of drug efflux pumps, the multidrug resistance gene 1 (MDR1 or ABCB1)-encoded P glycoprotein, the multidrug resistance-associated protein (MRP or ABCC1) and breast cancer resistance protein (BCRP or ABCG2) may play an important part in the intrinsic or acquired defence of cells against drugs. Recent studies have begun to show the broad tissue distribution and drug substrate specificity of the seven MRP family members (MRP1-7 or ABCC1-6 and ABCC10). MRPs are (multispecific) organic anion transporters, which can transport negatively charged anionic drugs and neutral drugs conjugated to glutathione, glucuronate or sulfate. MRP4 and MRP5 broaden the spectrum of drug resistance to nucleotide analogue drugs. Some MRPs can also...

Reversal of multidrug resistance lessons from clinical oncology

Molecular Therapeutics Section, Medicine Branch, National Cancer Institute, Bethesda, MD 20892, USA The history of multidrug resistance begins with the 1973 discovery by Keld Dano of the active outward transport of daunomycin in drug-resistant cells that had been selected in daunomycin, but were cross-resistant to doxorubicin and the vinca alkaloids (Dano 1973). A series of studies then described the multidrug resistance (MDR) phenotype in which cells selected for drug resistance in a single anticancer agent developed resistance to a variety of structurally unrelated compounds. Victor Ling, with other investigators, correlated overexpression of a 170 kDa protein termed P glycoprotein (Pgp) with reduced drug accumulation and multidrug resistance in a series of mammalian cell lines (Kartner et al 1983). The gene encoding Pgp was cloned and named the MDR1 gene expression of this gene was found in a variety of cancers. In some tumours expression was found at the time of diagnosis (kidney,...

Dedication

This book is dedicated to the life and memories of A. James Rowan, who lost his battle with cancer on August 27, 2006. Jim was a quiet man of modest physical stature, but he was a giant in the eyes of his family, friends, and colleagues. He always commanded our attention and gained our deep respect in everything he did. How will we remember him A colleague and good friend, Jim Cloyd, said it well ''I will always remember Jim standing with his hands on his hips and his head slightly cocked, with an impish grin on his face.''

Subject index

Balloon cells 170,172,176 bare lymphocyte syndrome 21 BCRP see breast cancer resistance protein BEfx 59 137-138 MDR1 expression 33-34 MRP expression 33-34 new connection formation 13 protection by MRP1 72-74 syndromes 5 breast cancer resistance protein (BCRP) 21, CNQX 190 colchicine 141-142 colon cancer 104 complex partial seizures 10 contraceptives, male 73 cortical malformations and intractability 7,10 Pgp and MRP1 expression 169-170, 172 cortical slices 186-199 neuronal properties 188 preparation 187-188 synapatic responses 188-191 (OATP) family 42, 49 ovarian cancer 117 214-215 cancer 104-107 choroid plexus 42, 50 drug binding sites 43 drug interaction 50-51 electron microscopy 43 epothilone A-resistance 123-124 functional diversity 107 gain-of-function 66 in glia 33

Chairs introduction

BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC, Canada V5Z 4E6 are able to kill certain parasites and on the other hand are not going to cause too much harm to the host organism when applied in effective doses. This is a paradigm that has driven both antibiotic development and also the concept of cancer chemotherapy. Many years later Erlich lamented that drug resistance has followed the development of new drugs 'like a faithful shadow'. I want to give a brief history of the development of P glycoprotein (Pgp) and the mechanism of drug resistance. Drug resistant clones of cells were derived, and these all turned out to be multidrug resistant (MDR). We identified Pgp as a highly over-expressed protein that was the causative mechanism of resistance by cloning the gene, transfecting it into a naive cell and showing that it caused a similar MDR phenotype. We found where it was localized and we purified and characterized it. We looked for expression in human cancers and normal...

Imaging studies

Another important lesson learned from clinical trials with Pgp antagonists has been the need for imaging studies. No anticancer agents were developed with confirmation of drug distribution into solid tumours penetration was assumed from the success of the agents. As the first generation of Pgp antagonist trials failed to provide a role for Pgp antagonists in the clinic, the questions emerged These studies also confirmed increased uptake in tumours in a subset of patients, suggesting that these third generation Pgp antagonists are able to penetrate tumours and reverse Pgp in cancer cells.

SM Sisodiya

Whilst for most patients with epilepsy, seizures come under control easily, in about one-third of adult and childhood cases, seizures continue to occur despite antiepileptic drug (AED) treatment. Comparatively little study has been undertaken to examine the causes of resistance to treatment. Cases are labelled medically refractory, are possibly considered for surgery or gravitate in specialist clinics, receiving successive novel or trial AEDs. More recently, increasing attention has been paid to the possible mechanisms of resistance to AED treatment, partly as a result of consideration of similar problems in cancer. Only a rational understanding of the underlying mechanisms can provide solutions to the problem of drug resistance. In this chapter, the problem and potential causes are considered.

Conclusions

The study of drug resistance in epilepsy has just begun. There is evidence that drug transport proteins known to contribute to anticancer drug resistance are overexpressed in brain tissue from patients with refractory epilepsy. There is also evidence that some AEDs are substrates for MDRl-mediated transport. It is also unlikely that other AEDs are not substrates for one or other of the 50 or so transporters now recognized. Whilst the parallels between cancer and epilepsy are limited, the neuroscience community could benefit from the experience of cancer researchers, because drug resistance is likely to be a complex and adaptive phenomenon, as might be expected of a biological response crucial to the survival of an organism in a changing toxin-laden environment. Study of the basis of drug resistance in epilepsy may reveal new aspects of epileptogenesis, allow early prediction of poor response to AED treatment, enhance understanding of normal brain function and should offer new...

Neoplastic Disorders

Seizures may occur in cancer patients from either direct invasion, secondary electrolyte abnormalities, paraneoplastic syndrome, infection, or drug effect from chemotherapy. The incidence of seizures complicating the treatment of systemic cancer in children has been between 4.5 and 14 (202, 203). Seizures have been seen with a variety of neoplasms, with about half as a complication of treatment and the rest by direct tumor invasion (203). Leukemia is the most common neoplasm associated with seizures, accounting for about half overall (204). In patients with leukemia, 47 had a cerebral lesion at the time of first seizure (205). Imaging abnormalities seen in leukemia include sinus and cortical vein thromboses, cerebral hemorrhage, meningeal leukemia, infection, leukemic infiltration, leukoencephalopathy, and radiation necrosis (206). Although seizures may result from metabolic derangements, medications may also be the primary risk examples of these medications would include...

Results

The best characterized mechanisms of resistance to anticancer drugs are those mediated by the multidrug transporters Pgp and MRP, and cells that overexpress these transporters are usually resistant to a wide variety of drugs. Pgp and MRP are plasma membrane ATP-dependent pumps that efflux a large variety of cytotoxic drugs out of the cell, resulting in a phenomenon referred to as multidrug resistance (MDR). In Pgp-mediated MDR, increased resistance is associated with increased expression of Pgp. To determine whether epothilone resistance might be mediated by Pgp and or MRP, the levels of expression of these drug transporters were compared in sensitive, epothilone A-resistant and Taxol-resistant MDR cells by western immunoblotting. As shown in Fig. 2, the Taxol-selected multidrug-resistant MDA T0.1 cells and the Adriamycin-selected multidrug-resistant HL60 cells expressed Pgp and MRP, respectively. However, these transporters were not

Acknowledgements

Quality of life in cancer patients an hypothesis. J Med Ethics, 10, 124-7. Fraser, S.C.A., Ramirez, A.J., Ebbs, S.R. et al. (1993). A daily diary card for quality of life measurement in advanced breast cancer trials. Br J Cancer, 67, 341-6. Geddes, D.M., Dones, L., Hill, E. et al. (1990). Quality of life during chemotherapy for small cell lung cancer assessment and use of a daily diary card in a randomised trial. Eur J Cancer, 26, 484-92.