The Pharmacogenomics Journal (2005) 5, 226–243
& 2005 Nature Publishing Group All rights reserved 1470-269X/05 $30.00
Genetic factors influencing Pyrimidine-
antagonist chemotherapy
JG Maring1
HJM Groen2
FM Wachters2
DRA Uges3
EGE de Vries4
1
Department of Pharmacy, Diaconessen Hospital
Meppel & Bethesda Hospital Hoogeveen, Meppel,
The Netherlands; 2Department of Pulmonary
Diseases, University of Groningen & University
Medical Center Groningen, Groningen, The
Netherlands; 3Department of Pharmacy,
University of Groningen & University Medical
Center Groningen, Groningen, The Netherlands;
4
Department of Medical Oncology, University of
Groningen & University Medical Center
Groningen, Groningen, The Netherlands
Correspondence:
Dr JG Maring, Department of Pharmacy,
Diaconessen Hospital Meppel & Bethesda
Hospital Hoogeveen, Hoogeveenseweg 38,
7943KA Meppel, The Netherlands.
Tel: þ 31 522 234900
Fax: þ 31 522 243900
E-mail: maring@diacmeppel.nl
Received: 17 December 2004
Revised: 3 May 2005
Accepted: 5 May 2005
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REVIEW
ABSTRACT
Pyrimidine antagonists, for example, 5-fluorouracil (5-FU), cytarabine (ara-C)
and gemcitabine (dFdC), are widely used in chemotherapy regimes for
colorectal, breast, head and neck, non-small-cell lung cancer, pancreatic
cancer and leukaemias. Extensive metabolism is a prerequisite for conversion
of these pyrimidine prodrugs into active compounds. Interindividual
variation in the activity of metabolising enzymes can affect the extent of
prodrug activation and, as a result, act on the efficacy of chemotherapy
treatment. Genetic factors at least partly explain interindividual variation in
antitumour efficacy and toxicity of pyrimidine antagonists. In this review,
proteins relevant for the efficacy and toxicity of pyrimidine antagonists will
be summarised. In addition, the role of germline polymorphisms, tumour-
specific somatic mutations and protein expression levels in the metabolic
pathways and clinical pharmacology of these drugs are described. Germline
polymorphisms of uridine monophosphate kinase (UMPK), orotate phos-
phoribosyl transferase (OPRT), thymidylate synthase (TS), dihydropyrimidine
dehydrogenase (DPD) and methylene tetrahydrofolate reductase (MTHFR)
and gene expression levels of OPRT, UMPK, TS, DPD, uridine phosphorylase,
uridine kinase, thymidine phosphorylase, thymidine kinase, deoxyuridine
triphosphate nucleotide hydrolase are discussed in relation to 5-FU efficacy.
Cytidine deaminase (CDD) and 50 -nucleotidase (5NT) gene polymorphisms
and CDD, 5NT, deoxycytidine kinase and MRP5 gene expression levels and
their potential relation to dFdC and ara-C cytotoxicity are reviewed.
The Pharmacogenomics Journal (2005) 5, 226–243. doi:10.1038/sj.tpj.6500320
Keywords: pyrimidine antagonists; 5-fluorouracil; gemcitabine; cytarabine; poly-
morphisms; mutations; gene expression
INTRODUCTION
Pyrimidine antagonists belong to the group of antimetabolite anticancer drugs
and show structural resemblance with naturally occurring nucleotides (see Figure
1). Their action is accomplished through incorporation as false precursor in DNA
or RNA or through inhibition of proteins involved in nucleotide metabolism.
The most commonly used pyrimidine antagonists are 5-fluorouracil (5-FU),
gemcitabine (dFdC) and cytarabine (ara-C). Newer oral variants of 5-FU are
capecitabine and tegafur. 5-FU and its analogues are used, for example, in the
treatment of colorectal, breast and head and neck cancer,1–3 whereas dFdC is
especially prescribed for non-small-cell lung cancer and pancreatic cancer.4,5 Ara-
C is used in the treatment of leukaemia.6 All pyrimidine antagonists are prodrugs
and intracellular conversion into cytotoxic nucleosides and nucleotides is
needed to produce cytotoxic metabolites. Proteins, involved in pyrimidine

Figure 1 Overview of the chemical structures of the naturally occurring pyrimidines cytosine and uracil and the synthetic pyrimidine
analogues cytarabine, dFdC, capecitabine, 5-Fu and tegafur.
metabolism, handle these synthetic drugs, as if they were
naturally occurring substrates. The extensive metabolism of
pyrimidine antagonists implies that the intracellular con-
centrations of cytotoxic metabolites, thus indirectly the
potential antitumour effects, largely depend on intracellular
metabolic enzyme activity.
The aim of this review is to summarise pharmacogenomic
data regarding proteins related to the efficacy and toxicity of
pyrimidine antagonists and to identify potential predictive
and/or prognostic genetic factors for toxicity and treatment
outcome. The impact of germline polymorphisms as well as
tumour-specific somatic mutations and protein expression
levels on the clinical pharmacology and metabolic pathways
of these drugs will be discussed.
Metabolic Pathways of Pyrimidine Antagonists
5-Fluorouracil
The anabolic conversion of 5-FU into nucleotides is essential
for its action. Several enzymes of the pyrimidine metabolic
pathway are required for the conversion of 5-FU to
nucleotides.7 Cytotoxic nucleotides can be formed by three
routes, as illustrated in Figure 2: (1) conversion of 5-FU to 5-
fluoro-uridine-monophosphate (FUMP) by orotate phos-
phoribosyl transferase (OPRT); (2) sequential conversion of
5-FU to FUMP by uridine phosphorylase (UP) and uridine
kinase; (3) sequential conversion of 5-FU to 5-fluoro-deoxy-
uridine-monophosphate (FdUMP) by thymidine phospho-
rylase (TP) and thymidine kinase (TK).8 The antitumour
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JG Maring et al
227
activity results from inhibition of thymidylate synthase (TS)
by FdUMP, as well as from incorporation of 5-FU metabolites
into RNA and DNA. Only a small part of the 5-FU dose is
activated via these routes, as in humans 80–90% of the
administered dose is degraded to 5,6 dihydrofluorouracil
(DHFU) by dihydropyrimidine dehydrogenase (DPD). DHFU
can be further degraded to fluoro-b-ureidopropionate
(FUPA) by dihydropyrimidinase (DPYS) and subsequently
to fluoro-b-alanine (FBAL) by b-ureidopropionase (BUP1). 5-
FU degradation occurs in all tissues, including tumour
tissue, but is highest in the liver.9
Capecitabine and tegafur
Capecitabine is an oral prodrug of 5-FU. After absorption
from the gut, capecitabine is converted into 50 -deoxy-5-
fluorocytidine (50 -dFCR) by carboxyl-esterase in the liver,
and subsequently further converted into 50 -deoxy-5-fluoro-
uridine (50 -dFUR) by cytidine deaminase (CDD). Finally, 5-
FU results from bioconversion of 50 -dFUR by TP10 (see Figure
2). Tegafur is another oral 5-FU prodrug, that is converted
into 5-FU by cytochrome P450 (CYP450) enzymes in the
liver. CYP2A6 is the main CYP450 enzyme involved in
tegafur activation, but CYP1A2 and CYP2C8 also play a role
(see Figure 2). Tegafur is combined with uracil in a molar
proportion of 1 : 4 available in the commercial preparation
UFTs. Uracil is a competitive substrate for DPD and its role
in UFTs is to diminish 5-FU catabolism by DPD.
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Figure 2 Metabolism of 5-FU and 5-FU analogues. For explanation of symbols and metabolic routes, see text.

dFdC and ara-C
The metabolic pathways of dFdC and ara-C are almost
alike11,12 (see Figure 3). Membrane transport of both dFdC
and ara-C is mediated by equilibrative nucleoside transpor-
ters. Subsequently, dFdC is phosphorylated into dFdC
monophosphate (dFdCMP) by deoxycytidine kinase (dCK).
The same enzyme is responsible for the intracellular
phosphorylation of ara-C into cytarabine monophosphate
(ara-CMP). dCK is the rate-limiting enzyme in the biotrans-
formation of both dFdC and ara-C. Inactivation of dFdCMP
and ara-CMP can occur through dephosphorylation by 50 -
nucleotidase (5NT). Monophosphates, escaping from de-
phosphorylation are available for further phosphorylation
into di- and triphospates by dCMP kinase and nucleoside
diphosphate kinase, respectively. dFdC diphosphate
(dFdCDP) is a potent inhibitor of the enzyme ribonucleotide
reductase (RNR), which will lead to depletion of deoxycy-
tidine diphosphate (dCDP) and deoxycytidine triphosphate
(dCTP) in the cell. This may favour the incorporation of
dFdCTP into DNA. Moreover, dFdC has the unique property
that, after incorporation of dFdC monophosphate in DNA,
one more deoxynucleotide molecule can be inserted. This
stops DNA polymerase.13 This pattern is distinct from that of
ara-C, which halts polymerase progression at the analogue
insertion site. The masked termination of dFdC makes the
inserted analogue more resistant to removal from DNA.12
Other differences with ara-C are the faster membrane
transport velocity of dFdC, the greater effectiveness of dFdC
phosphorylation by dCK and the longer intracellular
retention of dFdCTP. These factors may, at least in part,
explain the different spectra of antitumour activity of both
drugs. Only a small part of the dFdC and ara-C dose is
responsible for the cytotoxic effects, since more than 90% of
the dose is inactivated by the enzyme CDD into dFdU and
uracil-arabinoside (ara-U), respectively.
Germline Polymorphisms and Fluoropyrimidine Efficacy
5-Fluorouracil
Genetic polymorphisms of enzymes involved in the meta-
bolic activation pathway of 5-FU have been described for the
enzymes uridine monophosphate kinase (UMPK) and
orotate phosphorylase transferase (OPRT). Three allelic
variants of UMPK have been recognised in the human
population: UMPK1, UMPK2 and UMPK3.14 The UMPK1
allele is associated with about three times the catalytic
activity of the UMPK2 allele. Therefore, UMPK2 homo-

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Figure 3 Metabolism of dFdC and cytarabine. For explanation of symbols and metabolic routes, see text.
zygotes are relatively deficient of total UMPK enzyme. The
allele frequency of UMPK1 is about 95–97% and that of
UMPK2 3–5%, in both Caucasians and Asians.15–17 UMPK3 is
rarely seen. The consequences of this polymorphism for 5-
FU chemotherapy have not yet been studied.
In the OPRT gene, a G213A mutation in exon 3 and a
440G mutation in exon 6 have been observed, with allele
frequencies of 26 and 27%, respectively.18 Both mutations
do not significantly compromise in vitro OPRT activity, and
therefore it seems unlikely that they affect 5-FU-antitumour
efficacy.
Additionally to the 5-FU-activating enzymes, far more
information is available regarding polymorphisms of target
enzyme TS. For TS, at least five genotypes have been
identified, characterised by variable numbers of a 28-bp
tandem repeat sequence in the DNA promoter enhancer
region (TSER). So far, alleles containing 2 (TSER*2), 3
(TSER*3), 4 (TSER*4), 5 (TSER*5) and 9 (TSER*9) copies of
the tandem repeat have been identified.19 The double and
triple repeats are the predominant alleles. The triple tandem
genotype is associated with higher TS mRNA and TS protein
levels compared to the double tandem genotype.20–23 The
effect of higher numbers of repeats is not yet clear. The allele
frequency of TSER*3 appears almost similar in Asians,
Pyrimidine antagonist pharmacogenetics
JG Maring et al
229
Africans and Caucasians (about 50%), but the frequency of
homozygous TSER*3 was reported to be significantly higher
in Asians (67%) compared to Caucasians (38%).24 The
TSER*4 and TSER*9 alleles are found in higher frequencies
in African populations (2–7%) compared to Caucasians
(0–1%).25
The consequences of the TSER genotype for fluoropy-
rimidine chemosensitivity have been studied in both
tumour cell lines and clinical trials. In two studies with
tumour cell lines, the TSER polymorphism had no effect on
5-FU chemosensitivity.26,27 Contrary to in vitro data, in 65
patients with rectal cancer, tumour downstaging after
preoperative 5-FU-based chemoradiation was observed in
only 22% of homozygotes for triple tandem repeat
sequences compared to 60% of patients who were hetero-
zygous or homozygous for double tandem repeats.28 In
another small retrospective study of 24 patients with
metastatic colorectal cancer, three out of four homozygous
TSER*2 patients responded on capecitabine, whereas only
one out of 12 of heterozygotes and two out of eight
homozygous TSER*3 patients responded.29 Furthermore, in
a study of 221 patients with Dukes C colorectal cancer,
patients homozygous for TSER*3 gained no survival benefit
from 5-FU treatment, whereas survival was increased in
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 Pyrimidine antagonist pharmacogenetics
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230
heterozygotes and patients homozygous for TSER*2.30
However, the TSER genotype did not seem to be an
efficacious marker for tumour sensitivity to 5-FU-based oral
adjuvant chemotherapy in 135 Japanese colorectal pa-
tients.31 Surprisingly, in a small study of 54 colorectal
cancer patients, not the TSER*2 but the TSER*3 genotype
correlated with an increased disease-free survival after
adjuvant 5-FU chemotherapy.32
Several factors can possibly explain these inconclusive
data. Firstly, within the second 28 bp tandem repeat
sequence, a G/C polymorphism was recently discovered.
Functional analysis revealed that the TSER*3/G genotype
has three to four times greater efficiency of translation than
other polymorphic sequences.33,34 In a study of the G/C
polymorphism in 258 primary colorectal tumours, it was
found that all low-expression genotypes were associated
with longer survival after adjuvant fluoropyrimidine che-
motherapy, whereas no benefit was seen for high-expression
genotypes.33
Secondly, a 6 bp deletion genotype (TS1494del6) in the 30
untranslated region of the TS gene has been associated with
reduced TS mRNA stability.35,36 The frequency of this
genotype was found to be 41% in non-Hispanic whites,
26% in Hispanic whites, 52% in African-Americans and 76%
in Singapore Chinese. The relative instability of TSmRNA
may have its effect on TS protein activity and thus indirectly
on fluoropyrimidine chemosensitivity. However, this poly-
morphism was not directly related to in vitro chemosensi-
tivity in tumour cell lines27 or disease-free survival after
adjuvant 5-FU chemotherapy in a small study of 54 colo-
rectal cancer patients.32
Another cause of conflicting data is the loss of hetero-
zygosity (LOH), that is frequently observed for TS.37 The TS
gene is located on chromosome 18p11.32, a region most
frequently lost in colorectal cancer. In a small study of 30
stage IV colorectal cancer patients, LOH was observed in 17
out of 22 heterozygotes.38 The presence of a TSER*3 allele
(homozygous TSER*3, heterozygous and TSER*3/loss) was
associated with lower survival on fluoropyrimidine che-
motherapy. LOH in tumour tissue is a significant factor, to
be taken into account when TS genotypes are to be
considered for outcome prediction. It is important to bear
in mind that LOH limits the use of germline DNA from for
example, blood for predictive genotyping.
Finally, it must be stressed that many studies of the TS
polymorphism were underpowered to detect relations of the
different genotypes with clinical outcome. Hence, the exact
consequences of the triple tandem repeat genotypes for 5-FU
chemosensitivity are not yet clear. Sufficiently powered
clinical trials and additional mechanistic studies may be
needed to elucidate the cause of so far unexpected out-
comes.
Directly linked to the 5-FU-mediated inhibition of TS is
the presence of intracellular folate. A polymorphism that
may influence the efficacy of 5-FU and its analogues by
influencing folate pools is that of the methylene tetrahy-
drofolate reductase (MTHFR) gene. MTHFR catalyses the
conversion of 5,10-methyltetrahydrofolate to 5-methyl-
The Pharmacogenomics Journal
tetrahydrofolate. 5,10-Methyltetrahydrofolate is an essential
cofactor in the biosynthesis of dTMP (see Figure 2). The
dissociation of FdUMP from the ternary complex with TS
and 5,10-methyltetrahydrofolate is suppressed when levels
of 5,10- methyltetrahydrofolate are increased.39 So far, two
MTHFR polymorphisms have been recognised. A common
C677T transition in exon 4 of the MTHFR gene results in a
thermolabile enzyme variant with lower specific activity.40
The second polymorphism concerns a codon 1298 A to C
transition in exon 7, which is also associated with decreased
enzymatic activity.41 In vitro transfection of mutant 677T
MTHFR cDNA in colon and breast cancer cells increased the
chemosensitivity of these cells to 5-FU, suggesting at least a
modulating role of this genotype on cellular fluoropyrimi-
dine sensitivity.42 The geographic and ethnic distribution of
the 677T genotype was studied by Wilcken et al.43 The
homozygote T genotype was found to be particularly
common in northern China (20%), southern Italy (26%)
and Mexico (32%). In two studies with, respectively, 45 and
51 colorectal cancer patients, the 677T genotype appeared
to affect the folate pool.44,45 In the latter study, no effect was
seen of the 677T genotype on overall survival after oral 5-
FU-based chemotherapy.45 Contrary to this, in a study of 43
metastatic colorectal cancer patients receiving fluoropyri-
midine-based chemotherapy, the presence of one or two
mutant alleles was associated with increased tumour
response.46 In a recent study of 98 dissiminated colorectal
cancer patients, the C677T mutation was also associated
with higher response rates on 5-FU/folinic acid chemothe-
rapy.47 In the same study, the A1298C polymorphism was
studied, but this was not related to the response rate. The
exact roles of the MTHFR polymorphisms have to be
elucidated in larger prospective clinical trials.
Besides the above-mentioned polymorphisms in the 5-FU
anabolic route, genetic variations in 5-FU catabolic enzymes
can also have a profound effect on 5-FU toxicity. At least the
phenomenon of inherited DPD deficiency is an important
issue. DPD deficiency is caused by molecular defects in the
DPD gene that result in complete or partial loss of DPD
activity.48 This can cause extreme 5-FU toxicity. So far, 33
different mutations have been identified in the dihydropy-
rimidine dehydrogenase (DPYD) gene. At least 11 of these 33
mutations, including one polymorphism, were detected in
patients suffering from severe 5-FU-associated toxicity.48–50
In patients who are deficient for DPD, 5-FU clearance is
dramatically reduced and standard doses of 5-FU cause
excessive toxicity in these patients.48,51,52 The frequency of
DPD deficiency has been estimated to be as high as 2–3% in
Caucasians based on measurements of DPD activity in
peripheral mononuclear cells in patients and healthy
volunteers 53,54 This percentage is probably high enough
to justify screening on DPD deficiency prior to 5-FU-based
chemotherapy. Instead of screening for specific mutations in
the DPYD gene, Mattison et al55 developed a simple uracil
breath test for DPD phenotyping, based on the release of
13
CO2 from 2-13C uracil in the presence of intact DPD.
Expired air was collected 5–180 min after oral ingestion of
6 mg/kg 2-13C uracil. Partially deficient DPD breath profiles

were well differentiated from normal profiles. Oral loading
with uracil, prior to chemotherapy, with subsequent
measurement of the uracil clearance in plasma, might also
give a good prediction of the patient’s DPD status. Such tests
are currently developed, but not yet available.56
Apart from DPD, it was recently discovered that deficiency
in dihydropyrimidinase (DHP), the second enzyme in 5-FU
catabolism, can also result in severe 5-FU toxicity.57 At least
six mutations have been identified in the the DHP encoding
gene. Missense mutation G883A in exon 5 has been
associated with severe 5-FU toxicity.58 This mutation has
been shown to result in mutant DHP enzyme without
residual activity.
Capecitabine and tegafur
Polymorphisms in capacitabine-metabolising enzymes have
only been reported for CDD. Since this polymorphism may
also be relevant for dFdC and ara-C metabolism, it will be
discussed in the next paragraph. Furthermore, mutations in
CYP2A6 have recently been identified to affect tegafur
metabolism.59 Two mutant alleles, CYP2A6*4C and
CYP2A6*11, were detected in a patient with largely reduced
tegafur clearance. The prevalence of these mutations and its
impact on clinical outcome are not yet clear.
Gemcitabine and ara-C
There are at least two polymorphisms in the metabolising
pathway, that might be relevant for dFdC and ara-C toxicity
and efficacy. Firstly, cloning of human CDD revealed two
protein variants (CDD1 and CDD2) with different in vitro
deamination rates of ara-C.60 Theoretically, patients who
deaminate dFdC or ara-C more efficiently are shorter
exposed to the parent drugs, while faster metabolism of
capecitabine results in increased 5-FU levels. In vitro
transfection of human bladder cancer cells with CDD2
cDNA did increase CDD activity, and indeed made the cells
more sensitive to 50 dFUR and capecitabine, but resistant to
dFdC.61 This warrants further investigation of the possible
role of the CDD genotype in fluoropyrimidine chemosensi-
tivity.
Secondly, 50 -NT deficiency is an autosomal recessive
condition, known to cause haemolytic anaemia. Several
mutations causing 50 -NT deficiency have been identified.62
On theoretical grounds, in patients with 50 -NT deficiency,
treatment with dFdC or ara-C may result in increased
toxicity although this has not yet been published. An
overview of polymorphic genes and related enzymes with
possible relevance for fluoropyrimidine chemotherapy is
presented in Table 1.
Impact of Somatic Mutations And Gene Expression Levels:
5-FU and its Metabolic Enzymes
5-Fluorouracil
Data on expression levels of enzymes involved in the
metabolic activation of 5-FU in relation to chemosensitivity
are sparse. Low UMPK levels were observed in 29 colorectal
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JG Maring et al
231
tumour samples of patients with acquired 5-FU resistance.63
Low OPRT as well as UP and UK activity has been associated
with 5-FU resistance in tumour cell lines.64–67 The role of
OPRT has also been investigated in a few clinical studies.
High OPRT activity was associated with good in vitro
sensitivity to 5-FU, measured by Collagen Gel Droplet
Embedded Culture Drug Sensitivity test, Fluoresceine Dia-
cetate Assay or Histoculture Drug Response Assay, in human
colorectal cancer tissues.68,69 Furthermore, in 37 patients
treated with oral tegafur-uracil for disseminated colorectal
cancer, responding tumours had higher expressions of OPRT
than nonresponding tumours.70 In the same study, there
was no difference in UP mRNA between responding and
nonresponding tumours. The role of UP in 5-FU sensitivity
is probably marginal, since transfection of tumour cells with
UP cDNA did not affect fluoropyrimidine sensitivity.71 More
research is needed to establish the exact role of OPRT in 5-
FU sensitivity.
Most research of fluoropyrimidine activation pathways
has been focused on the role of TP. Results regarding the role
of tumoral TP expression appear to be contradictory. In
patients, high as well as low TP mRNA expression levels have
been correlated with response to 5-FU therapy. An increase
in both relapse-free survival and overall survival was
suggested in TP-positive compared to TP-negative breast
tumours in a small study of 109 patients treated with
adjuvant cyclophosphamide, methotrexate and 5-FU
(CMF).72 Furthermore, in 38 metastatic colorectal cancer
patients treated with 5-FU and leucovorin (LV), TP mRNA
levels in nonresponding tumours were higher than in
responding patients.73 In 28 patients treated for advanced
gastric cancer with 5-FU plus pirarubicin and cisplatin, high
tumour tissue TP expression was associated with response on
chemotherapy.74 In another 126 advanced gastric cancer
patients, TP overexpression was associated with increased
patient survival after fluoropyrimidine chemotherapy, but
correlated with unfavourable prognosis in patients not
treated with fluoropyrimidines.75 Consequently, it is hard
to draw conclusions from current, in general small trials.
Taking a close look at 5-FU metabolism, one might expect
that cells with higher TP levels would be more sensitive to 5-
FU, due to higher FdUMP levels resulting from increased 5-
FU activation (see Figure 2). However, TP also functions as
an angiogenesis factor since TP- and platelet-derived
endothelial cell growth factor (ECGF1) have been recognised
as the same protein. High TP gene expression might
therefore be associated with a more aggressive and malig-
nant tumour phenotype.73 Transfection of cancer cells with
TP cDNA has been performed in several in vitro studies to
investigate the effect of TP overexpression on chemosensi-
tivity. A clear correlation was found between TP activity and
in vitro sensitivity to the 5-FU analogue 50 -dFUR, and to a
lesser extent to 5-FU itself.76–81 Marchetti et al76 also studied
the effect of TP overexpression on in vivo tumour growth in a
rat model. The impact on tumour growth turned out to be
relatively modest and only involved the initial stages of
tumour growth. These results suggest that tumour growth
and chemosensitivity are independently related to TP
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Table 1 Overview of proteins may affect drug treatment outcome due to genetic polymorphisms

Enzyme Polymorphism Allele frequency Drug Patient data Consequences

Dihydropyrimidine 11 mutations found in IVS14G-A mutation 5-FU and analogues Miscellaneous cancer Increased toxicity of 5-FU
dehydrogenase (DPD) partial DPD-deficient most frequent types
patients 0.5–1%

Dihydropyrimidinase G883A missense mutation o1% 5-FU and analogues Colorectal cancer Increased toxicity of 5-FU

Pyrimidine antagonist pharmacogenetics

(DHP) in exon 5

Methylene C667T in exon 4 45% in northern China 5-FU and analogues Colorectal cancer Possibly increased efficacy
tetrahydrofolate reductase 51% in southern Italy of 5-FU
(MTHFR) 56% in Mexico
A1298C in exon 7 Unknown Colorectal cancer Unknown

Orotate phosphoribosyl G213A in exon 3 26% 5-FU and analogues Colorectal cancer Possibly increased efficacy

JG Maring et al
transferase (OPRT) of 5-FU
440G in exon 6 27%

Thymidylate synthase (TS) TSER*3 increased TS 50% in Asians and 5-FU and analogues Colorectal cancer Possibly decreased
activity Caucasians efficacy of 5-FU

TSER*4/TSER*9 2–7% in Africans Not available Unknown

0–1% in Caucasians

1494del6 26–41% in Caucasians Not available Unknown

52% in African-Americans
76% in Singapore Chinese

Uridine monophosphate UMPK1 variant 95–97% 5-FU and analogues Colorectal cancer Unknown
kinase (UMPK) UMPK2 variant 3–5%
UMPK3 variant o1%

Cytochrome P450 2A6 CYP2A6*4C Unknown Tegafur Colorectal cancer Decreased metabolism of
(CYP2A6) tegafur into 5-FU
CYP2A6*11 Unknown

Cytidine deaminase CDD1 variant 70% Capecitabine, Not available Unknown

(CDD) CDD2 variant 30% gemcitabine, ara-C

50 -nucleotidase (5NT) Several mutations Unknown Gemcitabine and ara-C Leukaemia Unknown
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JG Maring et al
233

expression. A major point of interest in interpreting the
clinical data in relation to in vitro data is the role of
infiltrating stromal fibroblasts and macrophages in TP
expression. In most tumour types, TP expression is much
higher in infiltrating cells compared to tumour cells.82 This
may largely trouble the interpretation of data of in vivo PCR
as well as immunohistochemistry (IHC) studies. Conse-
quently, this aspect particularly has to be taken into account
in study designs to validate TP as a predictive marker.
Data on the role of TK in 5-FU chemosensitivity are also
contradictory. Chemosensitivity was unchanged in TK-
deficient colon cancer cells compared to parent cells,
suggesting only a marginal role of TK in 5-FU sensitivity.83
In another study, TK overexpression has been associated
with 5-FU resistance in gastric tumour cell lines,66 but other
groups found a reduction of TK activity in chemoresistant
colon cancer cell lines.65,67 Intracellular availability of
deoxyribose-1-phosphate might account for these differ-
ences, since the activation of 5-FU by TP and TK is fully
dependent on the availability of this co-substrate. If cellular
levels of this co-substrate are too low, hardly any 5-FU can be
metabolised via this route. Only one patient study is
available regarding tumour TK activity in relation to
treatment efficacy. In this study, tumour TK activity could
not be related to the efficacy of second-line 5-FU (poly)-
chemotherapy in 121 advanced breast cancer patients who
failed on first-line tamoxifen treatment.84 Thus, TK is
probably not a strong factor related to 5-FU sensitivity.
A route that has been extensively evaluated in relation to
5-FU chemoresistance is the intracellular biodegradation of
5-FU by DPD. In vitro experiments in human tumour cell
lines demonstrated an inverse correlation between both
DPD mRNA expression and activity with 5-FU response.85
DPD mRNA levels were also related to primary 5-FU
resistance in seven human gastrointestinal cell lines.86
Furthermore, high DPD activity and DPD mRNA levels were
correlated with low sensitivity to 5-FU in three human
gastric, two colon, one breast and one pancreatic carcinoma
xenografts in the nude mice model.87 However, data of
presently available clinical studies are less unequivocal. An
overview of clinical relevant studies is presented in Table 2.
Most studies have been performed in colorectal cancer,68,88–91
some in gastric,92–94 head and neck,95–97 and non-small-cell
lung cancer,98–100 and few in breast and bladder can-
cer.101,102 A number of studies have indicated that there is
no strong link between DPD mRNA levels and DPD protein
activity levels. It has been reported that DPD mRNA, but not
DPD activity, is reduced in colorectal tumours compared
with normal mucosa, although considerable overlap
exists in measured mRNA levels.103–110 Reduced mRNA
levels have also been reported in ovarian cancer.111
DPD activity appears to be increased in breast cancer (see
Table 3).101,112 This suggests that DPD is not only regulated
at transcriptional and translational, but also at the post-
transcriptional, level. This hampers the use of DPD mRNA as
predictive marker for 5-FU efficacy. Inhomogeneity of
tumour tissue samples may, in part, also account for
conflicting results.
Summarising, it can be concluded that data on tumour
expression levels of 5-FU metabolising enzymes in
relation to chemosensitivity are sparse and that studies
show conflicting results. This may at least partly be due to

Table 2 Overview of studies regarding intratumoral DPD expression levels in relation to chmeosensitivity

Cancer Patients Chemotherapy regimen Assay Outcome Reference

88
Colorectal 33 5-FU/LV mRNA Low DPD related to response
89
100 5-FU ELISA No correlations found
90
348 5-FU mRNA No correlations found
68
54 5-FU Activity No correlations found
91
309 5-FU mRNA Low DPD related to longer survival

92
Gastric 81 5-FU Activity High DPD related to poor survival
93
22 DFUR ELISA Low DPD related to DFUR sensitivity
94
38 5-FU/MTX IHC No correlations found

95
Head and neck 62 5-FU Activity No correlations found
96
82 5-FU/LV/cisplatin Activity No correlations found
97
109 UFT IHC Low DPD correlated with UFT response

98
NSCLC 54 UFT IHC Low DPD correlated with better prognosis
99
68 5-FU IHC High DPD correlated with poor survival
100
60 5-FU Activity No correlations found

101
Breast 191 5-FU Activity High DPD related to poor DFS

102
Bladder 74 5-FU Activity Low DPD related to 5-FU sensitivity
MTX ¼ methotrexate;; IHC ¼ immunohistochemistry.

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Table 3 DPD expression and activity in different tissue types

Tumour type Samples Parameter Tumour vs Normal Reference

103
Gastrointestinal 51, matched mRNA Lower
Activity No difference

104
41, matched mRNA Lower
Activity No difference

105
10 tumours+7 metastases, matched mRNA Lower

106
15 tumours+10 metastases, 25 nonmatched controls Protein Lower

107
36, matched Protein No difference

108
43, matched mRNA Lower
Protein No difference
Activity No difference

109
36, matched Protein Lower

110
40, matched mRNA Lower
Protein Lower
Activity No difference

111
Ovarian 85 tumour+27 nonmatched controls mRNA Lower

112
Breast 26, matched Activity Higher

101
49, matched Activity Higher

small numbers and therefore lack of statistical power in
the studies.
Capecitabine/tegafur
In the animal model, high TP/DPD ratios have been
associated with antitumour efficacy of capecitabine and its
metabolite 50 dFUR in human tumour xenografts.113 In vivo,
high TP/DPD ratios suggested a better clinical outcome after
adjuvant treatment with 50 dFUR in a study of 88 colorectal
cancer patients, and in 17 metastatic gastric cancer
patients.114,115 TP expression was examined by IHC in 650
breast tumours of patients with early breast cancer receiving
adjuvant 50 dFUR.116 Eight-year follow-up data showed that
high TP expression in the tumour was a favourable
prognostic indicator. Thus, TP expression seems to be a
predictive factor for 50 dFUR efficacy. Since the activation of
tegafur depends on several CYP450 enzymes, interindividual
variations in enzyme expression may affect the rate of
tegafur metabolism. Indeed, the relative contribution of
each enzyme is known to differ among patients, but the
clinical consequences of this phenomenon are unclear.117
Impact of Somatic Mutations and Gene Expression Levels:
5-FU and its Target Enzymes
Contrary to enzymes related to the 5-FU metabolic activa-
tion pathway, the target enzyme TS has been extensively
studied in relation to 5-FU efficacy. A large amount of
preclinical in vitro data suggest a correlation between TS
activity and sensitivity to 5-FU. In a panel of 19 nonselected
breast, digestive tract and head and neck cancer cell lines, as
well as in a panel of 13 nonselected human colon cancer cell
lines, the TS activity was inversely correlated with 5-FU
sensitivity.85,118 Several in vitro studies in tumour cell lines
also suggest TS overexpression as a mechanism of resistance
after repeated exposure to 5-FU.86,119,120 Chemosensitivity
to 5-FU was also increased after transfection of human colon
cancer cells with antisense TS cDNA.121 However, conflict-
ing data have been observed in clinical studies evaluating
the prognostic role of mRNA, protein and activity levels of
TS in relation to tumour response and clinical outcome to 5-
FU-based chemotherapy. An overview of relevant clinical
studies is presented in Table 4. Most studies regarding TS
expression in relation to chemosensitivity have been
performed in patients with disseminated colorectal can-
cer,68,91,122–134 some in gastric cancer94,135–138 and few
studies in head and neck cancer,95,96,139 non-small-cell lung
cancer99,100 pancreatic and breast cancer.84,140,141
Several factors may account for the difficult interpretation
of combined clinical data. Firstly, it has been reported that TS
protein can downregulate its own translation, whereas its
transcription is regulated by E2F, a cell cycle checkpoint
regulator. Together, this results in low TS levels in stationary
phase cells. Although cells with a low TS might theoretically

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235

Table 4 Overview of studies regarding intratumoral TS expression levels in relation to chemosensitivity

Cancer Patients Chemotherapy regimen Assay Outcome Reference

Colorectal 47 5-FU/LV bolus Activity High TS related to non-response Peters et al122

46 5-FU/LV protracted mRNA High TS related to non-response Leichman et al123
36 5-FU/LV mRNA + IHC TS106 Low TS related to response Lenz et al124
41 5-FU/LV bolus IHC polyclonal Low TS related to response Cascinu et al125
52 5-FU/LV protracted IHC TS106 High TS related to non-response Wong et al126
48 5-FU/LV/MTX IHC polyclonal Low TS related to response Aschele et al127
108 5-FU/LV/MTX IHC TS106 Low TS related to response Paradiso et al128
27 5-FU/LV/MTX IHC polyclonal Low meta-TS related to response Aschele et al129
29 5-FU/LV/MITO or MITOX mRNA Low TS related to response Kornmann et al130
50 5-FU/LV/oxaliplatin mRNA High TS related to non-response Shirota et al131
134 5-FU/IFN alfa-2b IHC polyclonal No correlations found Findlay et al132
124 5-FU/LV; 5-FU/MTX IHC Low TS related to response 5FU/LV Aschele et al133
309 5FU/LV MRNA High TS related to longer survival Kornmann et al91
54 5-FU Activity Low TS related to 5-FU sensitivity Fujii et al68
54 5-FU/LV Activity Low TS related to 5-FU response Noordhuis et al134

Gastric 65 5-FU/LV/cisplatin mRNA Low TS related to longer survival Lenz et al135

38 5-FU/LV/cisplatin mRNA High TS related to non-response Metzger et al136
30 5-FU/LV/cisplatin IHC TS106 High TS related to non-response Yeh et al137
39 5-FU/cisplatin IHC Low TS related to response Boku et al138
38 5-FU/MTX IHC No correlations found Tahara et al94

Head and neck 70 5-FU/LV/cisplatin/MTX/IFN IHC TS106 High TS related to non-response Johnston et al139
82 5-FU/LV/cisplatin TS activity No correlations found Etienne et al96
52 5-FU TS activity No correlations found Etienne et al95

NSCLC 60 in vitro 5-FU sensitivity FdUMP binding TS not related to 5-FU sensitivity Higashiyama et al100
68 5-FU or UFTs IHC polyclonal Low TS related to longer survival Huang et al99

Breast 75 CAF regimen mRNA No correlations found Lizard-Nacol et al140

121 CAF or CMF regimen TS activity High TS related to better treatment Foekens et al84
Efficacy after failure on tamoxifen

Pancreatic 73 5-FU based TS mRNA High TS related to 5-FU response Hu et al141

MTX ¼ methotrexate; MITO ¼ mitomycine; MITOX ¼ mitoxantrone; IHC ¼ immunohistochemistry; TS106 ¼ monoclonal antibody against TS; IFN ¼ interferon.

be more sensitive to 5-FU, the low proliferation rate prevents
induction of DNA damage and 5-FU antitumour efficacy.142
Secondly, complex interactions between oncogenes and TS
have been demonstrated, such as binding of TS protein to p53
and c-myc RNA and inhibition of TS promotor activity by
wild-type p53. The inhibition of TS by 5-FU or antifolates may
also decrease the TS-protein-mediated downregulation of TS
mRNA translation, resulting in increased TS protein synthesis.
The clinical implications of these complex indirect and direct
interactions between oncogenes and TS are as yet unclear.143
Finally, the assay type may have influenced the outcome
of some studies, since IHC as well as rt-PCR were used to
measure TS expression. IHC has been performed using
different types of antibodies, including monoclonal TS106
as well as polyclonal antibodies. Differences in binding
specificity and selectivity may have had a decisive impact on
study outcome. Furthermore, the issue of infiltrating cells
disturbing tumour tissue homogeneity and thus troubling
PCR data, as mentioned earlier when interpreting TP data,
may also hold for TS.
Acknowledging the importance of TS expression in colo-
rectal cancer, another determinant for 5-FU cytotoxicity may
be the enzyme deoxyuridine triphosphate (dUTP) nucleo-
tidohydrolase (dUTPase), which is the key regulator of dUTP
pools. There are at least two isoforms of dUTPase, a nuclear
and a mitochondrial form, encoded by the same gene. In
tumour cell lines, increased dUTPase levels accounted for
resistance to the 5-FU metabolite 50 dFUR.144,145 In a small
retrospective study in tumours of 20 metastatic colorectal
cancer patients, high nuclear dUTPase protein expression was
associated with poor tumour response on 5-FU therapy.146
However, larger studies are needed to establish the role of
dUTPase in 5-FU chemoresistance.
Impact of Somatic Mutations and Gene Expression Levels:
dFdC and ara-C
Resistance to nucleoside analogues can be due to a number
of factors, affecting drug metabolism, including increased
deamination, loss of expression of activating kinases and
increased activity of nucleotidases. In vitro, gene transfer of

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CDD cDNA into murine fibroblast cells was shown to induce
cellular resistance to ara-C through increased deamina-
tion.147 In patients with acute myeloid leukaemia (AML),
pretreatment CDD activity did correlate with response on
ara-C induction treatment in two studies, both involving 36
patients.148,149 Ara-C resistance has also been associated
with low dCK activity both in vitro150,151 and in 21 AML
patients.152 In turn, increased dCK activity was associated
with increased activation of both compounds to cytotoxic
nucleoside triphosphate derivates. However, mutational
inactivation of dCK is not thought to confer resistance to
ara-C in AML patients because mutations in the dCK gene
are rarely found in refractory or relapsed AML pa-
tients.153,154 Alternatively, inactivation of dCK by the
formation of alternatively spliced dCK transcripts has been
demonstrated in seven out of 12 patients with resistant AML
compared to one out of 10 patients with sensitive AML.155
This mechanism is probably a cause of therapy failure in
patients with resistant AML.156 Finally, high 5NT expression
in blast cells was shown to be an independent prognostic
factor for poor outcome in 108 AML patients after ara-C-
containing regimens.157 The balance between dCK and 5NT
might predict drug toxicity, since strongly increased
5NT activity combined with reduced dCK activity was
observed in a human leukaemic cell line, resistant to ara-C
and dFdC.158
Apart from resistance to nucleoside analogues caused by
aberrant drug metabolism, altered drug transport may cause
decreased chemosensitivity. Recently, overexpression of the
human multidrug resistance protein 5 (MRP5), an ABC
transporter known to transport nucleotide monophos-
phates, has been associated with resistance to dFdC in
vitro.159 MRP5-mediated efflux of dFdC metabolites may
lower the accumulation of dFdC in cells. So far, other
chemoresistance-related transport mechanisms have not
been identified for pyrimidine antagonists.
Other Proteins Related to Pyrimidine Antagonist
Chemosensitivity
As mentioned in the previous sections, expression levels of
specific proteins, directly involved in drug metabolism of
pyrimidine antagonists, may affect treatment efficacy.
However, expression of genes related to cell growth and
the apoptotic pathway may also affect chemosensitivity.
This interaction of apoptosis regulator proteins with
chemosensitivity is an intriguing issue, but an extensive
analysis of current literature on this subject falls outside the
scope of this review. The most extensively studied genes
with regard to pyrimidine antagonist chemotherapy are bcl-
2, bax, c-myc and p53.160–168 Here, we will only briefly
report on the putative role of p53 with respect to 5-FU
efficacy, as this relationship has been most extensively
studied. Mutations in the p53 gene and p53 overexpression
have been associated with 5-FU chemoresistance both in
vitro169–171 and in vivo in colorectal,124,172–175 head and
neck,176,177 and breast cancer.178 However, results in some
other studies are less unequivocal.179,180 Recently, it has
been suggested that only patients whose primary colorectal
The Pharmacogenomics Journal
tumour contain amplified c-myc and wild-type p53 might
benefit from 5-FU-based chemotherapy.181 Interestingly,
there is an increasing evidence of interactions between TS
and p53. P53 gene mutation and protein overexpression are
associated with increased TS mRNA levels and TS cytoplas-
matic protein in colorectal tumours,124,128,182 It has been
demonstrated that wild-type p53 is able to bind TS mRNA,
which results in a feedback regulation of TS protein
synthesis.183 In cells with mutated p53, this feedback
mechanism fails and, as previously mentioned, overexpres-
sion of TS is associated with poor clinical outcome.
Impact of Current data on Clinical Practice
Summarising, we conclude that, in tumour material, none
of the enzymes discussed above can currently function as
predictive marker by itself. So far, only small studies have
been performed and drawing conclusions from combined
data of these often statistically underpowered studies is
fairly impossible due to differences in applied techniques or
patient groups. Clinical practice affecting studies are not
available yet. Good predictive genetic markers or marker sets
are lacking. The specificity of a predictive marker needs to be
high, as it will be used to discriminate between treat-
ment options. Probably, panels of genes will be needed
to obtain an adequate specificity. To find such gene
panels, far more studies are needed. Looking at current
data, a combination of the expression of DPD, TS, TP and
OPRT, all four crucial enzymes in the metabolism of 5-FU, at
least appears to be a promising approach in colorectal
cancer68–70,184–186 (Table 5).
Future Perspectives: The Polygenetic Approach
Despite the here summarised potential genes and proteins
interfering with pyrimidine antagonist metabolism, only
few factors indeed have been proven to affect chemotherapy
efficacy and/or toxicity. Most consistent data are available
regarding the role of TS, DPD and p53 in 5-FU chemother-
apy, and that of TP in capecitabine chemotherapy (see
Tables 1 and 5). The impact of germline DPD deficiency on
5-FU pharmacokinetics and the development of severe life-
threatening toxicity is obvious. Whether or not to screen
patients on DPD deficiency before starting chemotherapy is,
however, an issue of debate.187–189 Since genetic abberations
in the DPYD gene explain less than half of all cases of
extreme 5-FU-related toxicity, costly screening will only be
partially preventive. Therefore, a solid cost–benefit analysis,
preferentially embedded in a large prospective clinical trial,
will be needed to establish the added value of DPYD
genotyping. Screening (genotypically or phenotypically)
might become standard clinical practice as soon as a rapid,
sensitive and cheap test becomes available.
Regarding 5-FU efficacy, some attempts have been made
recently to identify putative markers of response in tumour
material for use in patient treatment guidance.96,138,183,190
However, despite some promising studies, the overall data are
difficult to interpret and not always in line with previous
results in larger patient groups. This might, at least in part, be
due to the complexity in transcription and translation of
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237

Table 5 Overview of proteins that potentially may affect drug treatment outcome due to altered gene expression

Protein Drug Patient data Consequences

Dihydropyrimidine 5-FU Miscellaneous cancer High DPD activity in tumour tissue associated
dehydrogenase (DPD) types with reduced 5-FU efficacy

dUTP nucleotidohydrolase 5-FU and Colorectal cancer High dUTPase activity may be associated
(dUTPase) analogues with reduced 5-FU efficacy

Thymidine kinase (TK) 5-FU and analogues Breast cancer Unknown, inconclusive data

Thymine phosphorylase 5-FU Colorectal cancer Unknown, inconclusive data

(TP) ¼ endothelial cell growth Gastric cancer
factor (ECGF1) Breast cancer

Thymidylate synthase (TS) 5-FU and Colorectal cancer High TS expression associated with reduced
analogues 5-FU efficacy

Cytidine deaminase (CDD) Ara-C Acute myeloid leukaemia High CDD expression associated with
(gemcitabine) reduced efficacy of ara-C

Deoxycytidine kinase (dCK) Ara-C Acute myeloid leukaemia Low dCK expression associated with
(gemcitabine) resistance to ara-C

50 -nucleotidase (5NT) Ara-C Acute myeloid leukaemia High 5NT expression associated with
(gemcitabine) reduced efficacy of ara-C

some of the genes discussed above (eg TS). Additional
mechanistic studies are needed to explore this issue more in
detail. Furthermore, as mentioned before, many available
studies are insufficiently powered to reach statistical signifi-
cance. Therefore, incorporation of pharmacogenomic issues
in future phase II and III clinical trials should be encouraged.
Another cause for inconsistency in current data may be
found in the applied scientific methodology. A crucial factor
in the search for predictive markers is the availability of a
standardised, accurate, precise and robust test. Method
validation, such as performed for the TS106 antibody for
TS IHC, is a prerequisite for standardised testing.191 Subse-
quently, these quality-controlled diagnostics should be
tested not only retrospectively, but also in prospective
multi-centre (and multi-laboratory) clinical trials. Unfortu-
nately, such tests are not available yet.
Also causing inconsistency in the outcome of monoge-
netic studies may be the fact that the impact of other genes
related to response and survival is ignored in the final
calculations. Since cancer is a genetically heterogeneous
disease, the monogenetic approach is likely too simple. This
implies that far more research is needed to gain more insight
into the exact role of genetic polymorphisms, and gene
expression levels on pyrimidine antagonist chemotherapy.
The interaction between TS and p53, combined with the
impact of several TS polymorphisms, illustrates the com-
plexity of pharmacogenomic research.
The two most important approaches in current and near
future research to find predictive marker sets will be the
candidate gene and the microarray strategies. A broad range
of candidate genes to focus on in future research has been
summarised in this review. On the other hand, further
developments in microarray techniques and proteomics
may eventually lead to the identification of a subset of
relevant genes for a certain drug in a certain tumour type.
Few studies in cancer cell lines and cancer xenografts have
already shown the possibilities of using cDNA microarray
profiling for identification of novel genes involved in
response or resistance to chemotherapy.192–195 Microarray
analysis of 2400 genes revealed five novel 5-FU-inducible
transcriptional target MCF-7 breast cancer cells (SSAT, annexin
II, MAT-8, thymosin b-10 and chaperonin-10).193 In another
study, analysis of 9216 genes in a panel of 30 colon carcinoma
cell lines revealed 420 genes that were correlated with 5-FU
response.194 Genes involved in DNA replication and repair
(including MLH1, PCNA, replication factor C, nucleosome
assemby protein 1, origin recognition complexes and topoi-
somerase II) and protein processing and targeting (including
several chaperones, lectin mannose binding 1, heat shock
70 kDa protein 8, nucleophosmin and hypoxia upregulated 1)
were significantly enriched for expression on the 430 gene
list. Recently, Wang et al analysed gene expression in five pairs
of 5-FU-resistant and parental cancer cell lines with a cDNA
microarray approach.195 They identified nuclear factor kappa
B (NFKappaB) p65 as one of the genes related to 5-FU
resistance and demonstrated that transfection of NFKappaB in
MCF-7 cells induced 5-FU resistance.
These studies show the potential power of these techni-
ques for identifying predictive markers for drug sensitivity,
as well as novel targets to overcome drug resistance.

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In the near future, identification of relevant germline

polymorphisms, combined with relevant mRNA expression MTHFR methylene tetrahydrofolate reductase
MTX methotrexate
levels in tumour tissue, might permit more effective, 5NT 50 -nucleotidase
individualised cancer chemotherapy. Ideally, a process of OPRT orotate phosphoribosyl transferase
‘chemotyping’, that is, choosing the right chemotherapy RNR ribonucleotide reductase
regimen in the right dose, based on selected genotypical and SNP single-nucleotide polymorphism
TK thymidine kinase
phenotypical information, should precede drug prescribing. TP thymidine phosphorylase
The interdisciplinary Pharmacogenetics Anticancer Agents TS thymidine synthase
Research (PAAR) group is an example of an excellent UDPK uridine diphosphate kinase
initiative to coordinate research on these issues.196 Even- UK uridine kinase
UMPK uridine monophosphate kinase
tually, well-controlled prospective clinical trials with ade- UP uridine phosphorylase
quate sample size and statistical power will be needed to USF upstream stimulatory factor
demonstrate the surplus value of such new concepts above
current practice.
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