Topoisomerase 

Poisons
Camptothecins, epipodophyllotoxins,
Anthracyclines and anthracenediones

1
• DNA在結構上主要有三種拓樸構型的變化：
超螺旋（supercoiling）、紐結（knotting）
與連鎖（catenation）。
• TOPO功能
• Relaxation：可以把Supercoil雙股DNA
解開成環狀
• Unknotting：把打結處解開成環狀
• Decatenation：可以把兩個環狀纏繞
DNA解開

Topoisomerases are enzymes that control the 
degree of DNA supercoiling and, in so doing, 
maintain proper DNA structure during 
replication and transcription to RNA.

Antineoplastic agents that function as 
topoisomerase poisons stimulate the DNA 
cleavage reaction but inhibit the DNA 
resealing activity of the enzymes, leaving the 
DNA irreversibly damaged and unable to 
replicate
2
 Formation of the topoisomerase•drug•DNA
ternary complex.

1 2
• The ternary complex may form by 
three possible routes.  3
• Drug may enter through interactions 
with
1. topoisomerase target (left), 
2. DNA (right), 
3. the enzyme•DNA complex (center).
topoisomerase•drug•DNA ternary complex

3
Camptothecins
• Irinotecan HCl (Camptosar)
• Topotecan HCl (Hycamtin)

4
 DNA
Topoisomerase

Drug 
(Camptothecin)

5
Camptothecins
MECHANISM OF ACTION 
• Camptothecins are chiral, extensively conjugated, amine‐containing pentacyclic
lactones. The biologic target of camptothecins is Topl, rather than the TopIIα enzyme 
that serves as the receptor for the epipodophyllotoxins and anthracyclines.
• stabilization of a cleavable ternary (drug‐enzyme‐DNA) complex that does not permit 
the resealing of nicked DNA. Although the fragmented DNA is capable of resealing in the 
absence of drug, when DNA replication forks encounter the fragmented DNA, shear 
stress induces a double‐stranded DNA break, killing the cell.

Camptothecins are most toxic to cells undergoing active DNA replication and cell division 
(e.g., they are S‐phase specific).

6
• The parent camptothecin alkaloid, isolated from the bark of Camptotheca acuminata 
(the Chinese xi shu or “happy tree ") , has antitumor activity, but its limited water 
solubility necessitates delivery as the sodium salt of the significantly less active 
hydrolyzed lactone.
• Lactonization of the hydroxy acid in acidic urine is significant, and elevated levels 
of active intact alkaloid in the kidney account for the hemorrhagic cystitis induced 
by this compound.
• Camptothecin's quinoline ring system is unsubstituted, but currently marketed analogs 
have a basic side chain incorporated at either C9 (topotecan) or C10 (irinotecan), allowing 
the  formation of water‐soluble salts of the intact semisynthetic alkaloid. 
• At pH 7.4, the active lactone exists in equilibrium with the hydroxy acid hydrolysis 
product, with the direction dictated by the extent of binding to serum albumin. 
• The preferential protein binding of the lactone, which occurs with irinotecan, shifts 
the equilibrium to favor the production of the more active lactone, thus enhancing 
potency

7
Irinotecan HCl (Conventional Formulation)
2 1

100‐1000 times more active
• In combination with fluorouracil and
leucovorin, this prodrug camptothecin 1
analog is considered first‐line therapy in
the treatment of metastatic colorectal
cancer. 2
• Given intravenously of 125 mg/m2,
conventional irinotecan is slowly
bioactivated in the liver through
hydrolysis of the C10‐carbarnate ester.
The catalyzing enzyme is a saturable
carboxylesterase known as irinotecan‐
converting enzyme.
• CYP3A4 also cleaves the terminal 
piperidine ring through oxidation at the 
α‐carbons. This is followed by hydrolysis 
of the resultant amides, which produces 
8
inactive metabolites.
• Diarrhea is a hallmark adverse effect, potentially exacerbated by coadministered 5‐FU.
• Acute diarrhea: the drug's ability to inhibit acetylcholine esterase and can be addressed
through anticholinergic pretreatment (atropine).
• Pretreatment helps patients to avoid “cholinergic syndrome.
• Delayed diarrhea: is dose‐limiting and potentially fatal
• vigorous loperamide therapy should be instituted at the first sign of symptoms.
• myelosuppressive, and leukoneutropenia (also potentially worsened by 5‐FU) can be severe in
patients with elevated bilirubin levels.
• Prophylactic antiemetic therapy should be given at least 30 minutes before the administration
to minimize the nausea and vomiting.
• Variations in expression of genes involved in the inactivating glucuronidation of irinotecan,
specifically overexpression of the low activity UGT1A1*6 and UGT1A1*28 alleles more
common in Asian and Caucasian populations are deemed responsible.
• Doses must be decreased in patients homogyzous (e.g., UGT1A1*28/*28) or double heterozygous
(e.g, UGT1A1*6/*28) for these poor metabolizer alleles to circumvent life‐threatening neutropenia
and diarrhea.
• a minimum 20%‐25% starting dose reduction in UGT1A1*28/*28 carriers has been recommended.
9
• Liposomal Formulation
• A pegylated liposomal formulation of irinotecan is marketed as Onivyde for
use in combination with 5‐FU/leucovorin in metastatic pancreatic
adenocarcinoma patients who have relapsed after gemcitabine (DNA
polymerase inhibitor) therapy.
• usual starting dose of 70 mg/m2 should be reduced to
50 mg/m2 in UGT1A1*28/*28 carriers, and slowly increased as tolerated.
• As with most liposomal formulations, the drug is stable in the circulation, and is
preferentially taken up and retained for a longer period of time in the tumor cell.
• This results in a more potent therapeutic effect with fewer adverse reactions,
although the boxed warning for life‐threatening neutropenia and diarrhea noted
for the conventional formulation still applies.

• As with conventional IV irinotecan, pre‐treatment with antiemetic and

anticholinergic medications prior to infusion is advised.
10
Topotecan HCl (Hycamtin)
• IV route treated ovarian, cervical and
small cell lung cancer. An oral dosage
form is used in relapsed small cell lung
cancer.
• CYP3A4‐mecliated N‐dealkylation to
mono‐ and di‐dealkylated metabolites
occurs to a limited extent, and the O‐
glucuronides that form at multiple points
along the metabolic path are excreted via
the kidney.
• metabolized by CYP3A4, the potential for
DDI must be evaluated.
• no topotecan liposomal formulation
currently marketed
11
Epipodophyllotoxins
鬼臼素;足葉草毒素
• Etoposide (VePesid)
• Etoposide phosphate (Etopophos)
• Teniposide HCl (Vumon)

12
 Epipodophyllotoxins topoisomerase IIα (TopIIα) poisons.

• Semisynthetic glycosidic derivatives of potophyllotoxin, the major component of the 
resinous podophyllin isolated from the dried roots of the American mandrake or 
mayapple plant (Podohyllum peltatum).
• these compounds are capable of binding to tubulin and inhibiting mitosis, their 
primary mechanism of antineoplastic action is TopIIα poisoning, a mechanism that they 
share with anthracyclines.
• Epipodophyllotoxins are cell cycle specific and 
have their most devastating impact on cells in 
the S or early G2 phase.

potophyllotoxin
13
Chemistry
• etoposide and teniposide, differ only in the nature of one ‐D‐glucopyranosyl
substituent (methyl or thienyl, respectively).
• Both are highly water insoluble, but teniposide's higher lipophilicity facilitates
cellular uptake and results in a 10‐fold enhancement of potency.
• solubility enhancers, such as polysorbate 80 (Tween, etoposide) or
polyoxyethylated castor oil (Cremophor EL, teniposide) , in IV formulations puts
patient at risk for hypersensitivity reactions that can manifest as hypotension and
thrombophlebitis.
• Epinephrine, antihistamines, and corticosteroids to minimize risk.
• A water‐soluble phosphate ester analog of etoposide can be administered in
standard aqueous vehicles, permitting higher doses than the oil‐modified
formulations would allow.
14
Metabolism
• undergo lactone hydrolysis to generate the 
inactive hydroxy acid as the major 
metabolite
• the parent drugs can be transformed by
CYP3A4‐catalyzed O‐demethylation and
phase 2 glucuronide or sulfate conjugation.
• Phase 2 accounts for 5% ‐ 22% of the dose 
• Clinically significant interactions between 
epipodophyllotoxins and 
• CYP3A4 inducers can enhance drug 
clearance by as much as 77%. 
• CYP3A4 inhibitors can decrease clearance, 
leading to unwanted toxicity. 15
Etoposide
• Etoposide and etoposide phosphate ester are used IV in combination with an
organoplatinum agent (cisplatin, carboplatin) in the treatment of small cell lung
cancer, and in combination with other agents in refractory testicular cancer.
• etoposide is the more commonly employed agent,
• polysorbate 80‐induced hypersensitivity can usually be thwarted with
corticosteroid/antihistamine pretreatment
• The phosphate ester would be a viable choice in hypersensitivity to etoposide
despite pretreatment.
• The oral formulation is reserved for lung cancer patients.
• Organoplatinum anticancer agents decrease etoposide clearance, especially in children.
If used in combination, administration must be separated by at least 2 days.

16
Teniposide
• Teniposide is used in combination with other agents for the
treatment of refractory childhood acute lymphoblastic leukemia.
• Exposure to heparin can cause teniposide to precipitate, so lines
must be thoroughly flushed before and after teniposide
administration.
• The drug can also spontaneously precipitate, particularly if solutions are
overagitated, and patients receiving 24‐hour infusions should be
monitored for blockage of access catheters.

17
Antibiotics
• Anthracyclines and Anthracenediones
• Miscellaneous Antineoplastic Agents

18
Anthracyclines and Anthracenediones
• Anthracycline antineoplastic antibiotics are very closely related to the
tetracycline antibacterials.

• Structurally, they are glycosides and contain a sugar portion (L‐daunosamine)

and a nonsugar organic portion.
• The nonsugar portion of glycosides is generically referred to as an aglycone.
• the aglycone moiety is referred to as the anthracyclinone or anthroquinone.

tetracycline antibacterials

Glycoside = aglycone (glycosidic linkage)  sugar

S‐, N‐, C‐, and O‐glycosidic bonds 19
MECHANISM OF ACTION
• TopIIα, the topII isoform that predominates in rapidly dividing cells, is the molecular
target for anthracycline anticancer agents.
• stabilize the cleavable ternary drug‐enzyme‐DNA complex, allowing DNA to be cut and
covalently linked to the conserved Tyr residue.
• by inhibiting proper alignment of the cleaved DNA segments, they inhibit the resealing
reaction.
• The aromatic portion of the anthracyclinone and the daunosamine sugar bind to
DNA, with the anthracyclinone A ring bridging the gap between DNA and enzyme.
• The site of DNA cleavage contains an essential thymine‐adenine (T‐A) dinucleotide
• a small number of anthracycline‐induced DNA breaks here results in a high level of
cell death.

20
CHEMISTRY
• DNA intercalation initiates the antineoplastic action of the anthracyclines.
• Rings B, C, and D slide between the two DNA strands, orienting the anthracyclinone
moiely in a perpendicular fashion and stabilizing the complex through π stacking and
other affinity‐enhancing interactions.
• doxorubicin was docked in a modeled DNA “post‐cleavage“ intercalation site
proposed highly efficacious H‐bonds between top Ser740 and the C5 quinone oxygen
(ring C), top Thr744 and the C4‐OCH3 (ring D) , and a DNA thymine base and the C9‐
OH (ring A). If present, a C14‐OH should H‐bond with the carbonyl oxygen of a DNA
thymine base.

C14
C9

C4 C5

21
DNA intercalation 
• Although the C4‐OCH3 helps hold drug to TopIIα enzyme, its removal increases
antitumor activity by enhancing anthracyclinone planarily (thereby facilitating
intercalation) and by directing the binding of the daunosamine sugar to stabilize
the inhibitory ternary cleavable complex.
• The daunosamine sugar is known to bind in the minor groove of DNA at the
DNA‐topoisomerase interface and subsequently orchestrate the DNA
sequence specificity of the intercalation and overall DNA poisoning process.
• the cationic daunosamine amino group binds with high affinity to the
carbonyl oxygen of a DNA thymine base when in the naturally occurring α
configuration .

22
Major resistance mechanisms 
• (1) compromised drug transport across cell membranes,
• (2) active efflux via P‐gp and MDR transporters,
• (3) changes in tumor cell responsiveness to apoptotic triggers,
• (4) alterations in topIIα expression and activity,
• (5) augmented biochemical defenses against anthracycline‐induced
oxidative stress.

• inhibiting the reductase enzymes could conceivably help

prevent/reverse resistance and could potentially protect against
myocardial damage.
• upregulation of the reductase enzymes that convert anthracyclines to their
less active or inactive secondary alcohol (rubicinol) metabolites has been
proposed as a potential mechanism of acquired resistance.
• rubicinols can be retained in lysosomes and are more vigorously effluxed
from tumor cells by P‐gp.
• rubicinols concentrate in myocardial tissue and mediate the chronic cardiac
toxicity. 23
the polyphenol epigallocatechin‐3‐gallate (EGCG, found in green tea) has been shown to
inhibit cellular efflux of the anthracycline doxorubicin and to sensitize doxorubicin‐
treated/resistant human colon carcinoma cells.

24
Chemical Mechanism of Cardiotoxicity
Acute Toxicity
• In the acute phase, is the formation of reactive oxygen species (ROS).
• the generation of superoxide radical anion and hydroxyl radical (∙OH), both of which
are formed via a one‐electron reduction of the anthracyclinone quinone (ring C) to
hydroquinone via a free radical semiquinone intermediate by NADPH/CYP450
reductase.
• Superoxide radical anions generate hydrogen
peroxide (H2O2) in a Cu2+‐dependent process
that requires superoxide dismutase and
proton.
• The fate of H2O2 dictates the degree of acute
myotoxicity observed from the anthracycline.
• In the presence of catalase, H2O2 is
rapidly converted to water and oxygen.
• in the absence of catalase and in the
presence of ferrous ion (Fe2+), the highly
damaging hydroxyl radical is generated
via the Fenton reaction.

25
• Anthracyclines chelate strongly with di‐ and trivalent cations, including
intracellular Fe3+, which can be reduced to Fe2+ enzymatically or via auto‐
reduction if the C13 substituent is CH2OH. Therefore, the ready availability of
the iron needed to generate hydroxyl radicals from H2O2 is essentially
guaranteed.

Fe3+, which can be reduced to

Fe2+ enzymatically or via auto‐
reduction if the C13 substituent
is CH2OH

26
• In the presence of ferrous ion (Fe 2+), hydrogen
peroxide is converted into the highly toxic
hydroxyl radical through a process called the
Fenton reaction.
• Hydroxyl radicals promote single strand
breaks in DNA, which is therapeutically
desirable to treat the uncontrolled growth
of cancer cells.
• Anthracycline anticancer agents are also
known to interfere with normal ferritin‐
iron mobilization, resulting in iron
accumulation.

27
Chronic (Delayed) Cardiotoxicity
• Rubicinol metabolites are believed responsible for the more life‐threatening
chronic cardiotoxicity that some patients experience.
• The C13‐carbonyl is reduced via a two‐electron mechanism to a usually less active or
inactive rubicinol via cytosolic aldo‐keto reductase (AKR1C3) and carbonyl reductase (CBR1)
enzymes.

• The larger the C13‐substituent the slower the AKR/CBR‐catalyzed reduction reaction, and the
longer the duration of cytotoxic activity. C13‐substituents found on most marketed anthracyclines
include CH3 (daunorubicin and idarubicin) and CH2OH (doxorubicin and epirubicin).
28
Important Mechanism of Use‐limiting Anthracycline 
Cardiotoxicity
• Acute Toxicity
• C ring 
• p‐Quinone reduce  p‐hydroquinone +superoxide radical anion

• superoxide radical anion  H2O2 by dismutase & Cu2+

• H2O2  +Fe2+ (Fenton reaction)  ・OH

• Chronic (Delayed) Cardiotoxicity

• Reduction to C13 alcohol metabolite (rubicinol)

• Deglycosidation to their 7‐hydroxy or 7‐deoxy aglycones

• O‐dealkylation of the C4 methoxy ether (if present) and conjugation with either 

glucuronic acid or sulfate
29
• toxicity is dose‐dependent, dosage adjustments must be made in patients with liver
dysfunction who cannot adequately metabolize and clear anthracyclines to avoid life‐
threatening toxicity.
• coadministration of dexrazoxane, an antioxidant and prodrug iron chelating agent, can
attenuate anthracycline‐induced cardiotoxicity (including chronic, delayed heart failure)
from the 13‐CH2OH substituted anthracyclines doxorubicin and epirubicin in both adults
and children.
• administered IV 30 minutes prior to the anthracycline to allow distribution to cells
where it will be needed.
• also be used to attenuate serious tissue injury following accidental anthracycline
extravasation. For this indication, it is administered IV once daily for three days,
beginning within 6 hours of the extravasation incident.

30
• Most of the anthracyclines are orally inactive and must be given by intravenous
injection.
• They are highly necrotic to skin and, if extravasation occurs, can cause such
severe blistering 起泡 and ulceration that skin excision, followed by plastic
surgery, may be indicated.
• contain photosensitive phenolic groups that must be protected from light and
air
• The highly conjugated structure imparts a reddish orange color to these
compounds (implied in the name “rubicin") , which is maintained when these
compounds are excreted in the urine.

31
• Doxorubicin C13 substituent is hydroxymethyl
• Retards the action of cytosolic reductase and slow the conversion to the less active
and chronically cardiotoxic doxorubicinol.
• A Iiposomal formulation of doxorubicin, marketed as Doxil, is used in the treatment
of AIDS‐related Kaposi sarcoma and organoplatinum‐resistant ovarian cancer.
• Epirubicin, stereoisomer of doxorubicin, has the 4'‐hydroxy group of the daunosamine
sugar oriented in the unnatural ‐position.
• Impact on pharmacokinetic properties
• Reduced to the C13 alcohol (epirubicinol) is much lower (60%)
• Overall cardiotoxicity at 30% lower
• Daunorubicin Hydrochloride
• The absence of the OH group at C14 in daunorubicin results in a faster conversion to
the less active and chronically cardiotoxic C13‐ol metabolite (daunorubicinol)
compared to hydroxymethyl‐ substituted anthracyclines like doxorubicin .
32
Idarubicin Hydrochloride
• Idarubicin is the 4‐desmethoxy analogue of daunorubicin, which facilitates intercalation
between DNA base pairs. In turn, this orients the daunosamine sugar in the minor groove
in a way that better stabilizes the ternary complex for the DNA cleavage reaction.
• The loss of the 4‐methoxy moiety also makes this compound more lipophilic than other
anthracyclines, resulting in better penetration into tumor cells.

Valrubicin
• Chemically, valrubicin differs from doxorubicin by the addition of a carbon‐rich C14‐
valerate ester and a nonionizable 3′‐trifluoroacetamide moiety.
• solubilizing with Kolliphor EL, instilled intervesically經膀胱灌注in the treatment of
bacille Calmette‐Guérin (BCG)‐refractory carcinoma in situ of the bladder.
• high lipophilicity effectively traps it at the site of action, so therapy can be considered
local.
• Valrubicin is not a doxorubicin prodrug; the trifluroacetamide and valerate ester remain
intact within the bladder.

33
• A maleimide‐containing hydrazone prodrug of doxorubicin, aldoxorubicin, is in clinical
trials for the treatment of advanced, relapsed/refractory soft tissue sarcoma.
• First‐line therapy for this aggressive cancer is currently doxorubicin in combination with
the DNA alkylating agent ifosfamide, but dose‐limiting doxorubicin‐induced
cardiotoxicity can limit treatment options.
• Aldoxorubicin is delivered to tumor cells covalently bound to albumin and
selectively released in situ, providing targeted therapy with minimal risk of
doxorubicin’s hallmark toxicities.

34
Mitoxantrone Hydrochloride
• Chemically, mitoxantrone is classified as an anthracenedione. The sugar moiety is
missing, cationic side‐chain amino nitrogens could bind to the anionic phosphate
residue of the DNA backbone in the same fashion that the anthracycline cationic amino
group is believed to do.
• This molecule has the structural features needed to intercalate DNA and inhibit TopIIα,
but the enhanced stability of the quinone ring (possibly through an increased potential
for intramolecular hydrogen bonding) makes the ring highly resistant to NADPH/CYP450
reductase.
• This limits the formation of the highly toxic ROS. In addition, there is no active
cardiotoxic metabolite to induce chronic toxicity by disrupting the movement of
myocardial cations.

35
Miscellaneous
Antineoplastic Agents
• Arsenic Trioxide
• Bleomycin sulfate
• Inotuzumab Ozogamicin Conjugate
• Trabectedin

36
 Arsenic Trioxide
• Arsenic trioxide (As2O3, the “King of Poisons”)is an odorless and tasteless
toxin well known in ancient Chinese medicine.
• originally introduced into Western medicine in the late 19th century for the
treatment of leukemia

• used IV to induce remission in patients with acute promyelocytic leukemia 

(APL).
• APL is characterized by the reciprocal translocation of chromosomes 15 and 17,
resulting in the abnormal joining of the promyelocytic gene and retinoic acid
receptor α (RARα) gene which produces a PML‐RARα fusion protein.
• results in the generation of immature leukemia cells, differentiation arrest, and the
induction of serious/fatal hemorrhagic and other coagulation‐related disorders.

37
• As2O3 induces remission in APL patients through
• the destruction of the offending fusion protein, promotion of promyelocyte
differentiation, and stimulation of apoptosis in malignant cells.
• One documented chemical apoptotic mechanism is
• inhibition of intracellular catalase and glutathione peroxidase, with the resultant
accumulation of the free radical precursor H2O2.

• Another is the downregulation of the antiapoptotic protein Bcl‐2.

• As2O3 can be used as initial therapy in combination with tretinoin (all trans‐

retinoic acid) in patients with low‐risk disease, as well as alone in those
who have relapsed after tretinoin/anthracycline chemotherapy.

• The pentavalent As(V) in the parent drug is rapidly reduced to the active 
trivalent As(III) by arsenate reductase.
38
• generate ROS in mitochondria that damage DNA and stimulate apoptosis.
• Prior to urinary excretion, As(III) is methylated  to  mono‐  and  dimethylarsonic 
acid.

• APL differentiation syndrome (also known as retinoic acid syndrome and

characterized by pleural/pericardial/pulmonary infiltrates or effusions,
dyspnea, weight gain, and fatigue) responds to corticosteroid intervention.
• Reversible hepatotoxicity
• strong emetogenic potential warrants coadministration of drugs to control
nausea and vomiting.
• rapid clearance of As(III) and its methylated metabolites precludes use in solid
tumors.
• combination therapy with GSH depleting agents and encapsulation in nanoparticles,
liposomes and polymersomes. 39
BLEOMYCIN 
• The commercially available bleomycin drug product is a mixture of 
naturally occurring glycopeptides, predominantly bleomycin A2. 
• Bleomycin is a natural product isolated from Streptomyces
verticillus. It is normally chelated with Cu2+, which must be 
removed via catalytic reduction before marketing. 
• This increases the cost of the drug
• but it frees up the critical bleomycin functional groups for 
chelation with intracellular Fe2+

40
• Through DNA intercalation in guanine‐rich regions, the aromatic bithiazole ring
system positions bleomycin for DNA destruction via cytotoxic free radicals.
• The disaccharide, polyamine, imidazole, and pyrimidine structures are very
electron rich and readily chelate intracellular Fe2+
• Once chelated, Fe2+ is oxidized to Fe3+ with a concomitant reduction of bound
oxygen and the release of the highly reactive and cytotoxic hydroxyl radical.
• The ferric hydroperoxide bleomycin complex is considered the cytotoxic
form for both single‐ and double‐stranded DNA breaks.

polyamine

pyrimidine
imidazole

disaccharide
41
• Through the direct abstraction of a hydrogen atom from 4' of
deoxyribose, a free radical is generated that subsequently
decomposes to a DNA‐destroying 4′‐hydroperoxide. A highly
electrophilic pyrimidine base propenal that inactivates essential
cellular proteins via Cys alkylation is also produced
• Reduced GSH is proposed to serve a protective role by acting as propenal
scavenger and, until depleted, saves cellular proteins from alkylation

42
• The action of bleomycin is terminated through the action of bleomycin hydrase,
a cytosolic aminopeptidase that cleaves the terminal amide moiety to form the
inactive carboxylate metabolite .
• The metabolic replacement of the electron‐withdrawing amide with an
electron‐donating carboxylate increases the pKa of the α‐amino group, which
normally interacts with DNA in the un‐ionized conjugate form.

• After hydrolysis, the ratio of ionized to un‐

ionized forms of this critical amine
increases approximately 126‐fold,
destroying DNA affinity and leading to
the loss of therapeutic action.
• Drug destruction via the bleomycin
hydrase pathway is rapid
• tumors will be resistant to bleomycin
if they contain high concentrations of
43
the enzyme.
• Bleomycin hydrase is found in all tissues except skin and lung.
• Approximately 10% of patients who are administered bleomycin will experience
potentially fatal pulmonary fibrosis, which can occur during therapy or several
months following termination of therapy, often without warning.
• The copper‐complexing agent tetrathiomolybdate may reduce the risk of
bleomycin‐induced fibrosis by inhibiting the action of copper‐dependent
inflammatory cytokines
• the protective effect of inhibitors of the N‐terminal catalytic site of angiotensin‐
converting enzyme (e.g., N‐acetyl‐Ser‐Asp‐Lys‐Pro or AcSDKP).

• Bleomycin is used intravenously in the palliative treatment安寧照護 of 

squamous cell head and neck cancers, testicular and other genital carcinomas, 
Hodgkin's Iymphoma, and NHL. 
• It is excreted via the kidneys, and serum concentrations of active drug are 
increased in patients with renal disease.
• Unlike many antineoplastic agents, bleomycin does not suppress the bone 
marrow, and it is often given in combination with compounds that do so that 
the dose of all drugs can be optimized.
44
• Bleomycin最讓人擔心就是使用之後，伴隨而來的肺部副作用，目前的醫學還沒
有辦法確實解決藥物造成的副作用
• 46%的患者可能會產生肺癌的現象，
• 其中3% 可能造成嚴重的肺纖維化，

• 較積極方式為在纖維化之前先抑制肺炎的發生。而兩者之間的機轉還無法確定
• Bleomycin的使用會造成肺血管內皮細胞的損傷，啟動身體免疫反應，巨噬
細胞和淋巴細胞在間質中的積聚，激活肺內的纖維細胞產生一些細胞因子，
而與膠原蛋白沉積在肺泡毛細管中，減少氧氣的交換，後續造成肺纖維化
的症狀。

45
 Inotuzumab Ozogamicin Conjugate
• a targeted chemotherapeutic agent, was approved in mid-2017 for use in
adults with relapsed or refractory B-cell precursor ALL.

• contains 6 molecules of a cytotoxic N-acetylated hydrazine derivative of γ-

calicheamicin conjugated with a Chinese hamster ovary (CHO)-derived human
MAb.
• bind specifically to antigenic markers expressed on the surface of B-cell (CD22) and
myeloid cell (CD33) malignancies

46
• Hydrolysis of the acid‐labile hydrazone linker at the low pH of lysosomes (∼6)
releases N‐acetyl‐γ‐calicheamicin dimethylhydrazide, which undergoes further
hydrolysis to generate calicheamicin, the active enediyne which binds within the
minor grove of DNA.

• The enediyne moiety of the DNA‐bound calicheamicin is vulnerable to SH‐

dependent conformational changes that generate di‐radicals, leading to H‐
abstraction from the DNA phosphodiester group and subsequent double‐strand
breaks in the DNA.

47
• Inotuzumab ozogamicin is administered IV in doses of either 0.5 or
0.8 mg/m2 for a maximum of six 21‐ or 28‐day cycles.
• The maximum tolerated dose has been reported at 1.8 mg/m2.
• The drug is highly bound to plasma protein (∼97%) with a terminal half‐life of
12.3 days.

• The N‐acetyl‐γ‐calicheamicin dimethylhydrazide is a substrate for P‐gp,

which negates the therapeutic value of the conjugate in P‐gp positive
malignant cells.

• While the targeted nature of conjugate delivery spares cells that do not
express CD22 from calicheamicin toxicity, the drug is myelosuppressive
(which increases infection risk)
• carries a boxed warning for potentially severe hepatotoxicity and an increased risk
of post hematopoietic stem cell therapy mortality unrelated to relapse.
48
Trabectedin
• a tri‐tetrahydroisoquinoline–containing alkaloid derived from the marine 
tunicate Ecteinascidia turbinate
• indicated in unresectable, metastatic, refractory soft tissue sarcoma (liposarcoma
脂肉瘤and leiomyosarcoma平滑肌肉瘤;  “l‐sarcomas”). 
• Treatment of this rare cancer is challenged by the more than 50‐60 histological subtypes that exist, and 
prognosis after first‐line chemotherapy with doxorubicin (alone or with ifosfamide) is dismal.

• Mechanism of Action
• alkylation of guanine N2 within a CGG‐rich region of the minor groove. 
• leads to DNA double strand cleavage 
• through simultaneous interaction with nearby proteins, RNA polymerase II degradation and transcription 
inhibition via a NER‐dependent process. 
• The cell cycle is arrested in the G2‐M phase and apoptosis results. 

• interferes with oncogenic transcription factor FUS‐CHOP function in liposarcomas
• promotes normalizing adipocyte differentiation
• attenuation of inflammation and angiogenesis through selective interference with monocytes and 
macrophages within the tumor microenvironment.
49
• Trabectedin is administered via 24-hour continuous IV infusion
through a central venous catheter in a usual dose of 1.5 mg/m2.

• Combination therapy with doxorubicin may provide a response

advantage and is being explored.

• 94%-98% protein bound, rapidly converted to many metabolites and

eliminated in feces.
• Multiple CYP isoforms (including 3A4) are presumed involved in the complex
metabolic pathway, coadministrated with CYP inhibitors or enhancers should
be undertaken with caution.

• Terminal half-life is long at approximately 7.5 days.

• The most commonly observed adverse effects are myelosuppression

(neutropenia, thrombocytopenia), GI distress, and hepatic enzyme
elevation.

50
DACTlNOMYCIN
• Dactinomycin has two pentapeptide lactones attached to an aromatic ( flat) 
actinocin (or phenoxazinone) structure. 
• It is capable of intercalating DNA and binds preferably between guanine and 
cytosine residues on a single DNA strand. 
• This interaction results in DNA elongation and distortion, commonly referred to 
as a point mutation.
• The p‐benzoquinoneimine segment of dactinomycin renders the molecule vulnerable 
to NADPH/ CYP450 reductase. 
• Free radicals can be generated, and additional single‐strand DNA breaks can 
result. 
• The loss of either aromatic methyl group results in a loss of activity.

51
MITOMYCIN 
• Mitomycin is activated through a two‐
electron bioreductive process using 
NADPH/CYP450 reductase and/ or NAD(P)H 
quinone oxidoreductase 1 (NQ01 reductase ), 
an enzyme extensively expressed in many 
neoplastic. 
• the quinone ring of mitomycin is readily 
reduced to the hydroquinone, generating 
superoxide radicals in the process that 
ultimately will be converted to cytotoxic 
hydroxyl radicals through the Fenton 
reaction.
• Formation of the hydroquinone is followed by 
aromatization to the indole ring through the 
loss of methanol. 
• Both the electrophilic aziridine ring and the 
+ methylene group adjacent to the 
carbamate ester are vulnerable to attack by 
DNA nucleophiles, such as the 2‐NH2 group of 
guanine or the 4‐NH2 group of cytosine, and 
can conceivably result in cross‐linked DNA and 
cell death. 52