Journal of Drug Delivery Science and Technology 55 (2020) 101348

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Journal of Drug Delivery Science and Technology

journal homepage: www.elsevier.com/locate/jddst

Delivery of erlotinib for enhanced cancer treatment: An update review on T

particulate systems
Duy Hieu Truonga,1, Vu Khanh Hoa Leb,1, Tung Thanh Phamc, Anh Hoang Daod,
Thi Phuong Dung Phame, Tuan Hiep Tranf,g,∗
a
Institute of Research and Development, Duy Tan University, Da Nang, Viet Nam
b
NTT Hi-Tech Institute, Nguyen Tat Thanh University, Ho Chi Minh City, Viet Nam
c
College of Pharmacy, Yeungnam University, Gyeongsan, Gyeongbuk, 38541, South Korea
d
National Institute of Medicinal Materials, Hanoi, Viet Nam
e
Faculty of Pharmacy, Dai Nam University, Hanoi, Viet Nam
f
Department for Management of Science and Technology Development, Ton Duc Thang University, Ho Chi Minh City, Viet Nam
g
Faculty of Pharmacy, Ton Duc Thang University, Ho Chi Minh City, Viet Nam

A R T I C LE I N FO A B S T R A C T

Keywords: Erlotinib is an epidermal growth factor receptor (EGFR) inhibitor that has been approved for metastatic non-
Erlotinib small cell lung cancer and highly aggressive pancreatic cancer. Although erlotinib contributes progressively to
EGFR cancer treatment, there is still room to develop a better platform for erlotinib-based therapy. The progression of
Nanoparticles the materials science field has offered many options to incorporate drugs with additional advantages. In this
Delivery systems
review, we summarize various strategies, including polymeric, lipidic, inorganic and hybrid-based carriers, to
Efficacy enhancement
Cancer
improve drug pharmacokinetics, reduce interpatient variability and minimize unwanted side effects. Moreover,
the combination of erlotinib with other therapeutic agents or modalities is further discussed as a potential
paradigm for realizing better efficacy and/or lower systemic toxicity in clinical practice.

1. Introduction
Erlotinib (ERL), a quinazoline derivative with the chemical name N-
(3-ethynylphenyl)-6,7-bis(2-methoxyethoxy)-4-quinazolinamine, is an
FDA-approved small-molecule tyrosine kinase inhibitor for the treat-
ment of metastatic non-small cell lung cancer (NSCLC) and locally ad-
vanced, unresectable or metastatic pancreatic cancer in combination
with gemcitabine [1]. By selectively occupying the adenosine tripho-
sphate (ATP) binding sites of epidermal growth factor receptor (EGFR),
this molecule reversely inhibits EGFR activation, resulting in the sup-
pression of further downstream signaling processes, mostly through the
phosphatidylinositol 3-kinase (PI3K) and mitogen activated protein
kinase (MAPK) pathways, and consequent inhibition of cellular pro-
liferation, angiogenesis and metastases [2,3]. To date, the potential of
this substance has been expanded to treat other types of cancer, such as
ovarian cancer, head and neck cancer, and glioblastoma [4–8].
As a substance with low aqueous solubility and high permeability
(logP of 2.7), ERL is categorized into class II in the biopharmaceutical
classification system [9]. Regarding the oral route of administration, its
poor solubility restricts the dissolution of the drug in the gastro-
intestinal fluid that can limit its absorption, thereby causing high
fluctuation in its bioavailability and large interpatient variability
[10,11]. Although the commercial tablet dosage form (Tarceva®) shows
an acceptable bioavailability of approximately 60% in healthy volun-
teers upon oral administration of 150 mg [12], similar to most of the
compounds used for chemotherapy, patients receiving this therapy still
suffer from drug resistance and severe toxicities, i.e., skin rash, diar-
rhea, gastrointestinal perforations and Stevens-Johnson syndrome, that
might hamper its clinical application [13]. These obstacles necessitate
the careful design of suitable delivery systems for not only improved
efficacy but also reduced side effects.
Recently, nanotechnology has been widely used to improve the
physicochemical and pharmacokinetic properties of poorly water-so-
luble drugs, such as solubility, dissolution, absorption and bioavail-
ability [14–16]. There have been many different techniques or strate-
gies that can be exploited for these purposes, e.g., spray drying, freeze
drying, wet milling and high-pressure homogenization, to fabricate
various nanoformulations, such as solid dispersions, drug nanocrystals

∗
Corresponding author. Ton Duc Thang University, Ho Chi Minh City, Viet Nam.
E-mail addresses: truongduyhieu@gmail.com (D.H. Truong), trantuanhiep@tdt.edu.vn (T.H. Tran).
1
These authors contributed equally to this manuscript.

https://doi.org/10.1016/j.jddst.2019.101348
Received 19 August 2019; Received in revised form 11 October 2019; Accepted 22 October 2019
Available online 23 October 2019
1773-2247/ © 2019 Elsevier B.V. All rights reserved.
 D.H. Truong, et al.

Table 1
Nanoparticles for delivery of erlotinib as a single therapeutic agent.
Type Materials Experiments Results Ref.

1. Polymer-based particles poly(D,L-lactic-co-glycolic acid) (PLGA) in vitro Decrease of toxicity and damage to internal organs [24]
polycaprolactone - polyethylene glycol - poly caprolactone (PCEC) in vitro Increase of cytotoxicity in A549 NSCLC cells [25]
sulfobutyl ether β-cyclodextrin in vitro, in vivo Increase of dissolution and bioavailability by 2-fold and 3.6-fold, respectively [29]
cyclodextrin-based nanosponge in vitro, in vivo Increase of dissolution and bioavailability by 2-fold, and cytotoxic effects in MIA PaCa-2 and PANC-1 [30]
pancreatic cell lines
glutathione-nanosponge in vitro, in vivo Increase of cytotoxicity in A549 NSCLC cells and inhibition of tumor growth, and decrease distribution in [31]
vital organs
albumin-bound nanoparticles in vitro Increase of cytotoxicity in ASPC-1 and PANC-1 pancreatic cancer cells [33]
albumin-bound nanoparticles in vitro, in vivo Decrease of proliferation of A549 NSCLC cells and inhibition of tumor growth [34]
polyvinylpyrrolidone in vitro, in vivo Increase of dissolution, bioavailability and antitumor effect in A549 xenograft model, and decrease of [35]
fasted/fed variability

2. Lipid-based particles self-emulsifying drug delivery system in vitro, in vivo Increase of dissolution and bioavailability [36]
liposomes in vitro, in vivo Increase of cytotoxicity in A549 NSCLC cells and bioavailability [37]
solid lipid nanoparticles in vitro Increase of cytotoxicity in A549 NSCLC cells [38]
solid lipid nanoparticles in vitro Increase of cytotoxicity in A549 NSCLC cells [39]

2
molecular complex in vitro, in vivo Increase of cytotoxicity in MIA PaCa-2 and PANC-1 pancreas adenocarcinoma cells, solubility and [40]
bioavailability

3. Inorganic particles carbon-coated, iron magnetic nanoparticles in vitro Decrease of proliferation of PANC-1 pancreatic cells, especially under radio frequency [44]
ultra-small superparamagnetic iron oxide nanoparticles in vitro, in vivo Suppression of migration and invasion of CL1-5-F4 lung adenocarcinoma cells, and inhibition of tumor [46]
growth
ultra-small superparamagnetic iron oxide nanoparticles in vitro, in vivo Dose-dependent cytotoxicity in CL1-5-F4 NSCLC, and inhibition of tumor growth and NF-κB activity [47]
iron oxide-gold nanoclusters in vitro Increase of uptake and cytotoxicity in PANC-1 pancreatic cells [48]

4. Hybrid particles polymeric polycaprolactone; phospholipid in vitro Decrease of cellular viability in A549 NSCLC cells [49]
aptamer-conjugated chitosan; liposome in vitro Increase of antiproliferation, induction of cell cycle arrest and apoptosis in EGFR-mutated H1975 and PC- [50]
9 cells
poly(L-aspartic acid); poly(ethylene glycol)-b-poly(L-aspartic acid) (PEG-b- in vitro, in vivo Increase of uptake and cytotoxicity in HCC-827 and NCI-H358 lung cancer cells, and inhibition of tumor [57]
PAsp) growth
polymer-gold hybrid nanomaterial in vitro Increase of uptake and cytotoxicity in A549 NSCLC cells [58]
thermosensitive micelles in vitro Increase of cytotoxicity in OVCAR-3 ovarian carcinoma cells [59]
poly(acrylic acid)-cystamine-oleic acid (PAA-ss-OA) in vitro, in vivo Increase of cytotoxicity in A549 and NCI-H460 NSCLC cells, and antitumor efficacy in a lung cancer [60]
xenograft model
magnetic mesoporous silica nanoparticles; folic acid-poly(ethyleneimine) Increase of drug release at acidic pH by 2-fold and cytotoxicity in HeLa cervical carcinoma cells [61]
conjugate
myofibroblast-targeting nanoparticles in vitro, in vivo Sustained drug release over 12 days, and decrease of tumor burden by 7.3-fold and hepatocyte damage [62]
Journal of Drug Delivery Science and Technology 55 (2020) 101348
 D.H. Truong, et al.

Table 2
Nanoparticles for delivery of erlotinib and other therapeutic agent/modalities.
Type Material Other active agents/modalities Experiments Results Ref.

1. Hybrid particles solid lipid core nanocapsules; polymer shell paclitaxel in vitro Increase of cytotoxicity in NCI-H23 cells [65]
aptamer-conjugated chitosan; liposomes perfluorooctylbromide in vitro, in vivo Increase of proliferation inhibition and induction of apoptosis of [67]
NSCLC cells, and significant decrease of tumor growth
aptamer-conjugated chitosan; liposomes survivin-recombinant short hairpin RNA- in vitro, in vivo Increase of gene transfection efficiency and toxicity in EGFR mutated [68]
expressing plasmid; chloroquine NSCLC cells, and inhibition of tumor growth
liposomes; hydrophilic thermally oxidized porous silicon doxorubicin; in vitro Synergistic effects on killing DOX-resistant MCF-7 breast cancer cells [70]
nanoparticles 17-AAG; DNA nanostructures; nano-magnetite;
gold nanorods
amino-functionalized mesoporous silica nanoparticles; 1,5- doxorubicin in vitro, in vivo Increase of proliferation and apoptosis in A549 NSCLC cells, and [82]
dioctadecyl-L-glutamyl 2-histidyl-hexahydrobenzoic acid inhibition of tumor growth
(HHG2C18)
gold nanocages; poly(acrylic acid); poly(N-isopropylacrylamide- doxorubicin in vitro, in vivo Synergistic tumor-killing effect in vitro and in vivo with stronger [84]

3
co-acrylamide) efficacy in highly EGFR-expressing A431 cells than in weakly EGFR-
expressing MCF-7 cells

2. Lipid-based liquisolid formulation valproic acid in vitro, in vivo Increase of cytotoxicity in ERL-resistant HCC827 lung adenocarcinoma [66]
particles cells and bioavailability
liposomes doxorubicin in vitro, in vivo Increase of apoptosis, decrease of EGFR expression in A549 NSCLC and [81]
BT-20 triple-negative breast cancer cells, and inhibition of tumor
growth

3. Polymer-based chitosan a heptamethine cyanine derivative in vitro, in vivo Increase of reactive oxygen species levels and tumor suppressor p53, [69]
particles and decrease of survivin expression in EGFR mutated NSCLC cells and
tumor growth
poly(L-lactide)-b-polyethylene glycol fedratinib in vitro, in vivo Increase of cytotoxicity in two ERL-resistant lung adenocarcinoma cell [75]
lines and tumor growth suppression in H1650 tumor-bearing mice
poly(L-lactide) DAPT in vitro, in vivo Increase of cytotoxicity in MDA-MB-231 triple-negative breast cancer [76]
cells, and inhibition of tumor growth
poly(L-lactide)-b-polyethylene glycol doxorubicin in vitro, in vivo Increase of cytotoxicity in MDA-MB-468 breast cancer cells and [83]
accumulation in tumor sites
Journal of Drug Delivery Science and Technology 55 (2020) 101348
D.H. Truong, et al.
and solid lipid nanoparticles (SLNs) [17–20]. What if these technologies
can enhance the properties of ERL? What is the outcome of these
changes? What is the potential of those interventions for clinical ap-
plication? To answer these questions, in this review, we summarize
several approaches to improve the therapeutic efficacy of ERL as a
therapeutic agent alone (Table 1) and in combination with other ther-
apeutic compounds or modalities (Table 2) using various drug delivery
systems, mainly focusing on nanocarriers.
2. Drug delivery systems containing erlotinib alone
2.1. Polymer-based systems
With the advance of chemical engineering, polymers, a large group
of compounds with versatile physical and chemical properties, can be
tuned to make nanocarriers for controlling the temporal or spatial re-
lease of therapeutic agents [21]. Among the different types of polymers,
biodegradable polymers, such as poly(D,L-lactic-co-glycolic acid)
(PLGA) and polycaprolactone-derived copolymers, are preferable to use
when designing delivery systems because of their high safety profiles
and controlled release capability of cargo [22,23]. To evaluate the
safety of PLGA for delivering ERL, this drug was loaded into PLGA
nanoparticles (NPs), and then the toxicity of these NPs following oral
administration in Wistar rats was assessed [24]. Compared to free ERL,
these ERL-encapsulated NPs showed significantly lower toxicity and
damage to internal organs, as confirmed by hematological and biolo-
gical analyses and histopathological examination. In another study,
polycaprolactone - polyethylene glycol - polycaprolactone (PCEC) tri-
block copolymers were used to prepare polymeric NPs in which ERL
was incorporated into their lipophilic cores [25]. The results showed
that the molar ratios of the polycaprolactone and polyethylene glycol
monomers defined the characteristics of these NPs. In particular, the
higher the ratio was, the larger the NP size and encapsulation efficacy
of ERL, and the lower release rate of ERL from the NPs. Drug-en-
capsulated NPs showed remarkably higher cytotoxicity than that of the
free drug, especially at higher doses and longer incubation periods, in
A549 lung cancer cells.
For a long period of time, cyclodextrins have been used to make
inclusion complexes with various drug compounds to improve their
solubility and bioavailability [26–28]. However, natural cyclodextrins
are not highly soluble in aqueous solutions, which limits their practical
applications as delivery vehicles. To overcome this hurdle, Suresh's
group employed one of the more hydrophilic cyclodextrin derivatives,
sulfobutyl ether β-cyclodextrin, to formulate an inclusion complex with
ERL by the freeze drying method [29]. By using the design of experi-
ments technique, the molar ratio of 1.05:1 between ERL and sulfobutyl
ether β-cyclodextrin was found to be the optimal ratio to easily prepare
an inclusion complex. Compared to free ERL, this formulation demon-
strated more than 2-fold higher dissolution at 60 min and 3.6-fold
higher AUC0-∞. Later, this group utilized a β-cyclodextrin-based na-
nosponge, which was prepared by cross-linking a β-cyclodextrin
monomer and the cross-linker carbonyldiimidazole, for complexing
with ERL [30]. After performing some preliminary solubility experi-
ments, the formulation with the optimum ERL and nanosponge ratio of
1:4 was prepared and characterized. In comparison to pure ERL, this
optimized formula approximately doubled the dissolution rate and oral
bioavailability and exhibited more cytotoxic effects on the MIA PaCa-2
and PANC-1 pancreatic cancer cell lines. For lung-specific delivery of
ERL, Momin et al. synthesized glutathione nanosponges through a high-
yielding reaction among β-cyclodextrin, 2-hydroxyethyl disulfide and
the cross-linker pyromellitic dianhydride [31]. ERL-loaded glutathione
nanosponges were able to show a sustained release pattern of ERL (up
to 7 days), which was proportionally dependent on the concentrations
of glutathione in the surrounding environment. The drug-loaded glu-
tathione nanosponges not only were markedly more cytotoxic in A549
NSCLC cells than free ERL but also demonstrated higher tumor growth
4
Journal of Drug Delivery Science and Technology 55 (2020) 101348
inhibition in a xenograft mouse model of lung cancer with significantly
lower biodistribution in the spleen, heart, kidney and liver resulting
from the targeting ability of glutathione. Taken together, these results
suggested that complexation with β-cyclodextrin derivatives could be
an effective method to enhance the efficacy of ERL with reduced side
effects.
Albumin has been proven as a safe vehicle that is approved in many
clinical products for drug delivery and bioimaging purposes, the most
notable of which is Abraxane® (paclitaxel albumin-bound particles for
injectable suspension) [32]. By using the same concept, Noorani and
colleagues synthesized ERL-loaded albumin NPs by desolvation fol-
lowed by a thermal cross-linking method [33]. The use of an aqueous
solution of albumin at pH 5 and an acetone/dimethyl sulfoxide mixture
with a 5:1 (v/v) ratio as the organic solvent resulted in a high drug
loading capacity (approximately 27%) of ERL in the albumin NPs with
hydrophobic interactions and hydrogen bonds between the two com-
ponents. In both the ASPC-1 and PANC-1 pancreatic cancer cell lines,
the ERL-loaded albumin NPs demonstrated higher cytotoxicity than
that of free drug. In another work, Shen and Li coated ERL albumin-
bound NPs with a hyaluronic acid layer to specifically target CD44-
overexpressing tumor cells [34]. Due to the presence of the coating
layer, the NPs showed excellent stability after 3 months and slower
drug release than their uncoated counterparts. Additionally, compared
to the uncoated NPs and free ERL, the NPs whose surface was modified
by hyaluronic acid exhibited significantly enhanced uptake into A549
lung cancer cells, thereby further suppressing their proliferation. Im-
portantly, the coated NPs demonstrated remarkable tumor growth in-
hibition in tumor-bearing mice without relapse within 30 days post-
treatment.
In another effort to enhance the oral bioavailability of ERL and
reduce the variation in bioavailability between the fasted and fed states,
a novel nanoparticulation method using fat and supercritical fluid
(NUFS™) technology was applied [35]. In this method, ERL was melted
with a mixture of myristyl alcohol and polyvinylpyrrolidone at 130 °C
before being rapidly cooled to 15 °C for the preparation of nanoparti-
culated ERL. Then, solidified myristyl alcohol was removed by super-
critical CO2 to obtain the formulation as a dried powder. This for-
mulation showed higher dissolution rates under both fasted and fed
conditions and a 5.5-fold higher AUC in the fasted state than did Tar-
ceva. Additionally, the ratio of fasted AUC to fed AUC for the for-
mulation was 1:1.8, which was significantly lower than that of Tarceva
(1:5.8). In particular, compared to Tarceva, the formulation markedly
improved antitumor efficacy in the A549 xenograft tumor model, which
likely resulted from the enhanced dissolution and potent inhibition of
EGFR signaling.
2.2. Lipid-based systems
Lipid-based delivery carriers have demonstrated great promise in
enhancing the delivery of poorly water-soluble drugs, with numerous
successful commercial products, such as Neoral® (self-emulsifying for-
mulations of cyclosporine), Onivyde > ® (liposomal irinotecan) and
AmBisome® (liposomal amphotericin B). Given the similarity in solu-
bility between these drugs and ERL, the abovementioned products
suggest several potential options of lipid carriers that can be used to
develop ERL-containing formulations with improved profiles.
Our work sought to utilize a self-emulsifying formulation to deliver
ERL [36]. By using the ternary phase diagram, we chose the optimized
formulation, consisting of 5% w/w of oil (linoleoyl polyoxyl-6 glycer-
ides or Labrafil® M2125CS), 65% w/w of surfactant (caprylocaproyl
polyoxyl-8 glycerides or Labrasol®) and 30% w/w of cosolvent (die-
thylene glycol monoethyl ether or Transcutol® HP), to dissolve ERL and
then solidified the resultant solution by spray-drying with dextran 40 or
Aerosil® 200 as the inert carrier. The incorporation of ERL into these
formulations in the amorphous form or as a molecular dispersion re-
markably improved its dissolution and bioavailability compared to
D.H. Truong, et al.
Fig. 1. (A) Dual functional FeDC-E NPs may serve both therapeutic effect and diagnostic utility in the same time in NSCLC. Reprinted with permission from Ref. [47].
(B) Schematic representation of the formation of Fe3O4@AuNCs@ERL nanocomposite. Reprinted with permission from Ref. [48].
those of the free drug.
Zhou and coworkers incorporated ERL into the hydrophobic layer of
a PEGylated liposomal formulation by the thin-film hydration method
[37]. In contrast to non-PEGylated ERL-loaded liposomes, the PEGy-
lated ERL-loaded liposomes exhibited slightly higher cellular cytotoxi-
city and a 2-fold increase in bioavailability without causing any ap-
parent damage to tissues of vital internal organs owing to the enhanced
permeation and retention effect.
The most well-known indication of ERL is to treat NSCLC; hence,
direct delivery of ERL to lung cancer tissues and cells is highly desir-
able. For that purpose, a microparticulate formulation of inhalable dry
powder (IDP) containing ERL-encapsulated SLNs was prepared [38].
The optimal SLNs, composed of Compritol® 888 ATO, Tween® 80 and
Poloxamer 407 at a weight ratio of 24:1:20, were spherical particles
with sizes of less than 100 nm. The ERL-encapsulated SLNs showed
enhanced cytotoxic effects of ERL on A549 human NSCLC cells. For the
delivery of ERL to deep lung tissues, the ERL-loaded SLNs were spray-
dried into mannitol, forming microparticles (1–5 μm) with suitable
flowability and aerodynamic properties, as confirmed by Hausner ratio,
Carr's index and the results of the pharmacopoeial Next Generation
Impactor® (NGI) test. Another SLN-loaded IDP for the pulmonary de-
livery of ERL was developed by Naseri et al. using different components
[39]. The oily phase, which was composed of glycerol monostearate,
Transcutol®, poloxamer 188 and ERL, was mixed in distilled water to
form SLNs. Similar to the abovementioned study, these drug-loaded
SLNs showed higher cytotoxicity than that of the free drug in the
A549 cell line. The fine particle fraction (FPF) and mass median aero-
dynamic diameter (MMAD) values of three mannitol-based powders
5
Journal of Drug Delivery Science and Technology 55 (2020) 101348
were approximately 10% and 4.5–6.7 μm, respectively, similar to those
of commercial products, demonstrating the suitability of these inhal-
able formulations for lung cancer treatment.
In addition to using polymers to improve ERL's efficacy [29,30],
Suresh's group also cooperated with Jain's group to employ phospha-
tidyl choline for developing a molecular complex with ERL [40]. A
drug-to-phospholipid ratio of 1–2 promoted stable complexation where
the drug was engulfed by the phospholipid, thereby transforming the
drug into a less crystalline phase and improving its hydrophilicity,
which led to 5.4-fold and 1.7-fold increases in the aqueous solubility
and oral bioavailability of ERL, respectively. Along with exhibiting
higher cytotoxicity and apoptotic index in two human pancreas ade-
nocarcinoma cell lines (i.e., MIA PaCa-2 and PANC-1) owing to efficient
internalization, the ERL-phospholipid complex also demonstrated
better safety profiles in blood and normal tissues than those of free ERL,
which might result from the protective and free radical scavenging ef-
fects of the phospholipid.
2.3. Inorganic systems
Magnetic NPs have versatile applications in cancer therapy, such as
diagnosis, drug delivery and theranostics [41–43]. Xu et al. prepared
carbon-coated iron magnetic NPs to combine the effect of hyperthermal
therapy induced by radio frequency with the effect of ERL attached
onto the carbon shells [44]. Because of the strong affinity of the drug
for the magnetic NPs, as shown by the high loading capacity, only 30%
of the drug was released at pH 7.4, with a slight increase to approxi-
mately 41% at pH 5.5 resulting from its protonation. Under a radio
D.H. Truong, et al.
frequency of 350 kHz, the release of ERL from the NPs was also am-
plified, especially in an acidic pH environment. In PANC-1 pancreatic
cells treated with the magnetic NPs, although radio frequency did not
significantly increase apoptosis, it halved cell proliferation to 25.4%.
Theranostics, which integrate diagnostics and therapeutics into a
single platform, have become increasingly important in clinical on-
cology and personalized medicine [45]. Theranostic agents can si-
multaneously provide the results of diagnostic tests and monitor drug
effects in real time for early disease detection and optimization of
personal treatment. Considering the dual role of ERL as a therapeutic
and EGFR-targeting agent, Chen's laboratory designed a theranostic
platform based on ERL-conjugated ultrasmall superparamagnetic iron
oxide nanoparticles (FeDC-E NPs) [46]. With ERL on the surface, the
FeDC-E NPs preferentially accumulated inside EGFR-overexpressing
cells, intracellularly released ERL and productively eradicated these
cells. These conjugated NPs showed remarkable suppression of the
EGFR-extracellular signal-regulated kinase-nuclear factor kappa B
(EGFR-ERK–NF–κB) signaling pathways, which subsequently resulted
in inhibition of the migration and invasion of CL1-5-F4 lung adeno-
carcinoma cells. Notably, in a xenograft-bearing mouse model, the
FeDC-E NPs markedly decreased tumor growth and reduced the nor-
malized T2-weighted MRI signal intensities within the tumor. Recently,
this group combined the MRI technique with a nuclear factor kappa-B
(NF-κB) reporter gene system to further evaluate the FeDC-E NP treat-
ment response for the potential clinical application of these NPs against
NSCLC and to understand their roles in the apoptotic mechanisms
(Fig. 1A) [47]. They found that the cellular uptake and intratumoral
distribution of this probe could be noninvasively monitored by using
ΔR2* values from MRI. Furthermore, because of the NF-κB reporter
gene system, the apoptotic mechanism of the FeDC-E NPs was shown to
effectively suppress antiapoptotic effects through NF-κB signaling and
significantly induce intrinsic and extrinsic apoptotic pathways in vitro
and in vivo. These results demonstrated the potential of this theranostic
probe for clinical translation in the treatment of lung cancer.
To enhance the targeting to EGFR-overexpressing pancreatic cancer
cells and combine multimodal imaging techniques for early cancer di-
agnosis and treatment, ERL was conjugated to iron oxide-gold na-
noclusters to form a Fe3O4@AuNCs@ERL nanocomposite (Fig. 1B)
[48]. The core-shell nanocomposite improved the uptake and cyto-
toxicity of ERL in PANC-1 pancreatic cells owing to the appearance of
ERL while still preserving the intense fluorescence property of the gold
nanoclusters, which can be employed to monitor these cells before
surgery by confocal laser scanning microscopy imaging.
2.4. Hybrid systems
Mandal et al. developed core-shell-type lipid–polymer hybrid NPs in
which an ERL-incorporated polymeric polycaprolactone core was cov-
ered by a phospholipid monolayer [49]. Optimization of the formula-
tion and process parameters resulted in an optimized formula with a
size of 170 nm, making it suitable for intravenous injection. The Cell-
Titre-Glo® luminescent cell viability assay showed that in comparison
with ERL solution, the ERL-loaded hybrid NPs remarkably reduced the
viability of A549 cells with a 25-fold lower IC50 value (100 nM), which
was consistent with the result of a colony formation assay.
As a strategy for active targeting of ERL to lung cancer cells with
EGFR gene mutation—a phenomenon that can cause drug resistance
and limit long-term efficacy—Li et al. anchored EGFR-binding aptamer-
conjugated chitosan onto liposomes, forming multifunctional liposomal
complexes [50]. The aptamer-modified complexes showed enhanced
recognition and internalization by EGFR-mutated H1975 and PC-9 cells
compared to EGFR-negative Helf cells and an increased drug release
percentage in the acidic tumor microenvironment compared to that of
their unmodified counterparts. These results likely contributed to the
observably increased antiproliferation and induction of cell cycle arrest
and apoptosis by the aptamer-modified complexes in these lung cancer
6
Journal of Drug Delivery Science and Technology 55 (2020) 101348
cells, and the effects on drug-resistant H1975 cells were much more
pronounced than those on drug-sensitive PC-9 cells, supporting the
usage of the selected aptamer to overcome erlotinib resistance caused
by EGFR mutation.
Recently, tumor microenvironment-responsive NPs have attracted
great attention in cancer therapy due to their capability to specifically
target cancer sites by exploiting the different signals and conditions in
the tumor microenvironment compared to healthy tissues, such as
acidic pH and abnormal levels of enzymes, glutathione, and reactive
oxygen species [51–56]. Kim et al. used lipid nanocapsules with a PE-
Gylated polypeptide shell, which can prolong systemic circulation, and
a pH-responsive poly(L-aspartic acid) core, which can accelerate the
release of encapsulated cargo in acidic environments, for ERL delivery
[57]. As expected, the lipid nanocapsules exhibited efficient cellular
uptake into cancer cells and higher drug release at pH 5.0 than at pH
7.4. In addition, in comparison with the untreated control and free ERL,
the ERL-encapsulated nanocapsules were dose-dependently cytotoxic to
HCC-827 and NCI-H358 lung cancer cells and significantly retarded
tumor growth in mice bearing an HCC-827 xenograft tumor.
Regarding the application of thermoresponsive NPs, Fathi et al.
exploited a widely used thermosensitive polymer, poly(N-iso-
propylacrylamide) (PNIPAAm), and chemosensitivity-induced oleic
acid for developing a polymer-gold hybrid nanomaterial in which bio-
degradable chitosan served as the reducing agent of auric salt (HAuCl4)
and steric stabilizer for the resulting NPs [58]. In addition to demon-
strating excellent stability in the pH range from 3 to 8 for several
months, the polymer-gold hybrid nanomaterials exhibited temperature-
dependent release of ERL, in which drug release was clearly faster
above the lower critical solution temperature. The efficient inter-
nalization of the hybrid NPs into A549 cells (approximately 86% over
3 h of incubation) led to greater cytotoxicity in this cell line. To further
enhance the active targeting ability of thermosensitive micelles based
on PNIPAAm, this group modified the surface of these NPs with folic
acid [59]. As expected, the folate-modified micelles were significantly
more cytotoxic to the folate receptor-positive OVCAR-3 ovarian carci-
noma cells than to the folate receptor-negative A549 lung adenocarci-
noma cells, which was consistent with enhanced internalization into the
OVCAR-3 cells. Additionally, drug-loaded surface-modified NPs de-
monstrated higher cytotoxicity than the corresponding free drug, sug-
gesting that receptor-mediated endocytosis of the targeted NPs might
help the P-glycoprotein substrate ERL bypass the efflux mechanism
through this transporter.
To enhance ERL delivery to cancer sites using multiple stimuli, Tan
et al. prepared pH-sensitive and redox-responsive NPs (PAA-ERL-NPs)
based on poly(acrylic acid)-cystamine-oleic acid (PAA-ss-OA), which
was formed through the conjugation among pH-sensitive poly(acrylic
acid), oleic acid and cystamine [60]. The outer layer composed of poly
(acrylic acid) decelerated drug release from the PAA-ERL-NPs, which
likely resulted from the fluid-phase endocytosis/pinocytosis of these
NPs into endosomal compartments before releasing ERL and inducing
more cytotoxicity than that of free ERL and ERL-loaded nonlayered NPs
in A549 and NCI-H460 NSCLC cells. Additionally, the PAA-ERL-NPs
exhibited the highest antitumor effect in a lung cancer xenograft mouse
model, supporting the efficacy of the dual-targeting approach in lung
cancer treatment. In another study, a folic acid-poly(ethyleneimine)
conjugate was attached to the surface of magnetic mesoporous silica
NPs to prepare a pH-sensitive nanocarrier [61]. After four days, the
percentage of ERL released from the coated nanocarrier at pH 5.5
(approximately 63%) was nearly double that at pH 7.4, confirming the
pH-responsive properties of the nanocarrier. Moreover, despite ex-
hibiting excellent biocompatibility with red blood cells, these coated
NPs demonstrated a significant cytotoxic effect on HeLa cervical car-
cinoma cells owing to the overexpression of the folate receptor on this
cell line.
To repurpose the use of the potent but toxic kinase inhibitor ERL
from therapy to safer prevention of liver cancer, versatile
D.H. Truong, et al. Journal of Drug Delivery Science and Technology 55 (2020) 101348

Fig. 2. Myofibroblast-targeting nanoparticles. (A) Schematic presentation of erlotinib-loaded nanoparticles that target PDGFRB-expressing myofibroblasts (PPB-NP-
erlotinib). Erlotinib is released after cellular internalization and inhibits intracellular kinase domain of EGFR protein. In the 3D structural modeling, PPB fits the
extracellular domain of PDGFRB with close proximity to the site of PDGF ligand binding. (B) Morphology of the nanoparticles in rat plasma over time by TEM
imaging. Scale bar indicates 200 nm. (C) Size of nanoparticles in rat plasma over time measured on TEM images (median of 59 nanoparticles at each time point).
Boxes represent 75th and 25th percentile, horizontal line is median, and whiskers mark lowest and highest values. Outliers outside 1.5 × of inter-quartile range are
shown as open circles. (D) Concentration of erlotinib released from the nanoparticles over time in vitro in rat plasma. (E) Cumulative amount (%) of erlotinib released
from the nanoparticles over time in vitro in rat plasma. PDGFRB: platelet-derived growth factor receptor-β, PPB: PDGFRB-binding peptide, NP: nanoparticle, GMBS:
N–maleimidobutyryl-oxysuccinimide ester, PEG: polyethylene glycol, EGFR: epidermal growth factor receptor. Reprinted with permission from Ref. [62].

myofibroblast-targeting NPs were fabricated (Fig. 2) [62]. The proof of
concept was to conjugate ERL-loaded NPs with a short peptide that can
specifically bind to platelet-derived growth factor receptor β (PDGFRB)
uniquely expressed on the surface of hepatic myofibroblasts. Due to the
polyethylene glycol layer coating, the NPs showed a sustained release
pattern of ERL with stable drug concentrations in rat plasma over the
period of 12 days (Fig. 2D and E), which is much longer than the half-
life of ERL (approximately 36 h) [1]. Compared to non-PGFRB-expres-
sing Hep G2 hepatoma cells, two types of PGFRB-expressing myofi-
broblasts, TWNT-4 and LX-2 cells, demonstrated higher uptake of the
targeted NPs and dose-dependent phospho-EGFR inhibition. In parti-
cular, by using a cirrhosis-driven liver cancer model in rats, the authors
observed a significant decrease in tumor size by 7.3-fold and reduced
hepatocyte damage in the group treated with the myofibroblast-tar-
geting NPs compared with the group systemically treated with the free
drug at an equivalent dose.
3. Combination with other therapeutic agents or modalities
Combination therapies that combine two or more therapeutic agents
or modalities, such as photodynamic or photothermal therapies, possess
several advantages over monotherapies in cancer treatment. They are
able to enhance efficacy and reduce tumor resistance by simultaneously
targeting various anticancer mechanisms, decrease costs and effort to-
ward the development of new therapeutic compounds, minimize side
effects, etc. [63,64].
Gupta et al. coloaded paclitaxel and ERL into the solid lipid core of
nanocapsules having a PEGylated block copolymer shell for dual-drug
delivery to NSCLC cells [65]. The authors found that these two drugs
could be released in a pH-dependent and controlled manner. Ad-
ditionally, by using this delivery system, both drugs are efficiently
taken up by NCI-H23 cells, resulting in remarkably higher cytotoxicity
than that of the free drugs individually or in combination.
To prevent or delay acquired resistance to ERL, a liquisolid for-
mulation containing ERL and valproic acid was prepared by using
polyethylene glycol 400 as the solvent [66]. With the assistance of
calcium silicate as a microporous adsorbent, the optimized formula, in
which the molar ratio between ERL and valproic acid was 1:2, de-
monstrated a significant enhancement in the dissolution and bioavail-
ability of ERL owing to the ionic interaction between the components.
Importantly, this formulation exhibited substantially higher cytotoxi-
city and apoptosis percentage in ERL-resistant HCC827 lung adeno-
carcinoma cells than those of ERL alone by downregulating the ex-
pression of survivin.
To reverse hypoxia-induced drug resistance in lung cancer, Gao's
laboratory codelivered ERL and perfluorooctylbromide—a high-capa-
city oxygen carrier—in aptamer-conjugated chitosan-anchored lipo-
somal complexes [67]. Owing to the presence of the anti-EGFR ap-
tamer, these multifunctional NPs were specifically recognized by EGFR-
positive A549, H1975 and PC-9 NSCLC cells, and compared to EGFR-
negative Helf cells, these EGFR-positive cells exhibited enhanced up-
take of the NPs. While ERL-loaded complexes showed a lower total
percentage of ERL release under hypoxic conditions than under nor-
moxic conditions, these coloaded complexes still demonstrated similar
release rates under both conditions, which might result from the pro-
motion of internal pressure by oxygen. In addition, the coloaded NPs

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D.H. Truong, et al. Journal of Drug Delivery Science and Technology 55 (2020) 101348

revealed strong effects on the inhibition of proliferation and induction
of apoptosis of NSCLC cells and a significant inhibitory effect on the
expression of EGFR, p-EGFR and hypoxia-inducible factor-1α (HIF-1α),
especially under hypoxic conditions. In vivo experiments showed pro-
found tumor growth suppression and relatively lower distribution in the
spleen and heart in the groups of mice treated with the coloaded NPs
compared to the other groups. Later, this laboratory attempted to
overcome ERL resistance in EGFR mutation-positive NSCLC by sy-
nergizing the effects of chloroquine on normalizing the disturbed tumor
vascular structure and downregulating the anti-apoptotic protein sur-
vivin [68]. In this study, the authors coloaded survivin-recombinant
short hairpin RNA-expressing plasmid (survivin-shRNA) with ERL into
anti-EGFR aptamer-modified polyamidoamine dendrimers. Chlor-
oquine was shown to markedly amplify the intracellular uptake and
gene transfection efficiency of these coloaded nanocomplexes, thereby
enhancing their cytotoxicity in EGFR-mutated NSCLC cells. In addition,
cotreatment with chloroquine and the nanocomplexes exhibited dra-
matic tumor suppression, which might partly stem from the decreased
tumor vessel leakage, improved tumor vessel maturation of and ele-
vated intratumoral drug concentration. Very recently, these authors
developed a nanotheranostic platform based on chitosan to encapsulate
ERL and a heptamethine cyanine derivative (Cy7) as a near-infrared
photosensitizer for photodynamic therapy (Fig. 3) [69]. These NPs
demonstrated high release of these two cargos in an acidic medium
with lysozyme and high uptake into PC-9 cells. With the combination of
near-infrared irradiation and the coloaded NPs, profound generation of
reactive oxygen species, marked upregulation of tumor suppressor p53
and downregulation of survivin expression were observed in three
subtypes of NSCLC cells, especially in PC-9 cells. Importantly, this sy-
nergistic combination significantly inhibited tumor growth in a mouse
model implanted with PC-9 cells, which might result from the specific
distribution of the NPs in the lung.
To overcome the multidrug resistance to DOX and other che-
motherapeutics in cancer cells and to reduce drug side effects, giant
liposomes that are coloaded with three drugs (DOX, ERL and 17-AAG),
DNA nanostructures, nanomagnetite and gold nanorods were as-
sembled with hydrophilic thermally oxidized porous silicon NPs on a
microfluidic chip to generate a nano-in-micro platform [70]. The use of
porous silicon NPs allowed high drug loading and sustained release of
the hydrophobic drug ERL as well as control over the drug ratio in the
liposomes, whereas the nanomagnetite and gold nanorods rendered the
platform magnetically and photothermally responsive, which might
facilitate targeted drug delivery at tumor sites. In particular, the com-
bination of DNA nanostructures and the three drugs achieved sy-
nergistic effects on killing DOX-resistant MCF-7 breast cancer cells with
a significantly lower percentage of cell viability than that achieved with
other combinations.
Considering the possibility that resistance to EGFR inhibition can be
induced by the activation of Janus kinase 2 (JAK2)/signal transducer
and activator of transcription 3 (STAT3) signaling [71,72] or Notch
signaling [73,74], the combination of ERL and JAK2 inhibitors or Notch
inhibitors might be a rational approach to overcome this resistance. In
one study, Chen et al. loaded both ERL and a JAK2 in-
hibitor—fedratinib—into poly(L-lactide)-b-polyethylene glycol (PEG-b-
PLA) NPs [75]. Compared to single drug-loaded NPs, the dual drug-
loaded NPs exerted significantly higher cytotoxic effects on two ERL-
resistant lung adenocarcinoma cell lines, H1975 and H1650, as well as
stronger tumor growth suppression ability in H1650 tumor-bearing
mice. In another study, Wan and colleagues coencapsulated ERL and a
gamma secretase inhibitor—DAPT—into poly(L-lactide) (PLA)-based
NPs [76]. To enhance their tumor targeting and penetrating abilities,
the prepared NPs were functionalized with a conjugate of a tumor-

Fig. 3. Schematic illustration of the preparation and the action of chitosan-based self-assembled nanoparticles CE7Ns. (a) Self-assembly and structural
composition of CE7Ns. The CE7Ns were composed of biodegradable polymer Cs, molecular targeted drug erlotinib, and NIRF dye Cy7 with PDT effects. (b) Schematic
illustration of the self-assembled nanoparticles as a robust nanoplatform for molecular targeted drug-mediated imaging of druggable mutations and combinational
therapy of drug-resistant lung tumor. Reprinted with permission from Ref. [69]. Copyright (2018) American Chemical Society.

8
D.H. Truong, et al. Journal of Drug Delivery Science and Technology 55 (2020) 101348

Fig. 4. Schematic illustration of preparation of erlotinib/DOX combination co-delivery nanocarriers and synergistic therapy of erlotinib and DOX. The surface of
mesoporous silica nanoparticles (A) were modified with 3-aminopropyltriethoxysilane (APTES) to form MSN-NH2 (B). MSN-NH2 were then loaded with DOX to
obtain DOX-loaded MSN-NH2 (C), followed by supported with erlotinib-loaded lipid bilayer (D) to yield M-HHG2C18-L(E + D) (E). After injection of M-HHG2C18-L
(E + D), the nanoparticles accumulated at the tumor site through enhanced permeability and retention effect in tumor blood vessels. M-HHG2C18-L(E + D) were
positively charged at extracellular environment (F) leading to easy internalization by tumor cells. After cell uptake, as erlotinib was loaded in the exterior lipid
bilayer and the controlled release ability of MSN-NH2, erlotinib released faster than DOX. Additionally, the lipid bilayer was more positive and induced a strong
repulsion with MSN-NH2 in intracellular environment (G), enhancing sequential staggered release of erlotinib and DOX, which was pretreated and staggered to
inhibit kinase domain of EGFR in cell membrane (H) and was targeted to cell nucleus (I) respectively, thus maximized the synergistic therapy. Effect of extracellular
and intracellular pH (pHe and pHi), respectively on the HHG2C18 (J). Reprinted with permission from Ref. [82].

homing peptide and a cell-penetrating peptide. Due to the presence of
an acid-sensitive hydrazone linkage between these two peptides, the
modified NPs showed the highest cellular uptake at an acidic pH of 6.0
and the highest cytotoxicity in MDA-MB-231 triple-negative breast
cancer cells. Notably, among all mice groups tested, tumor-bearing
mice injected with these modified NPs exhibited the lowest tumor size
without weight loss resulting from the highest tumor accumulation and
lowest distribution in other organs.
Long-term pretreatment with the EGFR inhibitor ERL was found to
significantly enhance or sensitize the efficacy of the DNA-damaging
agent doxorubicin (DOX) in NSCLC cells and triple-negative breast
cancer cells [77] and in MCF-7 and MDA-MB-468 human breast cancer
cells [29]. Similar phenomena were also observed with other combi-
nations of drug(s) and/or gene therapy in other cancer models [78–80],
suggesting that the efficacy of combination therapies does not depend
simply on their compositions but rather critically on the sequence of
their component's delivery. Bearing that in mind, to deliver both ERL
and DOX to the same tumor cells, Morton et al. encapsulated them in
the exterior hydrophobic layer and interior hydrophilic compartment of
folate-coated liposomes, respectively [81]. The folate coating enhanced
the uptake of the liposomes and DOX into folate receptor-over-
expressing A549 NSCLC and BT-20 triple-negative breast cancer cell
lines. The core-shell design facilitated the release of ERL first and DOX
later from the dual drug-loaded liposomes, which demonstrated a sig-
nificant increase in apoptosis and prolonged inhibition of EGFR in these
two cell lines compared to those induced by DOX-loaded liposomes.
Notably, although the dual drug combination reduced the tumor
burden in A549 and BT-20 xenograft-bearing mice, the two drugs must
be packed in the same vehicle to achieve the desired efficacy. In another
study, He et al. codelivered a combination of ERL and DOX by using a
pH-sensitive charge conversion nanocarrier (designated as M-HHG2C18-
L) [82]. In this system, DOX was loaded into the core of amino-func-
tionalized mesoporous silica NPs (MSN-NH2), which were then shielded
by an ERL-incorporated lipid bilayer to form M-HHG2C18-L(E + D)
(Fig. 4). Under the low pH in the tumor extracellular and intracellular
environments, the surface potential of the dual drug-loaded NPs shifted
from negative to positive due to the protonation of the zwitterionic
oligopeptide lipid in the external layer, thereby enhancing the inter-
nalization of the NPs into cancer cells and improving the release of both
drugs. Notably, the sequential release of the two drugs remarkably

9
D.H. Truong, et al. Journal of Drug Delivery Science and Technology 55 (2020) 101348

Fig. 5. Mechanisms of acquired resistance to gefi-

tinib/erlotinib in EGFR‐mutated NSCLC. EGFR, epi-
dermal growth factor receptor; ErbB3, v‐erb‐b2 avian
erythroblastic leukemia viral oncogene homolog 3;
NSCLC, non‐small‐cell lung cancer; RTK, receptor
tyrosine kinase; MET, met proto‐oncogene; AXL, AXL
receptor tyrosine kinase; mAb, monoclonal antibody;
TKI, tyrosine kinase inhibitor; NF‐κB, nuclear factor
kappa‐light‐chain‐enhancer of activated B cells; AKT,
v‐akt murine thymoma viral oncogene homolog 1;
STAT, signal transducers and activation of tran-
scription; ERK, extracellular signal‐regulated kinase;
BIM, BCL2‐like 11 (apoptosis facilitator). Reprinted
with permission from Ref. [87] under a Creative
Commons Attribution 4.0 International License (CC
BY 4.0).

Table 3
Advantages and disadvantages associated with different types of ERL-loaded delivery systems.
Delivery systems Advantages Disadvantages

Polymeric NPs Enhance bioavailability Poor drug loading capacity

Enhance toxicity to tumor cells and reduce toxicity to internal organs Use of organic solvent in formulation

Lipidic NPs
Solid self-emulsifying formulation
Liposomes
Solid lipid nanoparticles (SLNs)
Enhance bioavailability Poor drug loading capacity
Improve storage stability
Enhance bioavailability Poor storage stability
Ease of functionalization to enhance targeting and stability
Deliver both hydrophilic and hydrophobic agents
Use of biocompatible ingredients Poor storage stability
Ease of scale-up to industrial scale Poor drug loading capacity

Inorganic NPs Versatile applications (e.g. drug delivery, theranostics) Possible metabolism-associated issues
High cellular uptake
Biocompatibility

Hybrid NPs Deliver multiple therapeutic agents Poor storage stability

Ease of functionalization to enhance targeting and control drug release

synergized their antiproliferative and apoptotic effects on A549 cells
and dramatically delayed tumor growth in tumor-bearing mice with an
excellent safety profile. Recently, by using a different one-compartment
carrier design, Zhou et al. coloaded ERL and the hydrophobic form of
DOX into poly(L-lactide)-b-polyethylene glycol (PLA-b-PEG) NPs after
ion-pairing of positively charged DOX with a negatively charged lipid,
1,2-dioleoyl-sn-glycero-3-phosphate [83]. This complexation sig-
nificantly retarded the release rate of DOX while exhibiting burst re-
lease of ERL (approximately 80% in 4 h) that increased the efficacy of
the coloaded NPs against MDA-MB-468 breast cancer cells. Further-
more, an in vivo biodistribution study demonstrated that the polymeric
NPs considerably accumulated inside the tumor with marginal dis-
tribution in the major organs, confirming their efficacy and safety. To
control the time lag of drug administration even more precisely for
optimal efficacy, two separate gold nanocages with pH-sensitive poly
(acrylic acid) and thermosensitive poly(N-isopropylacrylamide-co-ac-
rylamide) shells were developed to carry ERL and DOX, respectively
[84]. Upon accumulation in the tumor microenvironment via the en-
hanced permeability and retention effect, the poly(acrylic acid)-covered
gold nanocages loosened their shell because of the acidic pH and re-
leased ERL. Then, after 6 h, under exogenous NIR irradiation, the gold
nanocages generated heat to make the poly(N-isopropylacrylamide-co-
acrylamide) shell collapse and release DOX. The combination of che-
motherapy and phototherapy demonstrated a synergistic tumor-killing
effect with more potent efficacy in highly EGFR-expressing A431 cells
than in weakly EGFR-expressing MCF-7 cells in both in vitro and in vivo
models attributed to the caspase-8 signaling pathway.
4. Current challenges
Despite some initial clinical success, acquired (secondary) resistance
to erlotinib usually develops in most NSCLC cases after 10–13 months
[85]. The resistance can stem mainly from the acquisition of a sec-
ondary EGFR mutation and amplification of the hepatocyte growth
factor receptor (HGFR/c-MET) oncogene (Fig. 5) as well as various
conditions in the tumor microenvironment. First, the gatekeeper T790
mutation is the most common type of mutation, occurring in approxi-
mately 50% of all resistant NSCLC cases, whereas amplification of c-

10
D.H. Truong, et al.
MET accounts for approximately 20% of mutations [3,86,87]. Several
second-generation EGFR tyrosine kinase inhibitors (e.g., afatinib and
dacomitinib) and third-generation inhibitors (e.g., osimertinib) that
bind irreversibly to EGFR and selectively to T790 M EGFR, respectively,
and c-MET inhibitors (e.g., crizotinib) have been developed to over-
come this type of resistance. Second, hypoxia, which refers to the low
oxygen levels in tumor tissues, and disturbed tumor tissue vasculature
are two major factors in the tumor microenvironment that substantially
limit drug penetration and antitumor activity in tumor tissues
[46,88,89]. These factors can be bypassed by delivering oxygen directly
into tumor sites and by using vascular normalization agents to restore
the functions of tumor vessels, respectively [67,68]. In addition, the
upregulation and activation of some proteins, such as survivin, STAT3
and phosphoglycerate dehydrogenase (PHGDH), in the tumor micro-
environment were found to be positively associated with drug re-
sistance and poor prognosis in lung cancer [90–92]. This can be ad-
dressed by silencing these genes using specific short interfering RNAs or
gene suppressors [68,90,92,93].
5. Authors’ outlook
In this review, we have discussed several approaches for delivering
erlotinib by using numerous carrier systems to enhance its efficacy.
First, polymer-based, lipid-based, inorganic and hybrid systems were
used to improve erlotinib's characteristics, such as its aqueous solubi-
lity, dissolution, bioavailability and toxicity. Second, NPs delivering
combinations of erlotinib and other therapeutic agents or modalities
were exploited to prevent the development of tumor resistance and
improve the effects of erlotinib. The advantages and disadvantages of
delivery systems of erlotinib are summarized in Table 3.
These promising results encourage the translation of these nano-
particulate systems into the clinic. Nevertheless, there are some chal-
lenges that delay their appearance on the market. First, the large-scale
manufacturing of NPs according to GMP guidelines is a laborious and
expensive process because of the high costs of materials, low production
yield, incomplete purification of the final products, etc. Second, in the
preclinical phase, there is a need for developing standardized protocols
to evaluate the toxicity of NPs in vitro, in vivo and in animal models and
to understand their interaction with cells/tissues/organs, etc. Third,
due to the complex nature of NPs, there is a lack of appropriate gov-
ernment regulations for nanoparticulate systems that would help guide
the manufacturing practices, quality control and design of optimal
clinical trials to evaluate their safety/toxicity and therapeutic efficacy
in humans [94]. Moreover, patents and intellectual properties can be
serious problems that halt the commercialization of nanomaterials be-
cause their nomenclature is much more complicated than that of con-
ventional products on the market. Therefore, by addressing all the
abovementioned issues, pharmaceutical companies might successfully
develop an oral formulation of erlotinib with improved pharmacoki-
netics and toxicity profiles for enhanced clinical efficacy and patient
compliance.
Declaration of competing interest
The authors declare no conflict of interest.
Acknowledgements
This research received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors.
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