What is cancer?

The word cancer is derived from the Latin word for crab because cancers
are often very irregularly shaped, and because, like a crab, they "grab on
and don't let go." The term cancer specifically refers to a new growth
which has the ability to invade surrounding tissues, metastasize (spread
to other organs) and which may eventually lead to the patient's death if
untreated.
The terms tumour and cancer are sometimes used interchangeably which
can be misleading. A tumour is not necessarily a cancer.
The word tumour simply refers to a mass.
Where as A cancer is a particularly threatening type of tumor.
Neoplasm-
1. A neoplasm is an abnormal new growth of cells.
The cells in a neoplasm usually grow more rapidly than
normal cells and will continue to grow if not treated. As they
grow, neoplasms can impinge upon and damage adjacent
structures.
2. The term neoplasm can refer to
a) benign (usually curable) or
b) malignant (cancerous) growths.

Tumor-A tumor is a commonly used, but non-specific, term

for a neoplasm. The word tumor simply refers to a mass. This
is a general term that can refer to benign (generally harmless)
or malignant (cancerous) growths.
Benign tumor-
1. Benign tumors are non-malignant/non-cancerous tumor.
2. A benign tumor is usually localized, and does not spread to
other parts of the body.
3. Most benign tumors respond well to treatment. However, if
left untreated, some benign tumors can grow large and lead
to serious disease because of their size.
4. Benign tumors can also mimic malignant tumors, and so for
this reason are sometimes treated.
Malignant tumor-
Malignant tumors are cancerous growths. They are often resistant to treatment,
may spread to other parts of the body and they sometimes recur after they were
removed.
Cancer- A cancer is another word for a malignant tumor (a malignant
neoplasm).
 NEOPLASIA NOMENCLATURE

NAMING a Neoplasm
In order to name a neoplasm, you need to combine three element
1. Place (organ)
2.Tissue of origin (epithelial/mesenchymal)
3.Growth behavior (benign/malignant)
Place + Tissue of origin + Growth behavior
 CANCER DEVELOPMENT OCCURS BY
1) INITIATORS
2) PROMOTERS
MUTAGEN :
A compound that covalently reacts with DNA and somehow changes the
genetic makeup of the cell is called a mutagen and thereby bringing
mutation error.

1. The mutagens that predispose cells to

develop tumors are called initiators
2. The non-reactive compounds that
stimulate tumor development are called
promoters (Promoters have no effect
when the organism in question has not
been previously treated with an initiator)
 Types

many mutagens are not mutagenic by themselves, but can form mutagenic metabolites
through cellular processes. Such mutagens are called promutagens
 Initiation
Initiation is the first step in the two-stage model of cancer
development .

The effects of initiators are irreversible;

once a particular cell has been affected
by an initiator it is susceptible to
promotion until its death.
Since initiation is the result of
permanent genetic change, any daughter
cells produced from the division of the
mutated cell will also carry the mutation
 Promotion

Once a cell has been mutated by an initiator, it is susceptible to the

effects of promoters. These compounds promote the proliferation of the

cell, giving rise to a large number of daughter cells containing the

mutation created by the initiator

promoters bind to receptors on the cell surface in order to affect

intracellular pathways that lead to increased cell proliferation

 TYPES OF PROMOTERS:

1. Specific promoters that interact with receptors on or in target cells

of defined tissues

2. Nonspecific promoters that alter gene expression without the

presence of a known receptor

 Progression

Refers to the stepwise transformation of a benign tumor to a neoplasm

and to malignancy.

Progression is associated with a karyotypic change since virtually all

tumors that advance are aneuploid (have the wrong number of

chromosomes).

This karyotypic change is coupled with an increased growth rate,

invasiveness, metastasis and an alteration in biochemistry and

morphology
 Stages of Tumor Development
Hyperplasia- The altered cell
divides in an uncontrolled
manner leading to an excess of
cells in that region of the tissue.
The cells have a normal
appearance but there are too
many of them.

Dysplasia- Additional genetic changes in the hyperplastic cells lead to increasingly

abnormal growth. The cells and the the tissue no longer look normal. The cells and the

tissue may become disorganized.

Carcinoma in situ-
 Additional changes make the cells and tissues appear even more
abnormal. The cells are now spread over a larger area and the region
of the tissue involved primarily contains altered cells.
 A key facet of in situ growths is that the cells are contained within the
initial location and have not yet crossed the basal lamina to invade
other tissues.

Cancers of this type are often

totally curable by surgery since

the abnormal cells are all in one

location.
Cancer (Malignant tumors)- These tumors have the ability to invade
surrounding tissues and/or spread (metastasize) to areas outside the local
tissue.
These metastatic tumors are the most dangerous and account for a large
percentage of cancer deaths.

Usually grow faster than benign

tumours
Spread into and destroy
surrounding tissues
Spread to other parts of the body
Some tumors do not progress to the point where they invade distant
tissues.
Such tumors are said to be benign
Usually grow quite slowly
Do not spread to other parts of the body
Usually have a covering made up of normal cells
They will only cause a problem if they
Grow very large
Become uncomfortable or unsightly
Press on other body organs
Take up space inside the skull (such as a brain tumour)
Release hormones that affect how the body works
 The Pathophysiology of Cancer

When you are healthy, your body has over a trillion cells that divide

at standard rate and pace.

1.One of the first steps :

change of the proto-oncogens oncogenes.

Proto-oncogenes are genes that are coded to maintain normal cell

growth.

An oncogenes is a gene that has muted to make the cells grow and

divide faster.
2. The second step : Tumor suppressor genes get turned off.

Tumor suppressor genes are a part of a healthy cells DNA that help stop

cancer from forming in healthy cells. Tumor suppressor genes help

slow down cell growth.

3.The last step :DNA repair genes gets turned off.

DNA repair genes help your healthy cells know if something is wrong

with its DNA and how to fix it. When these genes get turned off the cell

doesn’t know if it is sick, and it can’t fix any problems with its DNA.
Over 40 different proto-oncogenes have been discovered in the human body.
Examples include:

Ras encodes an intracellular signal-transduction protein. In other words, Ras is one of the
on/off switches in a series of steps in a major pathway that eventually leads to cell growth.

HER2. This gene makes protein receptors that are involved in the growth and division of cells
in the breast. Many people with breast cancer have a gene amplification mutation in
their HER2 gene. This type of breast cancer is often referred to as HER2-positive breast
cancer.

Myc
The Myc gene is associated with a type of cancer called Burkitt’s lymphoma. It occurs when a
chromosomal translocation moves a gene enhancer sequence near the Myc proto-oncogene.

Cyclin D
Cyclin D is another proto-oncogene. Its normal job is to make a protein called Rb tumor
suppressor protein inactive.
Architecture and function of the new tumor-associated vascular network
1. Their shape is tortuous and irregular, with irregular branching
patterns and sometimes no open ends, which results in abnormal and
inefficient perfusion [24].

2. Their lining is formed by fenestrated endothelial cells and sometimes

by tumor cells, without basement membrane, which makes them more
permeable than normal capillaries, especially to macromolecules.

3. They lack sphincters and pericytes (the perivascular contractile cells),

which make them largely independent from the normal mechanisms of
regulation of the capillary blood flow.
Tumor microenvironment

In cancer therapy, the tumor microenvironment is one of many areas

which are studied to design new therapies.

Tumor microenvironment

1. Angiogenesis in cancer

2. Enhanced Permeability and Retention (EPR)

3. pH
Angiogenesis in cancer
 Angiogenesis is defined as the formation of new blood vessels from existing ones.
 For solid tumors (1–2mm3), oxygen and nutrients can reach the center of the tumor
by simple diffusion.
 When tumors reach 2 mm3, a state of cellular hypoxia begins, initiating
angiogenesis. Angiogenesis is regulated by a fine balance of activators and
inhibitors [11].

angiogenesis process: FIVE PHASES

1. endothelial cell activation,

2. basement membrane degradation,

3. endothelial cell migration,

4. vessel formation,

5. angiogenic remodeling
 Hypoxia

Increases cellular hypoxia inducible factor (HIF)

transcription

 leading to upregulation of pro-angiogenic proteins

vascular endothelial growth factor (VEGF),
platelet derived growth factor (PDGF)
or tumor necrosis factor-α (TNF-α)
Activated endothelial cells  The activated endothelial cells
synthesize proteolytic enzymes,
express the dimeric such as matrix metalloproteinases
transmembrane integrin (MMPs), used to degrade the
basement membrane and the
αvβ3, which interacts with extracellular matrix.
extracellular matrix
 The inner layer of endothelial cells
proteins (vibronectin, undergoes apoptosis leading to
fibronectin, a.o.) and formation of the vessel lumen.
 Immature vasculature undergoes
regulates the migration of extensive remodeling during
the endothelial cell through which the vessels are stabilized by
pericytes and smooth-muscle cells.
the extracellular matrix This step is often incomplete
during vessel formation resulting in irregular shaped,
dilated and tortuous tumor blood
vessels
Steps include protease production, endothelial cell migration and proliferation, vascular tube
formation, anastomosis of newly formed tubes, synthesis of a new basement membrane and
incorporation of pericytes
Enhanced Permeability and Retention (EPR) effect

The abnormal vascular architecture plays a major role

for the EPR effect in tumor for selective
macromolecular drug targeting at tissue level that can
be summarized as follows

(1)Extensive angiogenesis and hypervasculature

(2) Lack of smooth-muscle layer, pericytes
(3)Defective vascular architecture: fenestrations
(4) No constant blood flow and direction
(5) Inefficient lymphatic drainage that leads to
enhanced retention in the interstitium of tumors
(6) Slow venous return that leads to accumulation from
the interstitium of tumor
pH
While the intracellular pH of cells within healthy tissues and tumors is similar, tumors
exhibit a lower extracellular pH than normal tissues. Accordingly, although tumor pH
may vary according to the tumor area, average extracellular tumor pH is between 6.0
and 7.0 whereas in normal tissues and blood, the extracellular pH of is around 7.4.
The low extracellular tumor pH mostly arises from the high glycolysis rate in hypoxic
cancer cells
Targeted drug delivery
Targeted drug delivery system is achieved with the advantage of
morphology and physiological differences between the normal cells and
tumor cells.
An ideal anticancer drug delivery system should fulfill the following
requirements
Effectively kill tumor cells
Be non-toxic for healthy organs, tissues, and cells
Not induce multidrug resistance
 Tumor barriers

•resistance of human tumors to anticancer drugs most often ascribed to

mechanisms that mediate drug resistance at the cellular level: gene

mutations, gene amplification, or epigenetic changes that influence the

uptake, metabolism, or export of drugs from single cells

•another important yet little-appreciated cause of anticancer drug

resistance is the limited ability of drugs to penetrate tumor tissue and to

reach all of the tumor cells in a potentially lethal concentration

 Improving drug delivery to the tumor

Why is it so difficult to reach a tumor?

Universal barriers to drug circulation (Metabolism, Efflux, BBB, …)

Specific tumoral barriers: case of pancreatic cancer

Enhancing tumor targeting efficiency

1. Enhancing tumor exposure: helping barrier crossing

Increasing blood residence time = increasing time of contact for
exchange

2. Disrupting the tumor barrier

3. Targeting strategies: increase of tumor exposure and decrease of non-
specific exposure
Nanoparticles: passive and active targeting strategies
The tumor microenvironment

solid tumors = organ-like structures = heterogeneous and structurally

complex

•cancer cells + stromal cells (i.e., fibroblasts and inflammatory cells)

embedded in an extracellular matrix (ECM) and nourished by a vascular

network

•heterogeneity of the composition in the same tumor

 Tumor microenvironment

More precisely, the knowledge and the understanding of the tumor

microenvironment allow researchers to elaborate different therapeutic

strategies,

numerous differences exists in tumor cells as compared with normal

tissue including 1.vascular abnormalities

3. oxygenation
,
4. perfusion

4. pH

5. Metabollic states

6.High interstitial fluid pressure

 The tumor microenvironment
1. Vascular abnormalities

Tumor stroma: altered extracellular matrix and an increased number of

fibroblasts that synthesize growth factors, chemokines, and adhesion

molecules

ECM varies greatly among tumors (amount, composition)

composition and structure of stromal components in tumors contribute

to an increase in interstitial fluid pressure (IFP)

well organized and richly interconnected collagen network: lower

penetration by high – molecular-weight agents

high packing density of the constituent cells + reduced interstitial space

and volume of the extracellular matrix: lower drug penetration

three-dimensional structure of tissue influences the sensitivity of

constituent cells to both radiation and chemotherapy: cells grown in

contact with each other more resistant than the same cells after

disaggregation
 Tumor vasculature

A. Normal tissues contain linear blood vessels maintained by pericytes. Collagen fibres,
fibroblasts and macrophages are in the extracellular matrix. Lymph vessels are present.

B. Tumor tissues contain

defective blood vessels with many sac-like formations and fenestrations. The extracellular matrix
contains more collagen fibres, fibroblasts and macrophages than in normal tissue.
Lymph vessels are lacking.
 Tumor vasculature and blood flow

vasculature abnormal in solid tumors

blood vessels in tumors often dilated and convoluted and have
branching patterns that feature excessive loops and arteriolar – venous
shunts
the vessels in some tumors not organized into arterioles, capillaries,
and venules but instead share features of all of these structures
walls of tumor vessels: fenestrations, discontinuous or absent basement
membranes, fewer pericytes, may lack perivascular smooth muscle

cancer cells has the ability to be integrated into the vessel wall
 Tumor vasculature and blood flow

blood flow disorganized and variable

difference in pressure between arterioles and venules reduced

viscous and geometric resistance increased

compression of blood vessels by cancer cells

→ increased resistance to blood flow and impaired blood supply to the

tumor

vary with location and with time, even in the same tumor
 Tumor vasculature and blood flow

reduction in delivery of nutrient metabolites and in the clearance of

breakdown products of metabolism, leading to hypoxic and acidic
regions in tumors
delivery of anticancer drugs is similarly compromised
solid tumors lack lymph vessels for fluid removal: contributes to the
increased interstitial fluid pressure (IFP)
IFP compresses blood vessels such that blood is diverted away from
the center of the tumor toward the periphery
Tumor hypoxia
limited vasculature of tumors: tumor cells typically farther from the
nearest capillary (e.g., more than ~ 100 μ m)→ hypoxia
hypoxia: amplification and increased expression of the genes encoding
P-glycoprotein
Tumor acidity

low extracellular pH,

average extracellular tumor pH is between 6.0 and 7.0 whereas in

normal tissues and blood, the extracellular pH of is around 7.4

intracellular pH neutral to alkaline:

The resulting pH gradients between intra- and extracellular tumor cells

but also between the tumor mass and the host tissue are therefore

potential sources of differential drug partitioning and distribution.

In a low pH extracellular environment, the uncharged fraction of a

weak acid increases and such a drug can thus more easily diffuse

through the cell membrane. The relatively basic intracellular

compartment may in turn favor the ionization of the molecule, thereby

promoting the cytosolic accumulation of the drug.

1.weakly basic drugs (pKa 7.5 – 9.5: doxorubicin, mitoxantrone,

vincristine, vinblastine, …) protonated: decreased cellular uptake

2. Acidic microenvironment inhibits active transport of some drugs

(methotrexate)
 Tumor high IFP (interstitial fluid pressure)

IFP of most solid tumors is High

.Many anti-cancer drugs — high molecular weight compounds in

particular — are transported from the circulatory system through the

interstitial space by convection rather than by diffusion.

Increased IFP contributes to a decreased trans capillary transport in

tumors, leading to a decreased uptake of drugs into tumor.

Transport steps in a tumor tissue unit consisting of blood vessels and the
surrounding tissue.
To reach all viable cells in the tumor,
anticancer drugs must be delivered
efficiently through the tumor vasculature
cross the vessel wall, and traverse the
tumor tissue (200 μM route)

1. convection: depends on gradients of pressure (both hydrostatic and osmotic) between

the vascular space and the interstitial space, vessel permeability, surface area for
exchange, volume and structure of the extracellular matrix
2. diffusion: determined by concentration gradients
penetration by most drugs probably relies more on diffusion than
convection
diffusion of a drug is determined by its concentration gradient in the
tumor tissue: sequestration of drugs in tumor cells and/or their binding to
components of the ECM or at the target site inhibit drug penetration to
deeper regions of the tumor
Ex: targeted antigens (e.g., trastuzumab binding to HER2 on cancer
cells), basic drugs (e.g., doxorubicin and mitoxantrone) sequestered in
acidic organelles, drugs that bind avidly to DNA (doxorubicin and
mitoxantrone)
•
Transport in tumors
General properties of the tumor microenvironment, including drug
delivery heterogeneity.
Three regions of tumors—the periphery, semi necrotic region, and
necrotic core—are delineated along with their characteristics
 Strategies used in vivo to improve drug
penetration
antiangiogenic therapy (counter intuitive) → pruning of immature
and abnormal blood vessels = “normalization” of the tumor vasculature
→ reduction in the IFP
Botulinum neurotoxin type A: relaxation of tumor vessels → higher
in vivo tumor perfusion
low-dose chemotherapy: limited cell killing → reductions in tumor
cell packing density and IFP → increased distribution of subsequent
doses
Treatment of tumors with ECM–dissolving enzymes: collagenase,
relaxin → improves macromolecular diffusion in tumors (risk of
metastatic spread)
Continuous infusion: maintains diffusion or convection for prolonged
periods → more uniform distribution than a single injection of drug +
increase of targeting efficiency (delivery to the less vascularized tumor)

macromolecular carriers (liposomes, nanoparticles): longer half-life,

pass through fenestrations in the tumor blood vessels and release drug
molecules into the interstitial space, coating with antibodies/peptides to
specific tumor antigens = targeting to malignant cells

anaerobic bacteria: preferentially colonize and replicate within the

hypoxic tumor microenvironment = far from blood vessels → vectors for
gene delivery (preclinical models)
Helping barrier crossing

Overcoming the stromal barrier for targeted delivery of

•barriers to diffusion caused by the dense stroma in pancreatic cancers

can be overcome: treating the stromal tissue in conjunction with drug to

increase its concentration within the tumor using drugs and enzymes

which breakdown the dense stroma: “Stromal collapse”

•hyaluronidase: several studies have been conducted along with clinical

trials using hyaluronidase enzymes to breakdown hyaluronic acid, which

results in a lowering of IFP

Treatment with hyaluronidase increases the localization of gemcitabine

and other drugs into the tumor

•increased tumor accumulation of both 40 and 2000 kDa dextrans was

found after administration of a PEGylated hyaluronidase treatment to the

tumor

Other stroma treating agents

•Abraxane® + gemcitabine in clinical trials for pancreatic cancer

treatment: caused stromal collapse, increased drug accumulation in the

tumor, increased survival

Hedgehog signal inhibitors can also influence the pancreatic stroma and

have demonstrated increased drug accumulation

stromal disruption in tumors could also be detrimental: may lead to

increased metastasis based on the fact that tumor cells rely on the stroma

for their support structure

•early evidence suggests that metastatic potential is not increased after

stromal breakdown and can even be reduced (as observed with a

Hedgehog pathway inhibitor IPI-269609)

 TUMOR TARGETING STRATEGIES
Goals and specifications of targeted nano scale drug delivery
system
TUMOR TARGETING STRATEGIES
Nanomedicine in drug delivery
A. Types of nanocarriers currently described in preclinical and clinical studies.
B. Schematic representation of PEGylation and ligand grafting.
Passive targeting refers to the accumulation of a drug or drug carrier
system at a desired site due to physicochemical or pharmacological
factors .
make use of the anatomical and functional differences between the
normal and tumor vasculature to deliver the drug to a targeted site, or
may include localized delivery
The tumor vasculature is very different from normal tissue. It is greatly
heterogeneous in distribution, larger in size, has high vascular density
and is more permeable and leaky, unlike the tight endothelium of normal
blood vessels [37-39].
The leaky and defective architecture of tumor vasculature may be due to
elevated levels of vascular mediators such as bradykinins, nitric oxide,
vascular endothelial growth factor (VEGF), basic fibroblast growth
factor (bFGF), prostaglandins, etc [39-43].
This leaky vasculature allows extravasation of circulating nanocarriers
within the tumor interstitium. This is called the enhanced permeability
effect .
This, coupled with the impaired lymphatic drainage of macromolecules
in solid tumors, allows an enhanced accumulation and retention of high
molecular weight drugs in solid tumors.
This is popularly known as the enhanced permeability and retention
(EPR) effect (Figure 3).
The EPR effect can predominantly be used for passive targeting of drugs
encapsulated in drug carriers such as polymeric drug conjugates,
liposomes, polymeric NPs and the micellar system to solid tumors
[39,43].
1st
depicts the normal vasculature, where due to the tight junction, drug-loaded NPs are not
able to extravasate,

while 2nd
depicts an increased accumulation in tumor due to leaky tumor vasculature leading to the
enhanced permeability and retention effect.
Passive targeting consists in the transport of nanocarriers through leaky
tumor capillary fenestrations into the tumor interstitiumand cells by
 convection
passive diffusion
The convection refers to the movement of molecules within fluids.
Convection must be the predominating transport mode for most large
molecules across large pores when the net filtration rate is zero.
So “passive targeting” is based on drug accumulation in the areas
around the tumors with leaky vasculature; commonly referred
to as the enhanced permeation and retention (EPR) effect.
Three properties of nanocarriers are particularly important for EPR effect
(i) The ideal nanocarrier size should be somewhere between 10 and 100 nm. On the other hand,
to avoid the filtration by the kidneys, nanocarriers need to be larger than 10 nm; and to
avoid the a specific capture by the liver, nanocarriers need to be smaller than 100 nm.
(ii) The charge of the particles should be neutral or anionic for efficient evasion of the renal
elimination.
(iii) The nanocarriers must be hidden from the reticulo–endothelial system, which destroys any
foreign material through opsonization followed by phagocytosis

(a) The exposed surface of a non-PEGylated nanoparticle quickly develops a protein corona.
The opsonized surface then promotes phagocytosis by MPS cells leading to rapid clearance
of the nanoparticles.
b) The hydrophilic polymers (PEO) grafted onto the nanoparticle form a brush-like barrier that
repels most proteins before it can bind to the surface and thus significantly slows the
clearance of the nanoparticles
Limitations of Passive Targeting

(i) The passive targeting depends on the degree of tumor vascularization

and angiogenesis. Thus extravasation of nanocarriers will vary with

tumor types and anatomical sites.

(ii) As previously mentioned, the high interstitial fluid pressure of solid

tumors avoids successful uptake and homogenous distribution of drugs in

the tumor

(III)larger and long-circulating nanocarriers (100 nm) are more

retained in the tumor, whereas smaller molecules easily diffuse

Examples of passively tumor-targeted nanocarriers in cancer therapy
Active targeting strategies. Ligands grafted at the surface of nanocarriers
bind to receptors (over)expressed by
(1) cancer cells
or
(2) angiogenic endothelial cells.
In active targeting

 Targeting ligands are attached at the surface of the nanocarrier for

binding to appropriate receptors expressed at the target site .

The ligand is chosen to bind to a receptor overexpressed by tumor cells

or tumor vasculature and not expressed by normal cells.

 Moreover, targeted receptors should be expressed homogeneously on

all targeted cells.

Main classes of ligand-targeted therapeutics.
A. Targeting antibodies are generally
monoclonal immunoglobulin g (IgG) (a) or
Fab′ fragments (b) or F(ab′)2 fragments (c).

B. Immunoconstructions
linking of antibodies or fragments to
therapeutic molecules.

C. Targeted nanocarriers :
presenting targeted ligands 
at the surface of the nanocarrier.

monoclonal antibodies and antibody fragments

nonantibody ligands (peptidic or not).
Targeted nanocarriers contain therapeutic drugs.
Immunoconjugates
 Combine the targeting power of mABs and cytotoxic activity of drugs
 Radio active substances
 ADEPT
 Drugs or toxins

Vitamins as Active targeting moieties

The folate receptor is significantly upregulated on many cancer cells
compared to normal tissue. Normal cells transport a reduced folate across
their membranes but, will not transport folate conjugates of any type
Malignant cells transport folate conjugates through the folate receptor,
which is considered the alternative route
In the active targeting strategy, two cellular targets can be distinguished:

(i) the targeting of cancer cell and

ii) The targeting of tumoral endothelium

 The targeting of cancer cell

Targeting of internalization-prone cell-surface receptors, over expressed

by cancer cells improves the cellular uptake of the nanocarriers.

active targeting is particularly attractive for the intracellular delivery of

macromolecular drugs, such as DNA, siRNA and proteins.

 INTERNALIZATION-PRONE CELL-SURFACE RECEPTORS

(i) The transferrin receptor

(ii)The folate receptor

(iii) Glycoproteins expressed on cell surfaces

(iv)The Epidermal growth factor receptor (EGFR)

 THE TRANSFERRIN RECEPTOR.
Transferrin, a serum glycoprotein, transports iron through the blood
and into cells by binding to the transferring receptor and subsequently
being internalized via receptor-mediated endocytosis.
The transferrin receptor is a vital protein involved in iron homeostasis
and the regulation of cell growth.
up to 100-fold increase in levels of expression in cancer cells than the
average normal cells.
its extracellular accessibility, its ability to internalize and its central
role in the cellular pathology of human cancer, make this receptor an
attractive target for cancer therapy
 THE FOLATE RECEPTOR

Tumor marker that binds to the vitamin folic acid ,folate–drug

conjugates or folate grafted nano carriers .

Internalization via receptor-mediated endocytosis.

Folic acid is required in one carbon metabolic reactions and is essential

for the synthesis of nucleotide bases.

The alpha isoform, folate receptor-α is over expressed on 40% of
human cancers.
folate receptor-β is expressed on activated macrophages and also on
the surfaces of malignant cells of hematopoietic origin
 Glycoproteins expressed on cell surfaces.
Lectins are proteins of non-immunological origin bind specifically to
carbohydrate moieties attached to glycoproteins expressed on cell
surface.
Cancer cells express different glycoproteins compared to normal cells.
Lectins can be incorporated into nanoparticles as targeting moieties that
are directed to cell-surface carbohydrates (direct lectin targeting)
and carbohydrates moieties can be coupled to nanoparticles to target
lectins (reverse lectin targeting).
The use of lectins for direct or reverse targeting strategies is a
traditional approach of colon drug targeting
 EPIDERMAL GROWTH FACTOR RECEPTOR (EGFR)

 EGFR: member of ErbB family (tyrosine kinase receptors)

 Its activation stimulates key processes involved in tumor growth and progression,
including proliferation, angiogenesis, invasion and metastasis.
 EGFR is frequently overexpressed in a lot of cancer, especially in breast cancer, has
also been found to play a significant role in the progression of several human
malignancies.
 Human epidermal receptor-2 (HER-2) is reported to be expressed in 14–91% of
patients with breast cancer [49,50].
 EGFR is expressed or overexpressed in a variety of solid tumors, including
colorectal cancer, non-small cell lung cancer and squamous cell carcinoma of the
head and neck, as well as ovarian, kidney, pancreatic, and prostate cancer.
 TUMORAL ENDOTHELIUM TARGETING
Advantages
1. No need of extravasation of nanocarriers to arrive to their targeted
site
2. Binding to their receptors directly possible after intravenous injection
3. Potential risk of emerging resistance decreased
4. Most of endothelial cells markers expressed whatever the tumor type:
ubiquitous approach, broad application spectrum
 MAIN TARGETS OF THE TUMORAL ENDOTHELIUM

1. Vascular Endothelial Growth Factors (VEGF) and their Receptors

2. αvβ3 Integrin

3. Vascular Cell Adhesion Molecule-1 (VCAM-1)

4. Matrix Metalloproteinases (MMPs)

 The vascular endothelial growth factors (VEGF) and their receptors
VEGFR-1 and VEGFR-2, mediate vital functions in tumor
angiogenesis and neovascularization .
 Tumor hypoxia and oncogenes up regulate VEGF levels in the tumor
cells, resulting in an up regulation of VEGF receptors on tumor
 endothelial cells.

 Two major approaches to target angiogenesis via the VEGF way have
been studied:
 (i) Targeting VEGFR-2 to decrease VEGF binding and induce an
endocytotic pathway
(ii) Targeting VEGF to inhibit ligand binding to VEGFR-2
 TARGETING αvβ3 INTEGRIN
• The αvβ3 integrin is an endothelial cell receptor for extracellular matrix proteins
which includes fibrinogen (fibrin), vibronectin, thrombospondin, osteopontin and
fibronectin [56].
• The αvβ3 integrin is highly expressed on neovascular endothelial cells but poorly
expressed in resting endothelial cells and most normal organs, and is important in
the calcium dependent signaling pathway leading to endothelial cell migration [1].
• Cyclic or linear derivatives of RGD (Arg–Gly– Asp) oligopeptides are the most
studied peptides which bind to endothelial αvβ3 integrins.
• The αvβ3 integrin is upregulated in both tumor cells and angiogenic endothelial cells
[56].
 VASCULAR CELL ADHESION MOLECULE-1 (VCAM-1)

 Is an immunoglobulin- like transmembrane glycoprotein that is

expressed on the surface of endothelial tumor cells.

VCAM-1 induces the cell to-cell adhesion, a key step in the

angiogenesis process.

Overexpression of VCAM-1 is found in various cancers, including

leukemia, lung and breast cancer, melanoma, renal cell carcinoma,

gastric cancer and nephroblastoma

 The matrix metalloproteinases (MMPs)

Are a family of zinc dependent endopeptideases.

Degrade the extracellular matrix, playing an essential role in

endothelial cell invasion and migration, in the formation of capillary

tubes and in the recruitment of accessory cells in the process of

angiogenesis.

Membrane type 1 matrix metalloproteinase (MT1-MMP) is expressed

on endothelial tumor cells, including malignancies of lung; gastric, colon

and cervical carcinomas;gliomas and melanomas .

 STIMULI-SENSITIVE NANOCARRIERS

Popularly called as “activable” or “activated” nanocarriers.

Nanocarriers maintain the stealth function during circulation, upon

arrival at the tumor site, transformation of the nanocarriers is triggered

by the unique tumoral extracellular environment, allowing the drug

release or the interaction with a specific target. The drug retention in

nanocarriers can also be solved by application of external stimuli

allowing a controlled and selective targeting of cells.

INTERNAL STIMULI
Different parts of the human body have different pH levels. The saliva
and blood are neutral but the gastric juices inside the stomach are acidic
Specifically, tumors have an acidic environment at around 6.75, which is
apparently below the pH (7.23) of normal tissues .
When being internalized into the cells, nanoparticles will encounter
more acidic endosomes and lysosomes (pH 5.0–5.5).
Based on these pH variations, researchers have developed various pH-
responsive nanoparticles to deliver drugs, genes and proteins to enhance
the curative effect in tumor sites and specific organs
pH-responsive drug release approaches/strategies
One approach is to introduce “ionizable” chemical groups, such as amines, phosphoric
acids and carboxylic acids among others, with nanomaterials.
These groups, with different chemical structures and pKa values, can accept or donate
protons and undergo pH-dependent changes in physical or chemical properties such as
swelling ratio or solubility, resulting in drug release
According to their constituents,
nanomaterials can be classified as
organic,
Inorganic
or hybrid.
Polymers are an important class of material that can be used for the preparation
of organic DDSs due to their abilities to encapsulate and protect cargoes, and to
respond to specific stimuli.

pHSensitive polymers are a class of polyelectrolytes with ionizable groups in their

backbones, side groups, or end groups. When the pH and the ionic composition of the
aqueous medium changes, “smart” polymers are ionized and dramatically change their
conformation.

Several research groups have developed pH-sensitive polymers by using acidic (e.g.
carboxylic and sulfonic acids) or basic (e.g. ammonium salts) groups, which either
accept or release protons in response to changes in the pH of the physiological
environment.
These polymers can undergo pH-sensitive conformational changes in three different ways:
a) dissociation,
b) destabilization (via collapse or swelling),
c) changes of partition coefficient between the drug and vehicle.

For inorganic nanoscale materials

some compounds, such as calcium phosphate (CaP), and zinc oxide (ZnO), are relatively
insoluble at physiological pH, but can be dissolved as nontoxic ions in acidic microenvironments,
such as endo/lysosomes and solid tumors.

Among the most commonly used pH-sensitive polymers are anionic polymers containing
carboxylic groups, such as
A) poly(acrylic acid) (PAA); B) poly(methacrylic acid) (PMAA); C) poly(ethylacrylic acid)
(PEAA); D) poly(propylacrylic acid) (PPAA); E) poly(butylacrylic acid) (PBAA); F) N-
isopropylacrylamide (NIPAM); G) poly(glutamic acid) (PGA)

pH-sensitive cationic polymers have various advantages, such as their positive surface charges,
which potentially enhances cellular uptake
Cationic polymers: J) poly(N,N′-dimethylaminoethyl methacrylate) (PDEAEM); K) poly(4-
vinylpyridine) (PVP); L) poly(L-histidine) (PHis); and M) poly(β-amino ester) (PbAE)
Another approach is to use acid-labile chemical bonds either to covalently attach drug
molecules directly onto the surfaces of existing nanocarriers or to construct new
nanocarriers .
These acid-labile chemical bonds are stable at neutral pH but are degraded or hydrolyzed in
acidic media. This unique property makes them promising candidates for the preparation of pH-
sensitive DDSs.
The acid-labile linkers most commonly used :acetal, orthoester, hydrazone, imine, and cis-aconyl
bonds.
Temperature-responsive nanoparticles
Temperature-responsive/thermoresponsive nano-particles could be prepared by
thermosensitive polymers.
 Such polymers exhibit a temperature-dependent phase transition in solution across a
critical temperature which is known as the critical solution temperature (CST).
The polymers which are water soluble below a certain temperature and turn to be
phase separated above that temperature are defined to have a lower critical solution
temperature (LCST), whereas the polymers exhibiting the opposite behavior are defined
to have an upper critical solution temperature (UCST)
The frequently reported polymers are N-substituted polyacrylamides and the
predominant one is poly(N-isopropylacrylamide) (PNIPAAm).
 EXTERNAL STIMULI

Light is one of the most desirable external stimuli to be used for intelligent drug
delivery systems regarding its unique cleanliness and remote control property.
The lightresponsive nanoparticles are typically fabricated from lightresponsive
polymers which are usually synthesized through incorporating such photo-
sensitizers as azobenzene, stilbene, and triphenylmethane.
 Photoisomerized azobenzene with trans and cis conformations is a chemical
compound composed of two phenyl rings linked by a N=N double bond. The two
isomers could be switched with ultraviolet light.
Upon photo irradiation, photo-sensitizers incorporated nanoparticles will undergo
certain macroscopical transition induced by the structure or polarity changes of the
photosensitizers, which could be further utilized to control the release of the loaded
drug
Ultrasound-responsive nanoparticles
The ultrasound-mediated targeting drug delivery has been explored. The biophysical modes of
ultrasonic action on biological systems are classified into two categories
I. Thermal mechanism
II. non-thermal mechanism (or mechanical mechanism).
For the thermal mechanism using continuous wave ultrasound, the drug release is tailored by
thermo-response of thermosensitive micelles upon ultrasonic heating.
Whereas for non-thermal mechanism using pulsed ultrasound, the drug release is triggered by
ultrasound
Different drugs including gene therapy drugs, chemotherapeutic drugs, and thrombolytic drugs
have been studied.
The drug release behavior was dependent on specific ultrasound parameters, e.g., frequency,
power density, pulse length, and inter-pulse intervals.

Rapoport had studied ultrasound responsive drug delivery systems with tumor targeting property
[67]. Their results showed that ultrasound irradiation could enhance the intracellular drug uptake
of the tumor cells and trigger localized drug release from nanoparticles via perturbing tumor
cell membranes.