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Key Words. Bisphosphonates Zoledronic acid Bone resorption Apoptosis Antitumor effects Mevalonate pathway
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A BSTRACT
Bisphosphonates effectively inhibit osteoclast-medi- mechanisms by which they exert antitumor effects. As a
ated bone resorption and are integral in the treatment of result of their biochemical effects on protein prenylation,
benign and malignant bone diseases. The evolution of bis- N-BPs induce caspase-dependent apoptosis, inhibit
phosphonates over the past 30 years has led to the devel- matrix metalloproteinase activity, and downregulate
opment of nitrogen-containing bisphosphonates (N-BPs), v3 and v5 integrins. In addition, zoledronic acid
which have a mechanism of action different from that of (Zometa; Novartis Pharmaceuticals Corp.; East
the nonnitrogen-containing bisphosphonates. Studies Hanover, NJ and Basel, Switzerland) exerts synergistic
conducted over the past decade have elucidated the antitumor activity when combined with other anticancer
mechanism of action and pharmacologic properties of the agents. Zoledronic acid also inhibits tumor cell adhesion
N-BPs. N-BPs exert their effects on osteoclasts and tumor to the extracellular matrix and invasion through
cells by inhibiting a key enzyme in the mevalonate path- Matrigel and has antiangiogenic activity. A growing
way, farnesyl diphosphate synthase, thus preventing pro- body of evidence from animal models demonstrates that
tein prenylation and activation of intracellular signaling zoledronic acid and other bisphosphonates can reduce
proteins such as Ras. Recent evidence suggests that skeletal tumor burden and prevent metastasis to bone.
N-BPs also induce production of a unique adenosine Further studies are needed to fully elucidate these bio-
triphosphate analogue (Apppi) that can directly induce chemical mechanisms and to determine if the antitumor
apoptosis. Our increased understanding of the pharma- potential of bisphosphonates translates to the clinical set-
cologic effects of bisphosphonates is shedding light on the ting. The Oncologist 2004;9(suppl 4):3-13
Correspondence: Jonathan R. Green, Ph.D., Novartis Pharma AG, Klybeckstrasse 141, WKL-125.901, CH-4002 Basel,
Switzerland. Telephone: 41-61-696-4415; Fax: 41-61-696-3849; e-mail: jonathan.green@pharma.novartis.com Received
July 19, 2004; accepted for publication August 3, 2004. AlphaMed Press 1083-7159/2004/$12.00/0
are released during bone resorption and are internalized by HMG CoA
osteoclasts, leading to inhibition of bone resorption and HMG CoA
Statins
reductase
induction of osteoclast apoptosis [4-6].
Mevalonate
There is now extensive preclinical evidence that bis-
phosphonates also have antitumor activity, as evidenced by
Mevalonate
reduced proliferation and viability of tumor cell lines in pyrophosphate
fourfold compared with either agent alone. Similar results nations tested, the only combination that produced synergis-
were reported when ibandronate or zoledronic acid were tic apoptotic effects was zoledronic acid for 48 hours fol-
combined with epirubicin (Ellence; Pharmacia and lowed by TRAIL for 24 hours. This combination yielded
Upjohn; Portage, MI) plus docetaxel (Taxotere; Aventis 14.7% apoptotic cells compared with 0.7% for zoledronic
Pharmaceuticals Inc.; Bridgewater, NJ) [50]. In cultures of acid alone and 2.7% for TRAIL alone (p < 0.001). The
primary breast cancer cells, the concentrations of epirubicin intriguing results of these in vitro studies suggest a novel
plus docetaxel were gradually reduced to suboptimal levels approach to enhance the synergy between N-BPs and
by serial dilution until there was little or no inhibition of chemotherapeutic agents in the clinical setting.
tumor cell growth with these two drugs alone. However, the
addition of 15 M ibandronate or zoledronic acid resulted in Animal Models
35% and 70% inhibitions of tumor cell growth, respectively. These in vitro findings are supported by data from many
Combinations of zoledronic acid with taxanes also have animal models showing that the newer N-BPs can significantly
demonstrated synergistic antitumor activity against prostate reduce the number and size of osteolytic lesions in tumor-bear-
cancer cell lines. The combination of zoledronic acid ing mice, reduce skeletal tumor burden, induce tumor cell
(12.5 or 25 M) with suboptimal concentrations of doc- apoptosis in bone lesions, reduce serum levels of tumor mark-
10
zoledronic acid administered either before doxorubicin or 13.6%
paraprotein significantly prolonged disease-free survival in Notably, the 4T1 mammary tumor model has provided
those mice. the first in vivo evidence of synergy between zoledronic acid
Numerous studies in breast cancer models have also and chemotherapy. In animals with established orthotopic
been reported. Zoledronic acid was shown to inhibit pro- tumors, the combination of zoledronic acid (250 g/kg) with
gression of established bone metastases and development of 20 mg/kg/day of oral UFT (a combination of uracil and tega-
new bone metastases in two models of breast cancer [54, fur [4:1 molar ratio]) reduced skeletal tumor burden more
55]. In nude mice injected with human MDA-MB-231 effectively than either agent alone [56]. Similarly, the com-
breast cancer cells and allowed to develop osteolytic lesions, bination of ibandronate with doxorubicin (150 g/day) has
mice treated with zoledronic acid (0.2, 1.0, or 5.0 g/day been investigated in the MDA-MB-231 model and was
s.c.) had significantly less radiographic bone lesion area, by shown to have additive antitumor effects in bone [61].
>80%, than controls [54]. Ibandronate (1.0 g/day) and Studies in a prostate cancer model have also recently been
alendronate (10 g/day) resulted in nonsignificant reduc- reported. In those studies PC-3 and LuCaP 23.1 cells were
tions in bone lesion area (65% and 55% reductions, respec- injected directly into the tibia of mice [40]; PC-3 cells form
tively). These findings were confirmed in another osteolytic lesions, and LuCaP 23.1 cells form osteoblastic
independent study using highly sensitive in vivo imaging of lesions. The treatment group received zoledronic acid (5 g
MDA-MB-231 cells genetically engineered to express green s.c. twice weekly) either at the time of tumor cell injection or
fluorescent protein [55]. Similar studies have been con- after tibial tumors were established (7 days for PC-3 tumors
ducted with ibandronate in nude mice bearing MDA-MB- and 33 days for LuCaP 23.1 tumors). Treatment with zole-
231 breast cancer cells, which typically form both adrenal dronic acid significantly inhibited growth of both osteolytic
and bone metastases. Treatment with ibandronate (4 g/day and osteoblastic metastases by radiographic analysis (Fig. 4)
s.c.) inhibited the radiographic progression of established [40] and also reduced skeletal tumor burden as evidenced by
osteolytic lesions and decreased skeletal tumor burden com- a significant decrease in serum levels of prostate-specific
pared with controls [9]. However, administration of iban- antigen in animals bearing LuCaP 23.1 tumors [40]. The
dronate at the time of tumor cell inoculation resulted in a observed reduction in serum prostate-specific antigen levels
twofold increase in adrenal tumor load [61]. In a murine provides compelling direct evidence of the antitumor activity
breast cancer model, treatment with zoledronic acid of zoledronic acid in this animal model.
(5 g/day) for 7 days after injection of 4T1 murine mam- The potential of zoledronic acid to prevent bone metas-
mary tumor cells (i.e., prevention setting) markedly tasis was also demonstrated in an animal model of prostate
decreased the formation of new bone metastases at day 28 cancer [62]. In that model, mice were injected with PC-3
[54]. The observed decrease in radiographic bone lesion cells, and the incidence of bone metastases was studied in
area was accompanied by an increase in the number of apop- normal mice and in mice that were rendered androgen defi-
totic osteoclasts and apoptotic tumor cells in bone lesions. cient by surgical castration. Androgen-deficient mice devel-
8 Bisphosphonates: Preclinical Review
oped significantly more bone metastases than did intact con- MECHANISMS OF ANTITUMOR EFFECTS
trol mice. This strongly suggests that excess bone resorption The precise mechanisms responsible for the antitumor
caused by androgen ablation can stimulate metastasis of PC- effects of bisphosphonates are beginning to be elucidated.
3 cells to the bone. This is consistent with current hypotheses Bisphosphonates appear to make the bone a less favorable
of tumor cell metastasis to bone. Moreover, daily treatment site for tumor cell growth via the inhibition of osteoclast-
with zoledronic acid significantly reduced the incidence of mediated bone resorption and osteoclastogenesis, thereby
bone metastases in both normal and castrated mice. reducing the release of growth factors that stimulate tumor
Although the majority of animal models suggest that the growth in bone. In addition, bisphosphonates directly
primary antitumor effect of bisphosphonates is manifested in inhibit tumor cell growth and survival and the ability of
the bone, where they reach the highest concentrations, pre- tumor cells to colonize the bone. Either or both of these
liminary data from the 4T1 mammary tumor model have mechanisms may be at work.
demonstrated that zoledronic acid can also inhibit visceral
metastases [57]. 4T1 cells expressing luciferase were used to Apoptosis
quantitate tumor burden in mice. After tumor cell inocula- One of the primary mechanisms responsible for the
tion, mice were treated with zoledronic acid (5.0 g every direct antitumor activity of bisphosphonates is induction
4 days), which resulted in lower tumor burdens than in con- of tumor cell apoptosis. Both N-BPs and non-N-BPs
trols not only in bone but also in the liver and lungs [57, 63]. appear to induce apoptosis of osteoclasts and tumor cells
Treatment with zoledronic acid also prolonged survival of by activation of caspases [9, 12-14, 16, 17, 64, 65]. One
tumor-bearing mice. In the same model, ibandronate mechanism by which bisphosphonates induce apoptosis
(4 g/day s.c.) had no effect on lung or liver metastases or on is through production of ATP analogues (either as direct
survival [61, 63]. As mentioned above, treatment of mice metabolites or as a result of inhibition of the mevalonate
bearing 5T2 myeloma cells with zoledronic acid (120 g/kg pathway), which can disrupt mitochondrial ATP/ADP
s.c. twice weekly) also resulted in a significantly longer dis- translocase. A recent study investigating the mechanism
ease-free survival time (median, 47 days versus 35 days for by which zoledronic acid induced apoptosis in human
untreated controls; p < 0.01) [53]. breast cancer cell lines (MDA-MB-231 and MCF-7)
These animal models provide convincing evidence of the indicated that this response was associated with
potential of bisphosphonates, particularly the more potent cytochrome c release from the mitochondria and subse-
N-BPs, to reduce tumor burden in bone and inhibit formation quent caspase-3 activation [66]. It appears that N-BPs
and progression of bone metastases in a variety of tumor mod- may induce cytochrome c release by modulating expres-
els. It is less clear whether bisphosphonates have antitumor sion of Bcl-2, a key antiapoptotic regulatory protein
activity beyond the bone, but it appears that zoledronic acid [66]. These events may be precipitated by inhibition of
may be sufficiently potent to inhibit extraskeletal tumor cell Ras activation, which requires protein prenylation
growth and to prolong survival in some animal models. (specifically farnesylation) [66].
Green 9
Inhibition of Tumor Cell Adhesion and Invasion of the [74]. Therefore, inhibition of the mevalonate pathway and
Extracellular Bone Matrix induction of caspase activity are important for the
Bisphosphonates have also been shown to inhibit adhe- inhibitory effects of N-BPs on tumor cell adhesion to the
sion of tumor cells to extracellular matrix (ECM) proteins and ECM and on invasiveness. Further, it has been shown that
to inhibit the process of tumor cell invasion and metastasis an activating Ras mutation enhances adhesion of a normal
[67-70]. Using an in vitro Matrigel-based invasion assay, breast epithelial cell line to ECM proteins, suggesting that
Boissier et al. have shown that bisphosphonates inhibit the increased Ras activation in response to growth factor recep-
ability of human breast and prostate cancer cells to invade the tor signaling may increase the metastatic potential of breast
ECM [67]. In this assay, zoledronic acid and ibandronate cancer cells [73]. Thus, by inhibiting protein prenylation
caused dose-dependent inhibition of cell invasion through the and Ras signaling, zoledronic acid should reduce the
Matrigel at extremely low concentrations (1010 M) that did metastatic potential of tumor cells.
not inhibit tumor cell motility or induce significant apoptosis.
Clodronate was approximately six orders of magnitude less Antiangiogenic Effects
potent in the same assay. Furthermore, the combination of In vitro and in vivo studies have further demonstrated that
ibandronate with taxanes enhanced the inhibitory effect on zoledronic acid has antiangiogenic effects. In vitro assays
100
Figure 5. Percent adherent
cells versus controls when
Adherent cells (% control)
MDA-MB-231 human
breast cancer cells were Control
incubated with zoledronic 50 0.1 M Zoledronic acid
acid for 24 hours (0.1 or
100 M) before culture 100 M Zoledronic acid
24-hour treatment
on plates coated with vari-
ous extracellular matrix
proteins. Adapted with 0
permission from Pickering Laminin Fibronectin Vitronectin Collagen I
et al. [73].
10 Bisphosphonates: Preclinical Review
resorption, and v3 expression confers on tumor cells a skeletal tumor burden. The evidence that they have antitu-
greater propensity to metastasize to bone [79]. In fact, a mor activity outside the bone is more tenuous. A variety
small molecule inhibitor of v3 was recently shown to of potential mechanisms to explain these observed antitu-
effectively prevent metastasis of MDA-MB-435 breast can- mor effects have been proposed, including indirect effects
cer cells to bone [80]. Therefore, effects on v3 could have on tumor cell growth in bone via inhibition of bone
pleiotropic effects on bone resorption and tumor metastasis. resorption and osteoclastogenesis. In addition, bisphos-
In addition, it has recently been reported that zoledronic phonates clearly have the potential to directly induce
acid decreases the survival of HUVECs by sensitizing them apoptosis of tumor cells, inhibit tumor cell adhesion to the
to TNF-induced programmed cell death [78]. Zoledronic ECM, reduce the metastatic potential of tumor cells, and
acid also appears to modulate serum levels of proangio- inhibit angiogenesis. Further research is ongoing to fully
genic growth factors such as vascular endothelial growth elucidate the molecular mechanisms involved and to
factor and bFGF in cancer patients [81]. These studies sug- determine the most effective dose and schedule of bispho-
gest a variety of potential mechanisms to account for the sphonates to maximize their antitumor potential in the clin-
observed antiangiogenic effects of bisphosphonates. ical setting, either alone or in combination with standard
antineoplastic agents.
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