Clinical Evaluation of Liposome Encapsulated Doxorubicin and the Modulation of Multidrug Resistance in Cancer Cells

Abstract

Doxorubicin is the cornerstone of some widely used combination chemotherapy regimens because of its high anticancer activity in a number of human neoplasms. However, its clinical use is highly compromised because of treatment-limiting acute and chronic toxicities of which cardiotoxicity has the most debilitating effect. Our laboratories have demonstrated that liposome encapsulated doxorubicin (LED) provides important advantages in regards to the attenuation of cardiotoxicity in rodents by altering pharmacokinetics and pharmacodynamics of the drug, provides effective protection from immunotoxicity and maintains full therapeutic activity of the drug in liposomes. A Phase I clinical trial of LED in cancer patients has establish the maximum tolerated dose of 90 mg/m² with granulocytopenia being the major treatment-limiting toxicity. We have performed a Phase II trial of LED in 20 recurrent breast cancer patients at a dose of 75 mg/m² as an intravenous infusion every three weeks. Objective responses were observed in 9/20 patients of which 5 demonstrated a complete response. Hematologic toxicity with LED consisted of only grade 1-2 granulocytopenia in some patients, whereas gastrointestinal toxicity, mucositis and venous sclerosis were markedly reduced. Alopecia was complete in all patients. Twelve patients received cumulative LED doses of more than 400 mg/m² and 8 of them received doses of over 500 mg/m². Five of these patients were followed by endomyocardial biopsies and 4 of them were found to be Billingham Grade 0 whereas one of them had Billingham Grade 1 toxicity (cumulative dose of 750 mg/m²). This Phase II trial demonstrates higher therapeutic efficacy of LED than free doxorubicin in recurrent breast cancer patients with strong indication of cardiotoxicity protection at doses of 500-800 mg/m².

The emergence of tumor cells resistant to major classes of cytotoxic agents is a predominant obstacle in cancer treatment. This resistance is frequently related to the expression of a plasma membrane P-glycoprotein (pgp) of 170 Kd that is encoded by a family of MDR genes. Support for the involvement of pgp in MDR has been shown by transaction of sensitive cells with an expression vector containing full length cDNA of the MDR1 gene, which results in the appearance of pgp and the sensitive cells convert to the drug-resistant phenotype. Our studies demonstrate that LED modulates very effectively the MDR phenotype in LZ cells, a Chinese hamster cell line made resistant to doxorubicin and the cellular drug uptake was 2 to 3 fold higher with LED exposure than with free drug. This modulation of drug resistance and enhanced cellular drug uptake is effected by the direct binding of liposomes to pgp on the surfaces of MDR phenotype cells. LED completely inhibited the photoaffinity labeling of pgp by azidopine in membrane vesicles of HL-60/VCR cells and in KB-GSV2 cells transfected with human MDR gene. These studies demonstrate that LED has unique effectiveness in overcoming MDR phenotype in cancer cells and appears to be a potentially attractive modality of treatment of human cancers.