Camptothecin analogs were developed in the 1990s to
prevent the solubility problems associated with camptothecin, a cytotoxic agent
developed as an anticancer agent in the early 1970s. Camptothecin and its
analogs inhibit DNA topoisomerase I eventually preventing DNA re-ligation
leading to the failure of the replication machinery 1. Irinotecan (also known
as CPT-11) is one of the analogs approved for first-line therapy of advanced
colorectal cancer in combination with 5-fluorouracil and/or leucovorin. In addition,
irinotecan has also been used with cisplatin as a combination therapy for other
cancers, such as lung and ovarian 2.
The major limiting factors of irinotecan are diarrhea
and neutropenia that can range from severe to potentially life-threatening. The
gastrointestinal and vascular effects have been associated with a high
mortality rate in patients receiving the combination of irinotecan with bolus
fluorouracil and leucovorin during the first 60 days of therapy. The severity
of toxicities and effectiveness of irinotecan therapy vary greatly in
populations due to genetic differences in different factors involved in
pharmacokinetics and pharmacodynamics. Pharmacogenomics can be applied to
screen patients for such genetic (DNA variations) prior to selecting irinotecan
therapy so as to optimize its therapy and reduce health care costs 3.
Irinotecan is a prodrug which is converted to SN-38 by
carboxylesterase 2, resulting in a greater than 1,000-fold enhancement of
cytotoxic activity. Irinotecan, before activation, is processed by cytochrome
P450 (CYP450) enzymes and transported by ATP-Binding Cassette (ABC) efflux
pumps. The active metabolite either binds to topoisomerase-I of the target
(tumor) cell or is exported out of the cell via efflux pumps. SN-38 can also be
inactivated by glucuronide conjugation. While
each of these steps has the potential to substantially regulate irinotecan
activity, it is glucuronidation by the protein UGT1A1 that has the clearest
potential impact on patient care.
Uridine-diphosphate glucoronosyl transferase (UGTs)
are responsible for glucoronidation of lipophilic compounds that converts them
to more polar form. UDP-glucoronic acid is used as a co-substrate for the
reaction that catalyzes a variety of substrates such as bilirubin, hormones,
drugs, and other xenobiotics, leading to the formation of more hydrophilic
conjugates facilitating their elimination through bile and urine.
Irinotecan is a prodrug, metabolized into the active
form, SN-38, via human carboxylesterases CES1 and CES2, primarily in the liver.
Irinotecan is converted into APC, an inactive metabolite by CYP3A4. The active
SN-38 can be subsequently inactivated through glucoronidation via members of
the UDP glucuronosyltransferase (UGT) family. A total of 13 UGT1A genes are
encoded at the UGT1A locus located on chromosome 2q37t. Each UGT1A enzyme has a
unique promoter and a unique exon 1, while the remaining four exons are shared
with all members of the UGT1A family 4.
hydrolyzed to the active form, SN-38, primarily by carboxylesterase-2 (CES2).
CES2 expression is highly variable among individuals, and increased CES2
expression leads to increased irinotecan metabolism 5. However, researchers
have not been able to identify any functional polymorphisms associated with the
CES2 gene expression. Some of the minor individual variations in CES2 expression
can be attributed to the control of its three distinct promoters 6. CES1
plays a minor role in irinotecan metabolism.
inactivates irinotecan through conversion into the metabolite APC. While there
is no evidence of variants in the CYP3A4 gene providing a useful screen for APC
conversion, the interindividual variability in CYP3A4 activity can be exploited
for irinotecan dosing 7.
comprehensively studied genetic marker linked to toxicity from irinotecan
therapy is found in the UDP-glucuronosyltransferase gene, UGT1A1. The UGT1A1
enzyme is responsible for hepatic bilirubin glucuronidation, and reduced UGT1A1
expression leads to Gilbert’s syndrome, a condition characterized by rise in
the plasma levels of unconjugated bilirubin. In fact, three forms of heritable
unconjugated hyperbilirubinemias exist in humans including Crigler-Najjar
syndrome type 1 and type 2 and Gilbert’s syndrome. These heritable syndromes
are all the result of low activity UGT1A1 gene or promoter alleles. A
polymorphic dinucleotide repeat within the UGT1A1 promoter TATA element consisting
of between five and eight copies of a TA repeat (TAnTAA) control the
expression of UGT1A1 gene. The (TA)6TAA allele is the most common (considered
wild-type) and (TA)7TAA is the most frequently recorded variant allele (usually
denoted UGT1A1*28) 8. The length of the repeat allele has been found to be
inversely proportional to UGT1A1 expression, that is, the longer the repeat
allele, the lower the corresponding UGT1A1 gene expression. The frequency of
the UGT1A1*28 allele has been assessed worldwide and ranges from approximately
15% in Asians to 45% in Africans. It is also found in 26–38% of Caucasians,
African–Americans and Hispanics. The decrease in expression of UGT1A1 gene
leads to reduced glucoronidation leading to build up of SN-38 metabolite in the
plasma, leading to increased toxicity 8.
Many studies have
established the link between UGT1A1*28 and irinotecan toxicity, and a prospective
study of 66 patients with advanced disease treated with irinotecan found that patients
homozygous for UGT1A1*28 had a significantly greater risk of grade IV neutropenia
compared with patients with at least one wild-type allele.
Other UGT1A1 polymorphisms—There
are other significant polymorphisms in the UGT1A1 gene. Patients with
haplotypes containing both the ?3156G>A variant and UGT1A1*28 experienced
significantly higher incidence of severe neutropenia compared with patients
with haplotypes not containing ?3156G>A 9.
In Asian populations where the frequency of UGT1A1*28
is low, other UGT1A1 variants can also play a role in irinotecan toxicity. For
example, in Korean patients with non-small-cell lung cancer treated with
irinotecan-containing therapy, there were associations between, irinotecan pharmacokinetics,
and toxicity from irinotecan therapy.
Other UGT1A genes—Variants
in UGT1A7 and UGT1A9 are also associated with SN-38 glucuronidation and
irinotecan toxicities, although these studies require further exploration. UGT1A7*3
has been associated with hematologic toxicity in metastatic colorectal cancer
patients treated with irinotecan 10. Furthermore, UGT1A7*2 and *3, as well as
UGT1A9 -118(dT) alleles, were associated with response to irinotecan.