Skip to main content
Top
Published in: Indian Journal of Pediatrics 12/2012

01-12-2012 | Special Article

Metronomic Chemotherapy in Progressive Pediatric Malignancies: Old Drugs in New Package

Authors: Ankur Bahl, Sameer Bakhshi

Published in: Indian Journal of Pediatrics | Issue 12/2012

Login to get access

Abstract

Despite intensive research in the field of cancer, many pediatric cancers are still incurable with current treatment protocols. Repetitive administration of conventional chemotherapy at maximal tolerated dose imposes many side effects that further limits the dosing and therefore decreases the anticancer effects. Usually limited options remain when a malignancy progresses after one or two lines of standard chemotherapy protocol. The goal of an oncologist at this point of time remains mainly palliative with an effort to halt the progression of cancer and improve quality of life. Metronomic chemotherapy is defined as the chronic administration of chemotherapeutic agents at relatively low, minimally toxic doses, and with no prolonged drug-free breaks. It is thought this type of chemotherapy inhibits tumor growth primarily through anti-angiogenic mechanisms, promoting apoptosis and immune- surveillance.
Literature
1.
go back to reference Steen RG. What is cancer? In Steen RG, Mirro J, eds. Childhood cancer: A handbook from St. Jude Children’s Research Hospital, Perseus Publishing Cambridge; 2000. pp. 3–10. Steen RG. What is cancer? In Steen RG, Mirro J, eds. Childhood cancer: A handbook from St. Jude Children’s Research Hospital, Perseus Publishing Cambridge; 2000. pp. 3–10.
2.
go back to reference Canadian Cancer Society, National Cancer Institute of Canada, Statistics Canada, Provincial/Terretorial Cancer Registries, and Health Canada. Canadian Cancer Statistics 2004. Canadian Cancer Society, National Cancer Institute of Canada, Statistics Canada, Provincial/Terretorial Cancer Registries, and Health Canada. Canadian Cancer Statistics 2004.
5.
6.
go back to reference Kerbel RS. Inhibition of tumor angiogenesis as a strategy to circumvent acquired resistance to anti-cancer therapeutic agents. Bioessays. 1991;13:31–6.PubMedCrossRef Kerbel RS. Inhibition of tumor angiogenesis as a strategy to circumvent acquired resistance to anti-cancer therapeutic agents. Bioessays. 1991;13:31–6.PubMedCrossRef
9.
go back to reference Gasparini G. The rationale and future potential of angiogenesis inhibitors in neoplasia. Drugs. 1999;58:17–38.PubMedCrossRef Gasparini G. The rationale and future potential of angiogenesis inhibitors in neoplasia. Drugs. 1999;58:17–38.PubMedCrossRef
10.
go back to reference Fox SB, Gasparini G, Harris AL. Angiogenesis: pathological, prognostic, and growth-factor pathways and their link to trial design and anticancer drugs. Lancet Oncol. 2001;2:278–89.PubMedCrossRef Fox SB, Gasparini G, Harris AL. Angiogenesis: pathological, prognostic, and growth-factor pathways and their link to trial design and anticancer drugs. Lancet Oncol. 2001;2:278–89.PubMedCrossRef
11.
go back to reference Miller KD, Sweeney CJ, Sledge Jr GW. Redefining the target: chemotherapeutics as antiangiogenics. J Clin Oncol. 2001;19:1195–206.PubMed Miller KD, Sweeney CJ, Sledge Jr GW. Redefining the target: chemotherapeutics as antiangiogenics. J Clin Oncol. 2001;19:1195–206.PubMed
12.
go back to reference Eberhard A, Kahlert S, Goede V, Hemmerlein B, Plate KH, Augustin HG. Heterogeneity of angiogenesis and blood vessel maturation in human tumors: implications for antiangiogenic tumor therapies. Cancer Res. 2000;60:1388–93.PubMed Eberhard A, Kahlert S, Goede V, Hemmerlein B, Plate KH, Augustin HG. Heterogeneity of angiogenesis and blood vessel maturation in human tumors: implications for antiangiogenic tumor therapies. Cancer Res. 2000;60:1388–93.PubMed
13.
go back to reference Klement G, Baruchel S, Rak J, et al. Continuous low-dose therapy with vinblastine and VEGF receptor-2 antibody induces sustained tumor regression without overt toxicity. J Clin Invest. 2000;105:R15–24.PubMedCrossRef Klement G, Baruchel S, Rak J, et al. Continuous low-dose therapy with vinblastine and VEGF receptor-2 antibody induces sustained tumor regression without overt toxicity. J Clin Invest. 2000;105:R15–24.PubMedCrossRef
14.
go back to reference Browder T, Butterfield CE, Kräling, et al. Antiangiogenic scheduling of chemotherapy improves efficacy against experimental drugresistant cancer. Cancer Res. 2000;60:1878–86.PubMed Browder T, Butterfield CE, Kräling, et al. Antiangiogenic scheduling of chemotherapy improves efficacy against experimental drugresistant cancer. Cancer Res. 2000;60:1878–86.PubMed
15.
go back to reference Kerbel RS, Kamen BA. The anti-angiogenic basis of metronomic chemotherapy. Nat Rev Cancer. 2004;4:423–36.PubMedCrossRef Kerbel RS, Kamen BA. The anti-angiogenic basis of metronomic chemotherapy. Nat Rev Cancer. 2004;4:423–36.PubMedCrossRef
16.
go back to reference Dunn GP, Bruce AT, Ikeda H, Old LJ, Schreiber RD. Cancer immunoediting: from immunosurveillance to tumor escape. Nat Immunol. 2002;3:991–8.PubMedCrossRef Dunn GP, Bruce AT, Ikeda H, Old LJ, Schreiber RD. Cancer immunoediting: from immunosurveillance to tumor escape. Nat Immunol. 2002;3:991–8.PubMedCrossRef
17.
go back to reference Kosmaczewska A, Ciszak L, Potoczek S, Frydecka I. The significance of Treg cells in defective tumor immunity. Arch Immunol Ther Exp (Warsz). 2008;56:181–91.CrossRef Kosmaczewska A, Ciszak L, Potoczek S, Frydecka I. The significance of Treg cells in defective tumor immunity. Arch Immunol Ther Exp (Warsz). 2008;56:181–91.CrossRef
18.
go back to reference Kono K, Kawaida H, Takahashi A, et al. CD4(+)CD25high regulatory T cells increase with tumor stage in patients with gastric and esophageal cancers. Cancer Immunol Immunother. 2006;55:1064–71.PubMedCrossRef Kono K, Kawaida H, Takahashi A, et al. CD4(+)CD25high regulatory T cells increase with tumor stage in patients with gastric and esophageal cancers. Cancer Immunol Immunother. 2006;55:1064–71.PubMedCrossRef
19.
go back to reference Ghiringhelli F, Larmonier N, Schmitt E, et al. CD4+CD25+ regulatory T cells suppress tumor immunity but are sensitive to cyclophosphamide which allows immunotherapy of established tumors to be curative. Eur J Immunol. 2004;34:336–44.PubMedCrossRef Ghiringhelli F, Larmonier N, Schmitt E, et al. CD4+CD25+ regulatory T cells suppress tumor immunity but are sensitive to cyclophosphamide which allows immunotherapy of established tumors to be curative. Eur J Immunol. 2004;34:336–44.PubMedCrossRef
20.
go back to reference Loeffler M, Krüger JA, Reisfeld RA. Immunostimulatory effects of low-dose cyclophosphamide are controlled by inducible nitric oxide synthase. Cancer Res. 2005;65:5027–30.PubMedCrossRef Loeffler M, Krüger JA, Reisfeld RA. Immunostimulatory effects of low-dose cyclophosphamide are controlled by inducible nitric oxide synthase. Cancer Res. 2005;65:5027–30.PubMedCrossRef
21.
go back to reference Lutsiak ME, Semnani RT, De Pascalis R, Kashmiri SV, Schlom J, Sabzevari H. Inhibition of CD4 (+) 25+ T regulatory cell function implicated in enhanced immune response by low-dose cyclophosphamide. Blood. 2005;105:2862–8.PubMedCrossRef Lutsiak ME, Semnani RT, De Pascalis R, Kashmiri SV, Schlom J, Sabzevari H. Inhibition of CD4 (+) 25+ T regulatory cell function implicated in enhanced immune response by low-dose cyclophosphamide. Blood. 2005;105:2862–8.PubMedCrossRef
23.
go back to reference Tanaka H, Matsushima H, Mizumoto N, Takashima A. Classification of chemotherapeutic agents based on their differential in vitro effects on dendritic cells. Cancer Res. 2009;69:6978–86.PubMedCrossRef Tanaka H, Matsushima H, Mizumoto N, Takashima A. Classification of chemotherapeutic agents based on their differential in vitro effects on dendritic cells. Cancer Res. 2009;69:6978–86.PubMedCrossRef
24.
25.
go back to reference Audia S, Nicolas A, Cathelin D, et al. Increase of CD4+ CD25+ regulatory T cells in the peripheral blood of patients with metastatic carcinoma:A phase I clinical trial using cyclophosphamide and immunotherapy to eliminate CD4+ CD25+T lymphocytes. Clin Exp Immunol. 2007;150:523–30.PubMedCrossRef Audia S, Nicolas A, Cathelin D, et al. Increase of CD4+ CD25+ regulatory T cells in the peripheral blood of patients with metastatic carcinoma:A phase I clinical trial using cyclophosphamide and immunotherapy to eliminate CD4+ CD25+T lymphocytes. Clin Exp Immunol. 2007;150:523–30.PubMedCrossRef
26.
go back to reference Tsujii M, Kawano S, Tsuji S, Sawaoka H, Hori M, DuBois RN. Cyclooxygenase regulates angiogenesis induced by colon cancer cells. Cell. 1998;93:705–16.PubMedCrossRef Tsujii M, Kawano S, Tsuji S, Sawaoka H, Hori M, DuBois RN. Cyclooxygenase regulates angiogenesis induced by colon cancer cells. Cell. 1998;93:705–16.PubMedCrossRef
27.
go back to reference Masferrer JL, Leahy KM, Koki AT, et al. Antiangiogenic and antitumour activities of cyclooxygenase-2 inhibitors. Cancer Res. 2000;60:1306–11.PubMed Masferrer JL, Leahy KM, Koki AT, et al. Antiangiogenic and antitumour activities of cyclooxygenase-2 inhibitors. Cancer Res. 2000;60:1306–11.PubMed
29.
go back to reference Hsueh CT, Chiu CF, Kelsen DP, Schwartz GK. Selective inhibition of cyclooxygenase-2 enhances mitomycin-C-induced apoptosis. Cancer Chemother Pharmacol. 2000;45:389–96.PubMedCrossRef Hsueh CT, Chiu CF, Kelsen DP, Schwartz GK. Selective inhibition of cyclooxygenase-2 enhances mitomycin-C-induced apoptosis. Cancer Chemother Pharmacol. 2000;45:389–96.PubMedCrossRef
30.
go back to reference D’Amato RJ, Loughnan MS, Flynn E, Folkman J. Thalidomide is an inhibitor of angiogenesis. Proc Natl Acad Sci USA. 1994;91:4082–5.PubMedCrossRef D’Amato RJ, Loughnan MS, Flynn E, Folkman J. Thalidomide is an inhibitor of angiogenesis. Proc Natl Acad Sci USA. 1994;91:4082–5.PubMedCrossRef
31.
go back to reference Yoneda T, Alsina MA, Chavez JB, Bonewald L, Nishimura R, Mundy GR. Evidence that tumour necrosis factor plays a pathogenetic role in the paraneoplastic syndromes of cachexia, hypercalcaemia, and leukocytosis in a human tumour in nude mice. J Clin Invest. 1991;87:977–85.PubMedCrossRef Yoneda T, Alsina MA, Chavez JB, Bonewald L, Nishimura R, Mundy GR. Evidence that tumour necrosis factor plays a pathogenetic role in the paraneoplastic syndromes of cachexia, hypercalcaemia, and leukocytosis in a human tumour in nude mice. J Clin Invest. 1991;87:977–85.PubMedCrossRef
32.
go back to reference Cabral FR. Isolation of Chinese hamster ovary cell mutants requiring the continuous presence of taxol for cell division. J Cell Biol. 1983;97:22–9.PubMedCrossRef Cabral FR. Isolation of Chinese hamster ovary cell mutants requiring the continuous presence of taxol for cell division. J Cell Biol. 1983;97:22–9.PubMedCrossRef
33.
go back to reference Wong NS, Buckman RA, Clemons M, et al. Phase I/II trial of metronomic chemotherapy with daily dalteparin and cyclophosphamide, twice-weekly methotrexate, and daily prednisone as therapy for metastatic breast cancer using vascular endothelial growth factor and soluble vascular endothelial growth factor receptor levels as markers of response. J Clin Oncol. 2010;28:723–30.PubMedCrossRef Wong NS, Buckman RA, Clemons M, et al. Phase I/II trial of metronomic chemotherapy with daily dalteparin and cyclophosphamide, twice-weekly methotrexate, and daily prednisone as therapy for metastatic breast cancer using vascular endothelial growth factor and soluble vascular endothelial growth factor receptor levels as markers of response. J Clin Oncol. 2010;28:723–30.PubMedCrossRef
34.
go back to reference Garcia AA, Hirte H, Fleming G, et al. Phase II clinical trial of bevacizumab and low-dose metronomic oral cyclophosphamide in recurrent ovarian cancer: a trial of the California, Chicago, and Princess Margaret Hospital phase II consortia. J Clin Oncol. 2008;26:76–82.PubMedCrossRef Garcia AA, Hirte H, Fleming G, et al. Phase II clinical trial of bevacizumab and low-dose metronomic oral cyclophosphamide in recurrent ovarian cancer: a trial of the California, Chicago, and Princess Margaret Hospital phase II consortia. J Clin Oncol. 2008;26:76–82.PubMedCrossRef
35.
36.
go back to reference Patil V, Noronha V, D’cruz AK, Banavali SD, Prabhash K. Metronomic chemotherapy in advanced oral cancers. J Cancer Res Ther. 2012;8:S106–10.PubMedCrossRef Patil V, Noronha V, D’cruz AK, Banavali SD, Prabhash K. Metronomic chemotherapy in advanced oral cancers. J Cancer Res Ther. 2012;8:S106–10.PubMedCrossRef
37.
go back to reference Sterba J, Pavelka Z, Slampa P. Concomitant radiotherapy and metronomic temozolomide in pediatric high-risk brain tumors. Neoplasma. 2002;49:117–20.PubMed Sterba J, Pavelka Z, Slampa P. Concomitant radiotherapy and metronomic temozolomide in pediatric high-risk brain tumors. Neoplasma. 2002;49:117–20.PubMed
38.
go back to reference Kieran MW, Turner CD, Rubin JB, et al. A feasibility trial of antiangiogenic (metronomic) chemotherapy in pediatric patients with recurrent or progressive cancer. J Pediatr Hematol Oncol. 2005;27:573–81.PubMedCrossRef Kieran MW, Turner CD, Rubin JB, et al. A feasibility trial of antiangiogenic (metronomic) chemotherapy in pediatric patients with recurrent or progressive cancer. J Pediatr Hematol Oncol. 2005;27:573–81.PubMedCrossRef
39.
go back to reference Fousseyni T, Diawana M, Pasquier E, André N. Children treated with metronomic chemotherapy in a low-income country: METRO-MALI-01. J Pediatr Hematol Oncol. 2011;33:31–4.PubMedCrossRef Fousseyni T, Diawana M, Pasquier E, André N. Children treated with metronomic chemotherapy in a low-income country: METRO-MALI-01. J Pediatr Hematol Oncol. 2011;33:31–4.PubMedCrossRef
40.
go back to reference Stempak D, Gammon J, Halton J, Moghrabi A, Koren G, Baruchel SA. pilot pharmacokinetic and antiangiogenic biomarker study of celecoxib and low-dose metronomic vinblastine or cyclophosphamide in pediatric recurrent solid tumors. J Pediatr Hematol Oncol. 2006;28:720–8.PubMedCrossRef Stempak D, Gammon J, Halton J, Moghrabi A, Koren G, Baruchel SA. pilot pharmacokinetic and antiangiogenic biomarker study of celecoxib and low-dose metronomic vinblastine or cyclophosphamide in pediatric recurrent solid tumors. J Pediatr Hematol Oncol. 2006;28:720–8.PubMedCrossRef
41.
go back to reference Choi LM, Rood B, Kamani N, et al. Feasibility of metronomic maintenance chemotherapy following high-dose chemotherapy for malignant central nervous system tumors. Pediatr Blood Cancer. 2008;50:970–5.PubMedCrossRef Choi LM, Rood B, Kamani N, et al. Feasibility of metronomic maintenance chemotherapy following high-dose chemotherapy for malignant central nervous system tumors. Pediatr Blood Cancer. 2008;50:970–5.PubMedCrossRef
42.
go back to reference Minturn JE, Janss AJ, Fisher PG, et al. A phase II study of metronomic oral topotecan for recurrent childhood brain tumors. Pediatr Blood Cancer. 2011;56:39–44.PubMedCrossRef Minturn JE, Janss AJ, Fisher PG, et al. A phase II study of metronomic oral topotecan for recurrent childhood brain tumors. Pediatr Blood Cancer. 2011;56:39–44.PubMedCrossRef
43.
go back to reference Bocci G, Tuccori M, Emmenegger U, et al. Cyclophosphamide methotrexate ‘metronomic’ chemotherapy for the palliative treatment of metastatic breast cancer. A comparative pharmacoeconomic evaluation. Ann Oncol. 2005;16:1243–52.PubMedCrossRef Bocci G, Tuccori M, Emmenegger U, et al. Cyclophosphamide methotrexate ‘metronomic’ chemotherapy for the palliative treatment of metastatic breast cancer. A comparative pharmacoeconomic evaluation. Ann Oncol. 2005;16:1243–52.PubMedCrossRef
44.
go back to reference De Vita S, De Matteis S, Laurenti L, et al. Secondary Ph+ acute lymphoblastic leukemia after temozolomide. Ann Hematol. 2005;84:760–2.PubMedCrossRef De Vita S, De Matteis S, Laurenti L, et al. Secondary Ph+ acute lymphoblastic leukemia after temozolomide. Ann Hematol. 2005;84:760–2.PubMedCrossRef
45.
go back to reference Rome A, André N, Scavarda D, et al. Metronomic chemotherapy induced bilateral subdural hematoma in a child with meningeal carcinomatosis. Pediatr Blood Cancer. 2009;53:246–7.PubMedCrossRef Rome A, André N, Scavarda D, et al. Metronomic chemotherapy induced bilateral subdural hematoma in a child with meningeal carcinomatosis. Pediatr Blood Cancer. 2009;53:246–7.PubMedCrossRef
Metadata
Title
Metronomic Chemotherapy in Progressive Pediatric Malignancies: Old Drugs in New Package
Authors
Ankur Bahl
Sameer Bakhshi
Publication date
01-12-2012
Publisher
Springer-Verlag
Published in
Indian Journal of Pediatrics / Issue 12/2012
Print ISSN: 0019-5456
Electronic ISSN: 0973-7693
DOI
https://doi.org/10.1007/s12098-012-0759-z

Other articles of this Issue 12/2012

Indian Journal of Pediatrics 12/2012 Go to the issue