[Pharmacology of camptothecin and its derivatives]

20 (S) Camptothecin was discovered in the early 60's as a result of the intensive screening of natural products by the NCI. Camptothecin lactone was poorly water soluble and was administered as the sodium salt in phase I trials. Despite some encouraging responses in early studies, continued evaluation of this compound revealed severe and unpredictable toxicities such as haemorrhagic cystitis and diarrhoea. The reversible opening of the lactone ring of a camptothecin is pH-dependent and yields a ring-opened carboxylate form which has greatly reduced activity in vivo and in vitro. Under physiological conditions, the carboxylate form predominates, but the exact position of this equilibrium in vivo also depends on other factors such as protein-binding and differential metabolism and elimination. The site of action of camptothecin is a complex formed by the nuclear enzyme topoisomerase I and DNA, which represents a novel target for cancer chemotherapy. The principal role of topoisomerase I is the relaxation of DNA required for transcription and replication. The transient covalent complexes formed by the linking of the enzyme and the 3' extremity of a nicked DNA strand are stabilised in the presence of camptothecin and involved in collisions with replication forks. The ensuing arrest of the fork is accompanied by the generation of permanent double-strand breaks which are thought to be responsible for the antiproliferative properties of camptothecin. The acquisition of resistance to camptothecin in cell culture appears, in general, to be due to a reduction in content and activity of topo-isomerase I. Single-point mutations of the gene of the enzyme have been detected in a number of these resistant variants. Camptothecin appears to be a poor substrate of P-glycoprotein and its intracellular accumulation is not appreciably reduced in cells expressing the multidrug-resistant phenotype. Several water soluble and active derivatives of camptothecin have been synthetized of which CPT-11 and topotecan are the most advanced in clinical trials. These compounds represent two different approaches to the problem of the poor water solubility of camptothecin lactone. CPT-11 is a soluble prodrug which is converted in vivo to the highly active SN-38, whereas topotecan itself is water-soluble due to the presence of a tertiary amine substitution which is charged at physiological pH. These two compounds present different pharmacological properties in the clinical setting.