is an antitumour antibiotic that involves minimal myelosuppression.
USMLE® Step 1 style questions USMLE
USMLE® Step 2 style questions USMLE
A 25-year-old man comes to the office because of unexplained weight loss for the past several months. He also reports night sweats, pruritus, and lymphadenopathy. A lymph node biopsy shows Reed-Sternberg cells. The man undergoes treatment and two weeks later presents with this skin finding:
Which of the following is the mechanism of the drug known to cause these "whip-like" post-inflammatory lesions?
Alright, we know that antibiotics kill microbes, but a certain class of antibiotics called antitumor antibiotics can kill cancer too.
These medications interfere with DNA replication and often damage the DNA itself, leading to cell death.
Most of them are cell cycle non-specific.
Now, the cell cycle refers to the events that somatic cells go through in order to divide into two identical daughter cells.
At the end of G1, there’s a control point called the G1 checkpoint - where the cell checks to see if the DNA is damaged and it synthesized the right proteins in the correct amount.
If there is any reason for the cell not to divide, the cell can either enter a non-dividing state, called the G0 phase, where the DNA repair mechanisms try to fix the problem, or the cell can self-destruct in a process called apoptosis.
Now, if the cell does get the go-ahead at the G1 checkpoint, it enters the S phase during which DNA is replicated.
Okay, so during DNA replication, we unzip the double helix with the enzyme DNA helicase, and this creates a replication fork, with the two prongs of the fork being the two strands that are separated from one another.
Now, as DNA helicase does its thing, the segments of DNA ahead of it start to overwind, meaning, the double helix becomes more tightly wound.
Overwinding of the DNA can slow down replication, so the enzyme DNA topoisomerase works ahead of DNA helicase to loosen up the tight DNA coils.
Next, RNA primase creates a matching RNA primer on one pron of the the replication fork.
This is the area where the next enzyme, DNA polymerase can bind to the DNA to use it as a template and start adding nucleotides that’s complementary to the DNA onto the end of the primer.
Eventually we get a completed complementary copy of the DNA.
However, before it can do that, it must pass the final G2 checkpoint to make sure there is no DNA damage after replication.
Now, during mitosis, the replicated DNA divides equally for the two daughter cells, and the cell cycle ends with cytokinesis, which is when the cell membrane actually divides to form the two new cells.
Alright, now the cancer cells are also going through the phases of the cell cycle, but they undergo this process much more frequently and without checking for errors.
Therefore, cancer cells are more sensitive to DNA damage from cytotoxic medications like the antitumor antibiotics.
There are also normal tissues that divide rapidly like bone marrow and hair follicles, and they are also more susceptible to damage, which explains why cytotoxic medications are more toxic to these tissues.
Okay let’s start with bleomycin, which is a peptide that has an iron binding site on one end and a DNA binding site on the other end.
Bleomycin binds to the DNA strand and in the presence of oxygen, it becomes activated and acts as an oxidase, which means it transfers electrons from the iron to the oxygen molecule, generating free oxygen radicals.
These oxygen radicals oxidize DNA bases, causing breaks in the DNA strand.
As a result, a super important side effect of bleomycin is pulmonary toxicity, which usually presents as pneumonitis, but can turn into life-threatening pulmonary fibrosis.
Skin toxicity presents with rash, exfoliation, and hyperpigmentation or darkening of the skin.
Bleomycin is also associated with mucous membrane toxicity, which manifests as stomatitis and mucositis in the mouth, and alopecia or loss of hair.
What is special with bleomycin is that it only causes minimal myelosuppression, which is unusual for an anticancer medication.
Dactinomycin is a peptide that intercalates into the DNA molecule, which means that it inserts itself between the normal base pairs.
As a result, RNA and DNA polymerase can’t bind to DNA, so RNA and DNA synthesis come to a halt.
Dactinomycin is used primarily in the treatment of pediatric tumors like: nephroblastoma or Wilms tumor; rhabdomyosarcoma, which is a type of cancer that develops from skeletal muscle cells; and Ewing sarcoma, which is a malignant bone tumor.
Also, dactinomycin is associated with significant myelosuppression and alopecia.
Anthracyclines are cell-cycle non specific medications and act through various mechanisms.
First, they intercalate with DNA inserting themselves between base pairs and inhibiting RNA and DNA synthesis.
Anthracyclines also inhibit topoisomerase II and thus DNA will overwind during replication until it tears itself apart.
In addition, anthracyclines also produce free oxygen radicals that damage the DNA strand, but they need to bind to iron found in the tissue to do so.
Indications for anthracyclines include the treatment of solid tumors like breast, thyroid, lung, and ovarian cancers, but also leukemias and lymphomas.
Now an important side effect of these medications is cardiotoxicity due to the buildup of free radicals in the myocardium.
- "Katzung & Trevor's Pharmacology Examination and Board Review,12th Edition" McGraw-Hill Education / Medical (2018)
- "Rang and Dale's Pharmacology" Elsevier (2019)
- "Goodman and Gilman's The Pharmacological Basis of Therapeutics, 13th Edition" McGraw-Hill Education / Medical (2017)
- "Nomograms" D. Nicoll , C. Mark Lu, S.J. McPhee (Eds.), Guide to Diagnostic Tests, 7e. McGraw-Hill (2017)
- "Overview of hemostasis" J.C. Aster, H. Bunn (Eds.), Pathophysiology of Blood Disorders, 2e. McGraw-Hill. (2016)
- "The use of anthracyclines in adult acute lymphoblastic leukemia" Haematologica (1995)
- "The Antibiotic Drug Tigecycline: A Focus on its Promising Anticancer Properties" Frontiers in Pharmacology (2016)
- "Successful treatment of primary bone marrow Hodgkin lymphoma with brentuximab vedotin: a case report and review of the literature" Journal of Medical Case Reports (2018)