ASSESSMENT OF ROLE OF CHOROQUINE IN MANAGEMENT OF CANCER PATIENTS OF

JAMSHEDPUR
Dr S Sircar, Dr R K Mandhan , Dr Ashish Biswas Dr U S Singh, Dr Indrajeet Kumar Dr M A Khan , MGM Medical
College , Jamshedpur
RATIONALE AND BACKGROUND

Autophagy is a homeostatic cellular recycling system that is responsible for degrading damaged or unnecessary cellular
organelles and proteins. Cancer cells are thought to use autophagy as a source of energy in the unfavorable metastatic
environment, and a number of clinical trials are now revealing the promising role of chloroquine, an autophagy inhibitor,
as a novel antitumor drug. On the other hand, however, the kidneys are highly vulnerable to chemotherapeutic agents.
Recent studies have shown that autophagy plays a protective role against acute kidney injury, including cisplatin-
induced kidney injury, and thus, we suspect that the use of chloroquine in combination with anticancer drugs may
exacerbate kidney damage. Moreover, organs in which autophagy also plays a homeostatic role, such as the neurons,
liver, hematopoietic stem cells, and heart, may be sensitive to the combined use of chloroquine and anticancer drugs.
Here, we summarize the functions of autophagy in cancer and kidney injury, especially focusing on the use of
chloroquine to treat cancer, and address the possible side effects in the combined use of chloroquine and anticancer
drugs.
Antimalarial drugs, chloroquine and hydroxychloroquine, are promising for cancer treatment Several clinical trials that
have been conducted or are in progress have shown favorable effects of chloroquine as a novel antitumor drug (4).
Although the precise mechanism remains to be determined, the anticancer effects of chloroquine may partially be
because of its inhibitory action on macroautophagy (hereafter referred to as autophagy).
Chloroquine (CQ) has been evaluated as an autophagy blocker for cancer treatment, but it is unknown if it acts solely by
inhibiting cancer cell autophagy. By normalizing tumor vessel structure and function and increasing perfusion, CQ
reduced hypoxia, cancer cell invasion, and metastasis, while improving chemotherapy delivery and response. Inhibiting
autophagy in cancer cells or endothelial cells (ECs) failed to induce such effects. CQs vessel normalization activity
relied mainly on alterations of endosomal Notch trafficking and signaling in ECs and was abrogated by Notch1 deletion
in ECs in vivo. Thus, autophagy-independent vessel normalization by CQ restrains tumor invasion and metastasis while
improving chemotherapy, supporting the use of CQ for anticancer treatment.
Chloroquine, a widely used antimalaria drug, is currently under investigation in clinical trials on cancer patients. It is the
ability of chloroquine to inhibit autophagy in tumor cells that has piqued researchers' interest. Autophagy is a
homeostatic process by which cells eat parts of themselves, so that damaged or unnecessary organelles and toxic
proteins are broken down and recycled. In the absence of nutrients, cells resort to autophagy to survive. This way,
autophagy helps cancer cells survive in tumor regions that are poor in nutrients and characterised by low oxygen and
acidic pH.
Also, tumor cells use autophagy to protect themselves from many forms of anticancer therapies, including
chemotherapy. Several studies have shown that inhibition of autophagy often increases chemosensitivity and
radiosensitivity in tumor cells. Chloroquine combined with existing cancer treatment is thus considered to be a
promising strategy. However, in some cancer models chloroquine seems to be unable to block autophagy, but the
underlying mechanisms have not yet been identified.
This study forms a new rationale for the use of chloroquine in anti-cancer treatment. With a view to clinical studies
(tests on humans) it is important to note that the effects on the tumor vasculature were even observed at chloroquine
concentrations that had little effect on autophagy in the cancer cells. This sheds new light on the therapeutic schedule
for combination therapy with chloroquine, which could result in decreased toxicity. In other words, the same "old"
medicine simultaneously targets the cancer cells themselves and the blood vessels with great efficiency
AUTOPGAGY AND CANCER
Autophagy is considered to have 2 contrasting roles, promotion and suppression, in cancer cells. First, autophagy
provides an energy source for cancer cells, which can survive in an environment that is unfavorable for normal cells.
Cancer cells can survive under hypoxic and acidic conditions despite the lack of mature vessels. For energy production,
cancer cells depend mainly on the glycolysis pathway (the Warburg effect), which is less efficient than the tricarboxylic
acid cycle pathway; thus, cancer cells require more glucose uptake than normal cells Autophagy is assumed to provide
energy for cancer cells under such unfavorable conditions, and thereby, have a cancer-promoting role.
On the other hand, autophagy also has a cancer-suppressing role. Heterozygous disruption of Beclin 1, an autophagy-
related gene, increases the frequency of spontaneous malignancies Thus, Beclin 1 has cancer-suppressing activity. Liver-
specific Atg7-deficient mice and mice with systemic mosaic deletion of Atg5 develop benign liver adenomas
Although Beclin 1 has multiple functions, including endocytosis, these observations suggest a cancer-suppressing role of
autophagy. A recent study suggested that autophagy is also necessary for anti-immune responses. In response to
chemotherapy, autophagy in dying cancer cells enables the release of ATP, which attracts immune cells and triggers anti-
immune responses Therefore, autophagy may have different effects at different stages of cancer. Further studies are
necessary to understand the precise role of autophagy in cancer cells
Chloroquine and Cancer Treatment
Chloroquine has long been used to treat or prevent malaria. Chloroquine is also used to treat autoimmune diseases in
some countries because of its immunosuppressive properties. Although the precise mechanism underlying the
antimalarial effects of chloroquine remains unknown, chloroquine seems to exert its effects through the weak-base
lysosome-tropic feature When chloroquine enters the lysosome, it becomes protonated because of the low pH within
the lysosome, and accumulation of the protonated form of chloroquine within the lysosome leads to less acidic
conditions and, thereby, decreased lysosomal function
Chloroquine has long been used to treat or prevent malaria. Chloroquine is also used to treat autoimmune diseases in
some countries because of its immunosuppressive properties. Although the precise mechanism underlying the
antimalarial effects of chloroquine remains unknown, chloroquine seems to exert its effects through the weak-base
lysosome-tropic feature When chloroquine enters the lysosome, it becomes protonated because of the low pH within
the lysosome, and accumulation of the protonated form of chloroquine within the lysosome leads to less acidic
conditions and, thereby, decreased lysosomal function.
Accumulating evidences indicates that chloroquine sensitizes cancer cells to radiation and other anticancer drugs. On
the basis of the data from a number of clinical trials now in process, it can be inferred that this drug may alter cancer
therapeutic strategies
Although the precise mechanism by which chloroquine exerts anticancer effects is unclear, 1 possible mechanism is its
antiautophagic activity. Autophagy is of the physiologic processes affected by chloroquine. Inhibition of lysosome
activity by chloroquine arrests the latter step of autophagy, degradation of the autolysosome, which results in the
failure to provide energy through the autophagy pathway. Because autophagy seems to contribute to promote cancer,
chloroquine may sensitize cancer cells through inhibiting autophagy. The dosage of chloroquine usually ranges between
100 and 500 mg/day. Side effects are minimal at low doses, while many more toxic effects occur at higher doses, such as
visual disturbances, gastrointestinal upset, electrocardiographic changes, headache, and pruritus.
In addition to chloroquine, other autophagy inhibitors, such as bafilomycin A1, 3-methyladenine, and pepstain A, have
been studied as antitumor drugs. One notion is that these drugs, including chloroquine and its derivatives, are not
specific modulators of autophagy activity, that is, these agents also have some other effects on cellular functions, such
as lysosomal function and endocytosis. Targeting more specific processes of autophagy is a more preferable approach in
cancer therapy, however, and is now under investigation
Exploring the mechanism of the drug's cancer-preventing action provided some intriguing insights.
At the doses used in the new study, which were similar to those needed to prevent malaria, chloroquine triggered the
death of premalignant cells. This suggests that within the context of MYC overexpression, the drug induces apoptotic
cell deathprogrammed cell deathin response to ineffective autophagic protein degradation and lysosomal changes
in the cell. (Lysosomes are cellular recycling centers that degrade old and unwanted material in the cell and recycle
building blocks that are used for cell growth.) The p53 protein can induce apoptosis in response to DNA damage or
stress, and the study's results suggest that alterations in lysosomal function trigger a p53-dependent cell death
response.
Autophagy is a complex adaptive cellular response that enhances cell survival in the face of starvation or other stresses,
including protein accumulation in the cell. Other recent studies from the Cleveland lab suggest that drugs that disable
the autophagy response can overcome treatment resistance, even in refractory tumors.
While the new study shows that chloroquine's disruption of lysosomal function makes it potentially useful in the
treatment of certain cancers, there are still questions to be answered before the treatment arrives in the clinic. The
team is working on defining the optimal use of this approach for cancer prevention and treatment. Issues include dosing,
particularly in combination with other agents that are used to treat cancer patients.


EVIDENCE
A recent study has demonstrated that chloroquine also normalizes the abnormal blood vessels in tumors. This blood
vessel normalization results in an increased barrier function on the one handthereby blocking cancer cell
dissemination and metastasisand in enhanced tumor perfusion on the other hand, which increases the response of
the tumor to chemotherapy.
The anti-cancer effect of the antimalarial agent chloroquine when combined with conventional chemotherapy has been
well documented in experimental animal models. To date, it was assumed that chloroquine increases the sensitivity of
cancer cells to chemotherapy by means of a direct effect on the cancer cells. However, a recent study by investigators at
VIB and KU Leuven has demonstrated that chloroquine also normalizes the abnormal blood vessels in tumors. This blood
vessel normalization results in an increased barrier function on the one hand thereby blocking cancer cell
dissemination and metastasis and in enhanced tumor perfusion on the other hand, which increases the response of the
tumor to chemotherapy.
Chloroquine is a well-known medicine with a good safety profile that has been in use since World War 2 for the
treatment of malaria and certain auto-immune diseases, including rheumatoid arthritis. More recently, chloroquine has
also been used in anti-cancer treatment. Chloroquine blocks autophagy, a process that cancer cells use to survive to
anti-cancer treatments. Therefore, blocking autophagy would reduce the resistance of the cancer cells to chemotherapy.
METHOS
We will explore the effect of inhibiton of autophagy, in preclinical models of SCLC.(Lung Ca) These includes cell
culture analyses of viability and of autophagic and apoptotic pathway induction,
After the permission of the local Ethical committee , there will be voluntary registration done of the patients of breast
cancers with their informed consent as per the Ethical Guidelines for Biomedical Research on Human Participants (ICMR
2006) and will take help of Local Meherbai Cancer Hospital , It will be Randomized Controlled study where there would
be two arms : we will study in a randomized controlled study of neo-adjuvant chemotherapy and trastuzumab with
or without metformin in women diagnosed with HER2-positive primary Breast Ca ( hence forth called as BC ) The
population target will be 50 women with clinically and histologically confirmed primary HER2-positive invasive BC, T2
T4, any N, M0, and suitable for neo-adjuvant chemotherapy plus trastuzumab. After biopsy, patients will be randomly
assigned to either 12 cycles of weekly paclitaxel followed by four cycles of fluorouracil, epirubicin, cyclophosphamide
(500/75/500) with concomitant weekly trastuzumab and daily Hydroxy cholroquine (HCQ) (200 mg/day) for 24 weeks
(arm A; n = 25 ) or equivalent neo-adjuvant chemotherapy with concurrent trastuzumab plus placebo (arm B; n =25) for
24 weeks. Our primary end point will be efficacy in terms of pathological complete response (pCR) Secondary end points
will include tolerability, 3-year actual disease-free survival (DFS) after surgery, and cardiovascular events
CONCLUSIONS
Chloroquine (CQ) is a 4-aminoquinoline drug used for the treatment of diverse diseases. It inhibits lysosomal
acidification and therefore prevents autophagy by blocking autophagosome fusion and degradation. In cancer
treatment, CQ is often used in combination with chemotherapeutic drugs and radiation because it has been shown to
enhance the efficacy of tumor cell killing. Since CQ and its derivatives are the only inhibitors of autophagy that are
available for use in the clinic, multiple ongoing clinical trials are currently using CQ or hydroxychloroquine (HCQ) for this
purpose, either alone, or in combination with other anticancer drugs. Here we show that in the mouse breast cancer cell
lines, 67NR and 4T1, autophagy is induced by the DNA damaging agent cisplatin or by drugs that selectively target
autophagy regulation, the PtdIns3K inhibitor LY294002, and the mTOR inhibitor rapamycin. In combination with these
drugs, CQ sensitized to these treatments, though this effect was more evident with LY294002 and rapamycin treatment.
Surprisingly, however, in these experiments CQ sensitization occurred independent of autophagy inhibition, since
sensitization was not mimicked by Atg12, Beclin 1 knockdown or bafilomycin treatment, and occurred even in the
absence of Atg12. We therefore propose that although CQ might be helpful in combination with cancer therapeutic
drugs, its sensitizing effects can occur independently of autophagy inhibition. Consequently, this possibility should be
considered in the ongoing clinical trials where CQ or HCQ are used in the treatment of cancer, and caution is warranted
when CQ treatment is used in cytotoxic assays in autophagy research.
Take home messages
CQ reduces cancer cell invasion and metastasis
CQ induces tumor vessel normalization and improves drug delivery and response
CQ-mediated vessel normalization is autophagy independent
Vessel normalization by CQ relies on increased endothelial Notch1 signaling

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