Professional Documents
Culture Documents
he class of steroid-like compounds designated cardiac glycosides includes well-known drugs such as
digoxin, digitoxin, and ouabain. Their continued efficacy in treatment of congestive heart failure and
as anti-arrhythmic agents is well appreciated. Less well known, however, is the emerging role of this
category of compounds in the prevention and/or treatment of proliferative diseases such as cancer. New
findings within the past five years have revealed these compounds to be involved in complex cell-signal
transduction mechanisms, resulting in selective control of human tumor but not normal cellular prolif-
eration. As such, they represent a promising form of targeted cancer chemotherapy. New clinical studies
of their anticancer potential as single or adjuvant treatments may provide insight into these potentially
valuable therapeutic options. This review focuses on recent findings on cellular pharmacology of cardiac
glycosides as they relate to treatment of human cancer and attempts to explain why these agents have been
overlooked in the past.
36
Cardiac Glycosides as Novel Cancer Therapeutic Agents
History of the Use of Cardiac Glycosides toad, known to contain multiple bufodeninolides (another type
for Cancer of cardiac glycoside), including bufalin (Figure 1) (5–7). The
potential use of cardenolide-like compounds for the treatment
The use of cardiac glycoside containing plants for medicinal of cancer, initially investigated forty years ago, was abandoned
purposes was first reported in ancient texts more than 1500 because of the toxicity of these compounds (8, 9). It was only
years ago. They have been used traditionally as arrow poisons, recently, however, that Scandinavian oncologists suggested that the
abortifacients, emetics, diuretics, and heart tonics. It is the latter apoptosis produced by digitalis in human tumor cells occurred at
pharmacologic activity that cardiac glycosides are most com- concentrations that could be achieved without toxicity in humans
monly associated with, and after 200 years, compounds such and, therefore, this agent might be useful for treatment of cancer
as digitalis and digoxin are still prescribed by Western doctors (10–12). In 1979, Stenkvist et al. (13) noted that the altered mor-
for control of congestive heart failure. Their use began after a phology of breast cancer cells from women treated with digitalis
meticulous analysis of a local herbalist’s formula in 1775 by the (who had undergone mastectomy). Women receiving digitalis had
English physician and scientist William Withering. He found that tumor cells with more benign characteristics than those tumor
a patient with “dropsy” (congestive heart failure) improved after cells in patients not receiving this cardiac glycoside. Moreover,
administration of an extract containing foxglove (Digitalis purpurea the cancer recurrence rate of women taking digitalis was lower,
L.) (1). Compounds extracted
from foxglove and oleander R=lactone ring
18
include cardenolides (Figure 17 O
12 H
Lactone Moiety
1), such as digitalis, digoxin, 19
11
H
13
16
O
9 14 15
O O
and oleandrin, which increase 2
1
10 8 Cardenolides R=
cardiac contractility and act 3 5 H 7
OH
4 6 H
as antiarrythmic agents to O O
H H
control atrial fibrillation (2, HO O
O H OH
3). The mechanism of their Steroid
Bufadienolides R=
HO Bufalin
action for the treatment of OH HO
H
congestive heart failure arises O O
from the inhibition of Na+,K+- Glycone
O O OH
ATPase, with a resulting HO
H H
increase in intracellular cal- HO H
cium concentrations. Cardiac H
H O
glycosides, however, have a H OH
narrow therapeutic index, H OH O O O
O OH
limiting their wider applica- O
O O HO
tion to the treatment of other HO H
Ouabain H
diseases, such as cancer. HO H
OCH3 Oleandrin OH
Despite their potential
to cause serious side effects, H OH
February 2008
Volume 8, Issue 1 37
Review
Table 1. List of Plants and Animals with Cardiac Glycosides Having Antiproliferative Activities
Plant/Animal Species Cardiac Glycoside(s) In Vitro Cytotoxic Effect Reference
Apocynum cannabinum L. Apocannoside, cymarin Human nasopharynx carcinoma (KB) (66)
(Apocynaceae)
Asclepias curassavica L. Calotropin, 16α-acetoxycalotropin, Human lung carcinoma (A549), breast carcinomas (67)
(Asclepiadaceae) 15β-hydroxycalotropin, calactin, (MCF-7 and MDA-MB-231), and hepatoma (HepG2)
15β-hydroxycalactin, asclepin,
16α-hydroxyasclepin, uscharidin,
uscharin, uzarigenin
Beaumontia brevituba Digitoxigenin, oleandrigenin, digi- Human breast carcinoma (BC1), colon carcinoma (68)
Oliver (Apocynaceae) toxigenin, α-l-cymaroside, digitoxigenin (Col2), fibrosarcoma (HT-1080), nasopharyngeal
β-gentiobiosyl-α-l-cymaroside, Δ16- carcinoma (KB), vinblastine-resistant KB (KB-V1), lung
digitoxigenin β-d-glucosyl-α-l-cymaroside carcinoma (Lu1), and melanoma (Mel2)
Bufo bufo gargarizans L. Bufalin, cinobufagin Prostate carcinomas (LNCaP, DU145, PC3), and (69, 70)
hepatoma (PLC/PRF/5)
Calotropis procera (Ait.) Calotropin, calactin, uscharin, voruscha- Human non-small-cell lung carcinoma (A549), human (71, 72)
R. Br. (Asclepiadaceae) rin, 2’’-oxovoruscharin glioblastomas (Hs683 and U373), human colon
carcinomas (HCT-15 and LoVo), hepatoma (Huh7),
non-hepatoma (COS-1), and colorectal carcinoma
(COLO 320)
Cerbera odollam Gaertner 2′-O-Acetyl cerleaside A, 17α-neriifolin, Human oral epidermoid carcinoma (KB), breast (73)
(Apocynaceae) 17β-neriifolin, cerberin carcinoma (BC), and small-cell lung carcinoma
(NCI-H187)
Coronilla varia L. Hyrcanoside Human lymphocytic leukemia (P-388) and (74)
(Fabaceae) nasopharynx carcinomas (9KB)
Crossopetalum gau- Securigenin-3β-O-β-6-deoxyguloside, Human oral epidermoid carcinoma (KB) (75)
meri (Loes.) Lundell 19-hydroxy-sarmentogenin-3β-O-β-6-
(Celastraceae) deoxyguloside, sarmentogenin-3β-O-
(α-allosyl-(1→4)-β-6-deoxyalloside),
securigenin-3β-O-(α-allosyl-(1→4)-β-6-
deoxyalloside)
Digitalis purpurea L. Digoxin, digitoxin, gitoxin Human prostate carcinomas (LNCaP, DU145, PC3), (76, 77)
(Scrophulariaceae) renal adenocarcinoma (TK-10), breast adenocarci-
Digitalis lanata noma (MCF-7), malignant melanoma (UACC-62),
(Scrophulariaceae) and chronic myelogenous leukemia (K-562)
Elaeodendron sp. Elaeodendrosides Human ovarian carcinoma (A2780) (78)
Euonymus alata (Thunb.) Acovenosigenin A 3-O-α-l- Human oral epidermoid (KB), promyelocytic (79)
Sieb. (Celastraceae) ramnopyranoside, euonymoside A, euo- lymphoma (HL-60), non-small-cell lung carcinoma
nymusoside A (A549), and cervical carcinoma (Hela)
Euonymus sieboldianus Euonymoside A Human lung carcinoma (A549) and ovarian (80)
Blume (Celastraceae) adenocarcinoma (SK-OV- 3)
Maquira calophylla (P.&E.) Maquiroside A Human oral epidermoid carcinoma (KB) (81)
C.C. Berg (Moraceae)
Nerium oleander L. Oleander, oleandrin, cardenolide N-1, Human Jurkat leukaemia (T-cell), histiocytic lymphoma (82, 83)
(Apocynaceae) cardenolide N-4, 3β-O-(β-d-sarmentosyl)- (U-937), promyelocytic lymphoma (HL-60), cervical
16β-acetoxy-14-hydroxy-5β,14β-card- carcinoma (Hela), breast carcinoma (MCF-7), pros-
20-(22)-enolide, 16β-acetoxy-3β,14- tate carcinomas (LNCap, DU145, PC3), malignant
dihydroxy-5β,14β-card-20-(22)-enolide fibroblast (VA-13), and liver carcinoma (HepG2)
38
Cardiac Glycosides as Novel Cancer Therapeutic Agents
Table 1. continued
Nierembergia aristata D. 17-epi-11α-hydroxy-6,7- Human breast carcinoma (BC1), fibrosarcoma (HT), (84)
Don (Solanaceae) dehydrostrophanthidin-3- lung cancer (LU1), melanoma (Mel2), colon carci-
O-β-boivinopyranoside; noma (Col2), oral epidermoid (KB), drug resistant KB
6,7-dehydrostrophanthidin- with and without vinblastine, epidermoid carcinoma
3-O-β-boivinopyranoside; (A-431), prostate carcinoma (LNCaP), hormone-
6,7-dehydrostrophanthidin-3-O-β- dependent breast carcinoma (ZR-75-1), and glioma
oleandropyranoside (U373)
Ornithogalum umbellatum Convallatoxin Human oral epidermoid carcinoma (KB) (85)
L. (Hyacinthaceae)
Pergularia tomentosa L. 3′-O-β-d-glucopyranosylcalactin, 12-dehy- Kaposi’s sarcoma (KS) (86)
(Asclepiadaceae) droxyghalakinoside, 6′-dehydroxygha-
lakinoside, ghalakinoside, calactin
Periploca graeca L. Periplocin isomers Human prostate carcinoma (PC-3) (87)
(Asclepiadaceae)
Rhodea japonica (Thunb.) Rhodexin A Human leukemia (K562) (88)
Roth. (Liliaceae)
Saussurea stella Maxim. 3-O-β-d-fucopyranosylstrophanthidin, Human gastric cancer (BGC-823) and hepatoma (89)
(Asteraceae) 3-O-β-d-quinovopyranosylperiplogenin, (Bel-7402)
3-O-β-d-glucopyranosyl-(1→4)-α-l-
rhamnopyranosylcannogenin, 3-O-β-d-
xylopyranosylperiplogenin, 3-O-β-d-
quinovopyranosylstrophanthidin,
3-O-β-d-xylopyranosylstrophanthidin,
3-O-β-d-fucopyranosylperiplogenin,
3-O-α-l-rhamnopyranosylcannogenol,
convallatoxin, 3-O-α-l-
rhamnpyranosylacovenosigenin A
Streblus asper Lour. Stebloside, mansonin Oral human epidermoid carcinoma (KB) (90)
(Moraceae)
Streptocaulon juven- Periplogenin digitoxoside, Human fibrosarcoma (HT-1080) (91)
tas (Lour.) Merr. Periplocymarin, digitoxigenin
(Asclepiadaceae) 3-O-(O-β-d-glucopyranosyl-(1→6)-
O-β-d-glucopyranosyl-(1→4)-β-d-
digitoxopyranoside, echujin, corchoru-
soside C
Streptocaulon griffithii 3-O-(β-glucopyranosyl)acovenosigenin A Human gastrointestinal cancer (HCG-27), lung carci- (92)
Hook.f. (Asclepiadaceae) noma (A549), breast carcinoma (MCF-7), and cervi-
cal carcinoma (HeLa)
Strophanthus gratus Ouabain Human prostate carcinomas (LNCaP, DU145, PC3) (76)
Thevetia ahouia (L.) A. Neriifolin, 3′-O-methylevomonoside, National Cancer Institute’s human disease oriented (93)
DC. (Apocynaceae) 2′-acetylneriifolin 60-cell line tumor screening panel
Thevetia peruviana Thevetin A and B, thevetoside Human hepatoma (SMMC-7721), gastric carcinoma (93)
(Pers.) K. Schum. (SGC-7901), and cervical carcinoma (HeLa)
(Apocynaceae)
Urginea maritime (L.) Proscillaridin A, scillaren A Human breast carcinoma (MCF-7) (94–96)
Baker (Liliaceae)
February 2008
Volume 8, Issue 1 39
Review
suggesting an important beneficial anticancer effect of this cardiac 1). The purpose of the present review, therefore, is to examine
glycoside (14). the hypothesis already expressed by some (10, 14–20), that use of
Within the past ten years, there has been a substantial selected cardiac glycosides may represent a worthwhile approach
increase in the number of studies observing the effects of cardiac toward control of malignant cell proliferation even despite their
glycosides on the growth of human malignant tumor cells. A narrow therapeutic index. This is all the more timely because
review of the literature indicates a surprising variety of plants and promising clinical trials of cardiac glycosides and extracts contain-
even animals whose extracts and isolated cardiac glycoside com- ing them have recently been initiated.
pounds have been cited for their antiproliferative effects (Table
NF-κB, Nuclear Factor-kappaB; JNK, c-Jun NH2-terminal kinase; AP-1, Activator Protein-1; FasL, Fas ligand; ROS, reactive oxygen species;
FGF-2, Fibroblast Growth Factor 2; IL-8, Interleukin-8; TNF-α, Tumor Necrosis Factor–α; TRAIL, (TNF)-related apoptosis-inducing ligand; NF-AT,
Nuclear Factor of Activated T cells; MAPKs, mitogen-activated protein kinases.
40
Cardiac Glycosides as Novel Cancer Therapeutic Agents
Na+,K+-ATPase: Beyond Cell Membrane cinogen 1,2-dimethyldrazine (24). There have also been reports
Exchange of Na+ and K+ of increased expression of particular subunits of Na+,K+-ATPase
in gastric (25) and bladder cancers (26). In addition, alterations
Na+,K+-ATPase, as an energy-transducing ion pump, has been in overall Na+,K+-ATPase activity and relative subunit abundance
studied extensively since its discovery in 1957 (21). This enzyme were observed in a highly invasive form of human renal carci-
consists of two types of subunits, designated α and β, in addition noma cells (27), non-small cell lung cancer (28), and carcinoma
to a single-transmembrane-spanning protein, FXYD––named for cell lines obtained from a number of other tissues (29). It would
the conserved amino acids in its signature motif: (Phe-Xxx-Tyr- appear, however, that simply looking at enzyme subunit content
Asp). The α subunit, responsible for binding of Mg2+, ATP, Na+, K+, or relative activity in malignant and non-malignant tissue may not
and cardiac glycosides, is considered the catalytic subunit of the provide adequate insight into the role of this enzyme in cancer.
enzyme. The β subunit is a glycoprotein that seems to act as an This can now be interpreted in the light of newly proposed conse-
adhesion molecule that regulates gap junction proteins; is involved quences of cardiac glycoside binding to Na+,K+-ATPase.
in structural and functional maturation of the holoenzyme; facili-
tates transport of the α subunit to the plasma membrane and main- Proposed Mechanism(s) of
tenance of the enzyme in the lateral membrane of epithelial cells Cardiac Glycoside–Mediated
(15–17). The function of the FXYD protein involves regulation of Antiproliferative Effects
the enzyme function, thus adapting the kinetic properties of active
Na+ and K+ transport to the specific needs of different cells (22, 23). An explanation of the role of Na+,K+-ATPase in complex cell
Four α subunit variants, as well as three β, and seven FXYD sub- signaling pathways, many of which are of critical importance
unit variants have been identified (17). The well-established func- to malignant cell proliferation, has been put forth by Xie and
tion of Na+,K+-ATPase is to use ATP as an energy source to drive colleagues (30–32). They have shown that binding of cardiac
excess Na+ out of cells in exchange for K+, thereby maintaining an glycosides (e.g., ouabain) to Na+,K+-ATPase triggers a complex
essential ionic and osmotic
Apo2/TRAIL
balance. Binding of certain α Upregulation of death receptors
(J)
subunits by cardiac glycosides (A) Altered membrane
DR4 fluidty
DR5 Oleandrin,
inhibits ATP binding and dis- bufalin,
TNF-A
C
av
rupts the ability of the enzyme eo
lin
digitoxin
TNFR
February 2008
Volume 8, Issue 1 41
Review
A 120
tion has been compiled (Table 2 and Figure 2), and there are
Panc-02
BxPC3 several excellent reviews on this subject (15–17). There are uni-
100
MiaPaca fying themes that link mechanisms involving the water-soluble
PANC-1
Percent of control cell growth
B
Panc-02
PANC-1
BxPC3
42
Cardiac Glycosides as Novel Cancer Therapeutic Agents
diac glycosides have a selective effect on malignant but not normal some prognostic value if that patient is to be subsequently treated
cell proliferation. For example, oleandrin suppresses the activation with a cardiac glycoside.
of certain transcription factors and potentiates ceramide-induced Mijatovic et al., on the other hand, suggest that, rather than
apoptosis in human tumor cells but not in normal, primary the α3 subunit, it is the α1 subunit of Na+,K+-ATPase that could
human cells (19). In vitro observations that leukemia cells under- represent a novel anticancer target (47). They have shown that
go apoptosis in the presence of oleandrin and bufalin, but that human lung cancer cell lines overexpressing the α1 subunit were
normal leukocytes do not, are also consistent with the hypothesis sensitive to a few select cardenolides. They noted that the cardiac
of a potentially therapeutic, selective therapeutic effect of cardiac glycosides produced a marked change in the actin cytoskeleton,
glycosides on tumor growth (37–39). Not only do cardiac gly- suggesting this abets tumor cell death. Whether it is altered
cosides appear to be more effective at inhibiting proliferation of expression of α1, as suggested by Mijatovic et al., or an elevation
malignant cells than normal cells, but they also are more effective of α3, as indicated by our own work, or perhaps even a specific
at sensitizing tumor cells to irradiation, which would appear to ratio of α3:α1 that is most important as a predictor of cell sensi-
increase their potential utility in the clinic. Research reported by tivity, remains to be determined. More research, using human tis-
several investigators (40–42) indicates that cardiac glycosides sen- sues and not just cell lines, will no doubt shed light on the poten-
sitize human tumor but not normal cells to subsequent radiation tial importance and perhaps even prognostic value of the enzyme
treatment. These data suggest that it may be possible to exploit subunit composition within individual types of tumors.
differences in the Na+,K+-ATPase pumps of normal as opposed to It is significant that the relative composition of Na+,K+-ATPase
tumor cells to improve the therapeutic index of radiation therapy. subunits may not be static within human tissues. The relative ratio
Modern drug development seeks specific biochemical differ- of α subunits within the enzyme may shift when tissues are trans-
ences between malignant and normal cells that may be critical to formed from a benign to a malignant state. Sakai et al. (46) recent-
survival of cancer cells. One then attempts to develop selective ly showed, for example, that a decrease in the α1 isoform and an
inhibitors to disrupt these pathways. Na+,K+-ATPase, however, is increase in the α3 subunit occurs in colon tissue when a normal
a ubiquitous enzyme present in every mammalian cell. At first phenotype changes to a malignant one. If, as our data suggest, it
appearance, therefore, it would appear to make Na+,K+-ATPase is the relative expression of α3 that is important for determining
an anticancer target of dubious value unless, of course, the target sensitivity of a tissue to inhibition by cardiac glycosides then, in
were found to be fundamentally different in normal versus malig- essence, the report by Sakai et al. suggests that the tumor becomes
nant human cells or between rodent and mammalian cancer cells. a more sensitive target than normal tissue to cardiac glycoside
Our recent data suggest that, in fact, there is a difference in the therapy (46). Given the current as well as proposed clinical trials
basic subunit composition of Na+,K+-ATPase that might explain of cardiac glycosides for treatment of cancer, specific determina-
the differential species-dependent sensitivity to cardiac glycosides. tion of enzyme subunit composition in specific tissue types as
Although human tumor cells and tissues commonly express both well as pathologic characterization may prove to be a timely tool
α1 and α3 subunits, all rodent tumor cell lines we have examined to help optimize the effectiveness of this class of potential cancer
to date only express the α1 subunit (Figure 3). Early reviews of therapeutic agents.
the biochemical properties of Na+,K+-ATPase suggested that cardi-
ac glycoside binding may be equal to all four α subunit isoforms; Cardiac Glycoside-Mediated Cancer Cell
however, more recent studies have shown a clear preferential Death: Autophagy and Apoptosis
binding of cardenolides to the α3 form over that of the α1 or α2
isoforms (43–45). For example, O’Brien et al. (45) cite a 1000-fold Although it is clear that lipid-soluble cardiac glycosides (i.e.,
difference in binding of ouabain to the α3 isoform over that of digitoxin, oleandrin, and bufalin) have a potent ability to pro-
α1. Given the fact that rodent tumor cells possess the α1 subunit, duce human tumor cell death, the mechanisms by which this is
lack expression of α3, and are unresponsive to inhibition of prolif- accomplished are still being defined. Apoptotic cell death medi-
eration with cardiac glycosides, we suggest that the α3 subunit is ated by cardenolides has been demonstrated in a number of cell
critical. The increased expression of α3 over α1 subunits has also lines. Sreenivasan et al., for example, have shown that oleandrin
been noted in human colon colorectal cancer and colon adeno- produced an increase in expression of Fas and Tumor Necrosis
carcinoma cell lines (e.g., KM12-L4, T-84, HT-29, and WiDr), Factor Receptor 1 (TNFR1), resulting in potentiation of apoptosis
whereas no significant expression of the α3 isoform protein was in tumor cells but not in normal primary cells, such as peripheral
noted in the normal kidney and renal tissues (46). Moreover, blood mononuclear cells or neutrophils (48). Fas–Fas ligand and
human tumor cell lines with a low ratio of α3:α1 are relatively TNF–TNFR1 death pathways are important mediators of apopto-
resistant to growth inhibition with cardiac glycosides but those sis (49). Another recent report has shown that oleandrin, bufalin,
tumor cell lines with high α3:α1 ratios are very sensitive (Figures digoxin, and digitoxin initiate apoptosis induced by Apo2L/TNF-
3 and 4). This finding, of course, also suggests that determination related apoptosis-inducing ligand (TRAIL) in non-small-cell lung
of the relative α3:α1 ratio in tumor biopsy specimens may have cancer cells by increasing the expression of death receptors 4 and
February 2008
Volume 8, Issue 1 43
Review
5 (18). Because Apo2L/TRAIL induces apoptosis in tumor cells Cardiac Glycosides and Cancer Prevention
with little if any toxicity to normal cells, this cytokine is of great
interest to cancer researchers. The selective cardenolide activation Recent investigations of potent cardiac glycosides have focused on
of death receptors may very well contribute to the observation their potential application to the treatment of established cancers;
that compounds such as oleandrin are relatively selective in their however, at least one report has suggested that there may also be
cytotoxic activity. a chemopreventive role for this class of agents. That is, Afaq et al.
Oleandrin elicits caspase-associated apoptosis in human have suggested that oleandrin might serve as an effective agent
prostate carcinoma cells (50). Interestingly, however, treatment of for the prevention or treatment of skin cancer (57). Their research
human PANC-1 pancreatic cancer cells produces clear hallmarks investigated the topical application of oleandrin to CD-1 mice to
of autophagy, including formation of autophagosome bodies with counteract the effects of TPA (12-0-tetradecanoylphorbol-13-ace-
damaged mitochondria and expression of light chain-1 protein, an tate), a widely used skin tumor promoter. The topical application
early indicator of autophagosome formation (51). Frese et al. have of TPA to mouse skin or its treatment in certain epidermal cells is
also suggested that the apoptotic potential of cardiac glycosides known to result in several biochemical alterations, changes in cel-
depends on the cell type treated (18). Our data on the differential lular functions, and histological changes leading to dermal tumor
effects of oleandrin on tumor cells, such as pancreatic vs prostate promotion. The data of Afaq et al. clearly show that application of
tumor cells, as compared to oleandrin-treated normal human cells oleandrin to skin prior to TPA administration affords significant
concurs with this. inhibition of TPA-induced skin edema, hyperplasia, epidermal
ornithine decarboxylase (ODC) activity, and protein expression of
Cardiac Glycosides and Estrogen ODC and cyclooxygenase-2 (COX-2), classical markers of inflam-
Receptor Interaction mation and tumor promotion. Their data also show that topical
application of oleandrin prior to TPA inhibits activation of PI3K
Selected cardiac glycosides may be of particular importance in the and phosphorylation of Akt, activation of NF-κB, and degradation
treatment of human breast cancer. Chen et al. (15) have recently and phosphorylation of the inhibitor of NF-κB α protein (IκBα).
suggested several reasons why cardenolides should be developed These authors, therefore, recommend the use of chemopreven-
as anti-breast cancer drugs. These include the facts that: 1) Na+,K+ tive agents (i.e., oleandrin) in formulations such as emollients or
-ATPase is a key player of cell adhesion and is involved in cancer patches for the prevention or treatment of skin cancer (57). This
progression; 2) the enzyme serves as a versatile signal transducer suggestion is all the more relevant when considered in light of our
involving a number of hormones, including estrogens; and 3) the own work which shows a potent ability of oleandrin to inhibit
aberrant expression and activity of this enzyme in breast cancer human melanoma proliferation (58).
implicates an etiologic or at least contributing role of Na+,K+-
ATPase in the development and progression of this malignant In Vivo Efficacy and Development of
disease. For example, there is now strong evidence that Na+,K+- Cardiac Glycosides for Clinical
ATPase plays an important role in the assembly of tight junctions Cancer Therapy
(TJs) and cell adhesion (52–55). Chen et al. convincingly argue
that altered expression and malfunction of Na+,K+-ATPase may Rodent tumor cells fail to respond to cardiac glycosides in vitro.
lead to abnormal TJ structure and, thus, to altered cell adhesion Similarly, it has been very difficult to demonstrate an in vivo
important in the progression of breast cancer. As mentioned pre- response of syngeneic rodent tumors to administration of this class
viously, there are also strong data supporting the role of Na+,K+- of compounds. However, as shown in Figure 4, there is no ques-
ATPase in a complex signalosome involved in transmitting mem- tion that human tumor cell lines are extremely sensitive to treat-
brane signals to the nucleus. ment with cardiac glycosides such as oleandrin and bufalin. Thus,
A series of reports suggests that estrogen receptor (ER) ligands it is possible that human tumor xenografts would respond. Indeed,
(e.g., 17β-estradiol and estrogen-like molecules) can also serve as this is exactly the case, as shown by several investigators. Han et
ligands of Na+,K+-ATPase. Use of 17β-estradiol enhances Na+,K+- al. (7), for example, explored the response of a human hepatocel-
ATPase activity (56) possibly through improvement of the interac- lular carcinoma cell line (BEL-7402) implanted orthotopically
tion of the enzyme with ATP as well as Na+ and K+ ions. Because (i.e., transplantation of cells or tissue into its normal anatomical
the interaction of 17β-estradiol with ERs serves as an important site) in liver tissue to intraperitoneal treatment with bufalin. They
determinant of breast cancer growth, and cardiac glycosides can found that this toad-derived cardiac glycoside produced significant
block this interaction, cardenolides could be considered effective reductions in tumor volumes and a prolongation in life-span of
modulators of estradiol-dependent breast cancer proliferation. the animals. Importantly, no adverse morphological changes were
noted in myocardial, hepatic, or renal tissues. Another interesting
report involved use of the semi-synthetic cardenolide UNBS-1450
against orthotopically implanted human non-small-cell lung cancer
44
Cardiac Glycosides as Novel Cancer Therapeutic Agents
BxPC3 PANC-1
shown, however, that single cardenolides, or those derived from
various extracts of plants and animals (Table 1), represent potent
ATPase-A3
February 2008
Volume 8, Issue 1 45
Review
11. Haux, J., Klepp, O., Spigset O., and Tretli, S. Digitoxin medication and
targeted, antiproliferative cardiac glycosides could be helped by cancer; case control and internal dose-response studies. BMC Cancer 1,
systematic evaluations of several formulations and chemical vari- 11 EPub (2001).
ants. Furthermore, assays of the relative presence of α1 and α3 12. Haux, J., Lam, J., Marthinsen, A.B.L., Strickert, T., and Lundgren, S.
Digitoxin, in non toxic concentrations induces cell death in Jurkat T cells
subunits in clinical samples, for example, may give some direction in vitro. Z. Onkol. 31, 14–20 (1999).
for the assessment of which cancers might be most susceptible 13. Stenkvist, B., Bengtsson, E., Eriksson, O., Holmquist, J., Nordin, B., and
to cardiac glycoside therapy. Further development of synthetic, Westman-Naeser, S. Cardiac glycosides and breast cancer. Lancet 10,
semi-synthetic, or naturally occurring cardiac glycosides, with 563 (1979)
assessment of their toxicity and structure-activity relationships, 14. Stenkvist, B. Is digitalis a therapy for breast cancer? Oncol. Rep. 6,
493–496 (1999).
might expand the possibilities of finding a cardiac glycoside with
15. Chen, J-Q., Contreras, R.G., Wang, R., Fernandez, S.V., Shoshani, L.,
a wider therapeutic index. Because of concerns with toxicity of Russo, I.H., Cereijido, M., and Russo, J. Sodium/potassium ATPase
internally used cardiac glycosides, topical formulations should (Na+,K+-ATPase) and ouabain/related cardiac glycosides: A new para-
digm for development of anti-breast cancer drugs? Breast Cancer Res.
also be considered for skin cancer prevention and/or treatment.
Treat. 96, 1–15 (2006).
Additionally, because chemotherapy has had limited benefits in 16. Nesher, M., Shpolansky, U., Rosen, H., and Lichstein, D. The digitalis-
most advanced malignancies, cardiac glycosides could also be like steroid hormones: New mechanisms of action and biological signifi-
investigated for possible adjuvant therapy. They may, for example, cance. Life Sci. 80, 2093–2107 (2007).
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at the College of Medicine at the University of Illinois, Chicago.
115. Glibert, M. and Knox, S. Influence of Bcl-2 overexpression on Na+,K+-
ATPase pump activity: Correlation with radiation-induced programmed In collaboration with the University of Illinois and other univer-
cell death. J. Cell Physiol. 171, 299–304 (1997). sity facilities in the US and Israel, Dr. Block conducts research in
116. Lopez-Lazaro, M. Digitoxin as an anticancer agent with selectivity for nutrition and in the use of natural medicines in cancer treatment.
cancer cells: Possible mechanisms involved. Expert Opin. Ther. Targets
11, 1043–1053 (2007).
117. Johansson, S., Lindholm, P., Gullbo, J., Larsson, R., Bohlim, L., and
Peiying Yang, PhD, (Collaborator)
Claeson, P. Cytotoxicity of digitoxin and related cardiac glycosides in is an Assistant professor in the
human tumor cells. Anticancer Drugs 12, 475–483 (2001). Department of Experimental
118. Bielawski, K., Winnicka, K., and Bielawska, A. Inhibition of DNA topoi- Therapeutics. Dr. Yang’s research
somerase I and II and growth inhibition of breast cancer MCF-7 cells by oua-
bain, digoxin and proscillaridin A. Biol. Pharm. Bull. 29, 1493–1497 (2006). has focused on bioactive lipids
119. Yang, Q., Huang, W., Jozwik, C. et al. Cardiac glycosides inhibit TNF- and natural products in cancer
alpha/NF-κB signaling by blocking recruitment of TNF receptor-associat- development and prevention. She
ed death domain to the TNF receptor. Proc. Natl. Acad. Sci. U.S.A. 102,
developed a rapid, specific, and
9631–9636 (2005).
120. Mijatovic, T., Matthieu, V., Gaussin, J.F., DeNeve, N., Ribaucour, F.,
sensitive method for simultaneous-
VanQuaquebeke, E., Dumont, P., Darro, F., and Kiss, R. Cardenolide- ly determination of arachidonate
induced lysosomal membrane permeabiliazation demonstrates thera- metabolites in various biological matrices. Additionally, Dr. Yang
peutic benefits in experimental human non-small cell lung cancers.
Neoplasia 8, 402–412 (2006).
is interested in the effects of nutritional supplements, such as fish
oil, and Chinese herbal medicine.
Robert A. Newman, PhD,
received his undergraduate train- Alison Pawlus, RPh, PhD, com-
ing at the University of Rhode pleted her graduate training, in
Island and graduate training at the 2007, in Pharmacognosy at the
University of Connecticut, where University of Illinois at Chicago in
he obtained MS and PhD degrees the laboratory of Dr. A. Douglas
in pharmacology and toxicology. Kinghorn. She is a Postdoctoral
His postgraduate work was per- Fellow in the Department of
formed at the Medical School of Experimental Therapeutics at the
Georgia and at the University of University of Texas, M.D. Anderson
Vermont Medical School. After a sabbatical at Stanford University Cancer Center where she studies
in 1983, Dr. Newman joined the faculty of the University of Texas the use of natural products for cancer treatment and prevention.
M.D. Anderson Cancer Center. He is a Professor of Experimental
Therapeutics and holds the D.B. Land Professorship. Dr. Newman
also jointly runs the Pharmacology and Analytical Core lab for the
institution as well as co-directs the Pharmaceutical Development
Center that has introduced more than six compounds into the
clinic over the past seven years. He is the author of over 250 peer-
reviewed publications and several books. His current research
deals with the science of nutraceuticals and understanding how
these can be specifically applied for prevention and treatment of
inflammation and malignant disease. E-mail rnewman@mdander-
son.org; fax (713) 563-9093.
February 2008
Volume 8, Issue 1 49