The antitumor activity of a lactosaminated albumin conjugate of doxorubicin in a chemically induced hepatocellular carcinoma rat model compared to sorafenib.

BACKGROUND: Worldwide, consistent survival benefit for chemotherapy in hepatocellular carcinoma (HCC) is a golden goal for concerned researchers. Nexavar® (sorafenib) is the only approved agent that achieved touchable successes in this regard. Thus, there is a pressing medical need for new promising drugs to improve HCC therapy. AIMS: our designed lactosaminated albumin conjugate of doxorubicin (L-HSA-DOXO) that rapidly and preferentially accumulates in the liver is compared, for the first time at its MTD, with doxorubicin and sorafenib, not only for antitumor efficacy but also for overall survival. METHODS: HCC was induced in male Wistar rats with N-nitrosodiethylamine added to drinking water (100mg/L) for 8 weeks. Endpoints were antitumor efficacy, tolerability and overall survival. RESULTS: L-HSA-DOXO proved to be superior at least over doxorubicin in the majority of assessed endpoints. Circulating AFP-L3% was diminished in L-HSA-DOXO (14.5%) and sorafenib (18.4%) groups compared to DENA (31.1%) and doxorubicin (29.5%) groups. This superiority was further confirmed by Western blot analyses of some novel HCC biomarkers. Survival study reinforced consistent benefits of both L-HSA-DOXO and sorafenib. CONCLUSIONS: L-HSA-DOXO shows at least comparable activity to sorafenib which clinically achieves only ∼3 months overall survival benefit. Combination of these two agents could act beneficially or synergistically via two different modes of action to fight HCC.

Evaluation of combination therapy schedules of doxorubicin and an acid-sensitive albumin-binding prodrug of doxorubicin in the MIA PaCa-2 pancreatic xenograft model.

In this work, we evaluated combinations of doxorubicin with INNO-206, a (6-maleimidocaproyl)hydrazone derivative of doxorubicin (DOXO-EMCH) that is currently undergoing two phase II clinical trials, in a primarily chemoresistant tumor indication, i.e. pancreatic cancer. Thus, we compared the antitumor efficacy and tolerability of the following weekly intravenous treatments in the MIA PaCa-2 xenograft model: 3×6 mg doxorubicin (MTD), 3×24 mg/kg DOXO-EMCH (doxorubicin equivalents, MTD), 3×3 mg/kg doxorubicin followed 6h later by 3×12 mg/kg DOXO-EMCH, and 3×12 mg/kg DOXO-EMCH followed 6 h later by 3×3 mg/kg doxorubicin. Whereas therapy with doxorubicin only produced a moderate tumor inhibition, all other therapy arms induced complete and partial remissions up to the end of the experiment on day 43. Although the total amount of doxorubicin equivalents is 72 mg/kg when DOXO-EMCH is administered alone, but only 45 mg/kg doxorubicin equivalents are administered in the combination regimens, the antitumor efficacy in all treated groups was essentially identical, a surprising finding of this study. However, there were significant differences in the tolerability as assessed by the body weight changes: whereas therapy at the MTD of DOXO-EMCH (3×24 mg/kg) produced a body weight loss of -16% including one death, therapy with 3×12 mg/kg DOXO-EMCH followed 6h later by 3×3 mg/kg doxorubicin produced -7% body weight loss, and 3×3 mg/kg doxorubicin followed 6h later by 3×12 mg/kg DOXO-EMCH produced a body weight gain of +2% as a clear indication of minimal systemic toxicity. In addition, cell culture experiments revealed additive to synergistic effects when MIA PaCa-2 cells were exposed to doxorubicin followed 6h later to exposure of the albumin-bound form of DOXO-EMCH spanning a ratio of 1:5 to 5:1 (analyzed for synergistic, additive or antagonistic effects using the software program CalcuSyn(®)). This animal study demonstrates that the time-dependent schedule of an albumin-binding prodrug and a free drug has a critical influence on the overall tolerability. A combination of doxorubicin and DOXO-EMCH is currently being investigated in a phase Ib study.

Finding the optimal balance: challenges of improving conventional cancer chemotherapy using suitable combinations with nano-sized drug delivery systems.

Anticancer drugs as well as nano-sized drug delivery systems face many barriers that hinder penetration deeply and evenly into solid tumors: a chaotic, tortuous vascular compartment resulting in tumor tissue distant from microvessels, a heterogeneous blood flow distribution with a concomitant defective microcirculatory exchange process, and a high interstitial fluid pressure. Furthermore, a resulting hostile tumor microenvironment characterized by hypoxia and/or extracellular acidosis can reduce the efficacy of anticancer drugs and confer drug resistance. Conversely, the enhanced permeation and retention effect has become the gold standard for developing macromolecular prodrugs and nano-sized drug delivery systems. Preclinically, there are meanwhile numerous in vivo proof-of-concepts that demonstrate not only a better tolerability of nano-sized drug delivery systems but also of enhanced antitumor efficacy compared to the conventional clinical standard. When faced with such a complex and heterogeneous disease as cancer in humans, it is more likely that a tailor-made combination of different therapeutic strategies will achieve the best results. In this respect, combining low-molecular weight cytostatic drugs with nano-sized drug delivery systems appears to be a natural choice for combination therapy that aims at distributing anticancer drugs at higher concentrations in the tumor in a more even manner. To date, such drug delivery approaches have been inadequately explored. In this review, we summarize the state-of-the-art of combination approaches with liposomal doxorubicin (Doxil™), the paclitaxel-albumin nanoparticle (Abraxane™) and the albumin-binding doxorubicin prodrug DOXO-EMCH (INNO-206), and discuss the insights obtained and perspectives for further research in this intriguing and promising field of drug delivery research.

Development of a novel prodrug of paclitaxel that is cleaved by prostate-specific antigen: an in vitro and in vivo evaluation study.

In developed countries, prostate cancer is the third most common cause of death from cancer in men. Unfortunately, whilst accumulating clinical data have suggested that taxanes may prolong the survival in a subset of men with prostate carcinoma, the dose and duration of administration of these drugs are limited by their significant systemic toxicities due to a lack of tumour selectivity. In an attempt to improve both the water solubility and tumour-targeting properties of paclitaxel (Taxol®), we set out to develop a water soluble paclitaxel prodrug that is activated specifically by prostate-specific antigen (PSA) which is almost exclusively expressed in prostate tissue and prostate carcinoma making it an ideal molecular target for prodrug strategies. Using albumin as a drug carrier, we describe a novel albumin-binding prodrug of paclitaxel, EMC-Arg-Ser-Ser-Tyr-Tyr-Ser-Leu-PABC-paclitaxel [EMC: ε-maleimidocaproyl; PABC: p-aminobenzyloxycarbonyl] that was synthesised by reacting EMC-Arg-Ser-Ser-Tyr-Tyr-Ser-OH with H-Leu-PABC-paclitaxel. This prodrug was water soluble and was bound to endogenous and exogenous albumin. Moreover, incubation studies with PSA demonstrated that the albumin-bound form of the prodrug was cleaved rapidly at the P1-P1' scissile bond releasing the paclitaxel-dipeptide H-Ser-Leu-PABC-paclitaxel. Last but not least, due to the incorporation of a PABC self-eliminating linker, this dipeptide was rapidly degraded to liberate paclitaxel as a final cleavage product within a few hours in prostate tumour tissue homogenates. Of note was that the albumin-bound form of the prodrug was approximately three-fold more active in killing PSA-positive LNCaP cells than paclitaxel. In addition, orientating toxicity studies in mice showed that the maximum tolerated dose of the novel paclitaxel prodrug was twice that of conventional paclitaxel. When tested in vivo in an orthotopic mouse model of human prostate cancer using luciferase-transduced LNCaP LLN cells, both paclitaxel and the new paclitaxel prodrug showed distinct antitumour efficacy on the primary tumour and metastases that was significantly better than the effect of doxorubicin which was used as a comparison and showed no antitumour efficacy. The new paclitaxel prodrug (3 × 24 mg paclitaxel equivalents) showed comparable antitumour activity on the primary tumour to paclitaxel at its maximum-tolerated dose (3 × 12mg/kg), reduced circulating PSA levels and demonstrated a better antitumour effect on lung metastases but not on bone metastases.

Optimization of an albumin-binding prodrug of Doxorubicin that is cleaved by prostate-specific antigen.

We have developed a novel albumin-binding prodrug of doxorubicin that incorporates p-aminobenzyloxycarbonyl (PABC) as a 1,6 self-immolative spacer in addition to the heptapeptide, Arg-Ser-Ser-Tyr-Tyr-Ser-Leu, as a substrate for the prostate-specific antigen (PSA) that is overexpressed in prostate carcinoma and represents a molecular target for selectively releasing an anticancer agent from a prodrug formulation. The prodrug exhibited good water solubility and was bound rapidly to the cysteine-34 position of human serum albumin. Incubation studies with PSA demonstrated that the albumin-bound form of the prodrug was cleaved rapidly at the P1-P1' scissile bond, releasing H-Ser-Leu-PABC-DOXO, which was further degraded to release doxorubicin as a final cleavage product within a few hours in prostate tumor tissue homogenates as well as in PSA-positive LNCaP LN cell lysates. Moreover, our prodrug exhibited antiproliferative activity in a low micromolar range against a PSA-expressing prostate cancer cell line (LNCaP).

Development of pH-responsive core-shell nanocarriers for delivery of therapeutic and diagnostic agents.

In this paper new dendritic core-shell architectures with pH-labile linkers based on hyperbranched polyglycerol cores and biocompatible poly(ethylene glycol) shells were synthesized which encapsulate the anticancer agent doxorubicin and a dye for near-infrared imaging, an indotricarbocyanine. Acid-sensitive properties of the new nanocarriers and in vitro cytotoxicity of the doxorubicin-nanocarrier are presented as well as preliminary data regarding their toxicity and tumor targeting potential in nude mice.

Cellular accumulation and cytotoxicity of macromolecular platinum complexes in cisplatin-resistant tumor cells.

The development of resistance is one of the major limitations for the use of platinum (Pt) complexes in cancer chemotherapy. As reduced cellular uptake is a well-known resistance mechanism of cisplatin we explored the potential to overcome resistance in cisplatin-resistant A2780 ovarian carcinoma cells by means of macromolecular prodrugs exploiting endocytosis as alternative uptake mechanism. Two Pt-albumin (PL04-HSA, PL07-HSA) complexes and one Pt-polyethylene glycol complex (PEG(10k)-(Mal-Pt-DACH)(2)) were investigated. Intracellular platinum accumulation was quantified by FAAS. Cytotoxic activity was measured using the MTT assay. Endocytosis mechanisms were investigated by co-incubation experiments with bafilomycin A(1) and methyl-beta-cyclodextrin, inhibitors of the clathrin-mediated and caveolae-mediated endocytosis, respectively. Whereas the intracellular accumulation of the low molecular precursors PL04 and PL07 was reduced in the resistant cell variant, no difference between sensitive and resistant cells was observed for the three macromolecular complexes. In the presence of bafilomycin A(1) intracellular accumulation of all investigated macromolecular complexes was decreased whereas methyl-beta-cyclodextrin only affected the Pt-PEG complex. The Pt-PEG complex exhibited a higher cytotoxic activity than the albumin conjugates but also showed cross-resistance with cisplatin. In conclusion, cellular accumulation of macromolecular platinum complexes is not altered in cisplatin-resistant A2780 cells as these complexes enter the cells mainly via endocytotic pathways. Macromolecular platinum complexes specially designed to circumvent reduced cellular accumulation may be a promising approach to overcome cisplatin resistance.

2,4-Bis(hydroxymethyl)aniline as a building block for oligomers with self-eliminating and multiple release properties.

Linear self-eliminating (LSE) systems are oligomers of branched self-eliminating linkers that disassemble upon a single triggering event under complete degradation of the linear backbone, accompanied by the release of side-chain bound effector molecules. Enabling a controlled and almost simultaneous release of different effectors (drugs) in defined ratios, LSE systems may gain importance for the development of novel combination therapeutics. On the basis of the well-known self-eliminating p-aminobenzyloxycarbonyl (PABC) linker, 2,4-bis(hydroxymethyl)aniline was considered a suitable branched linker for building LSE systems that degrade by 1,6- and 1,4-benzyl elimination reactions. A first LSE model system based on this linker was prepared in a simple procedure and was shown to release its effector payload efficiently after activation. In addition, elimination model compounds were synthesized to study the release behavior of LSE systems based on 2,4-bis(hydroxymethyl)aniline. It was found that chain degrading 1,6-benzyl elimination occurs much faster than the effector releasing 1,4-elimination.

Prodrug strategies in anticancer chemotherapy.

The majority of clinically approved anticancer drugs are characterized by a narrow therapeutic window that results mainly from a high systemic toxicity of the drugs in combination with an evident lack of tumor selectivity. Besides the development of suitable galenic formulations such as liposomes or micelles, several promising prodrug approaches have been followed in the last decades with the aim of improving chemotherapy. In this review we elucidate the two main concepts that underlie the design of most anticancer prodrugs: drug targeting and controlled release of the drug at the tumor site. Consequently, active and passive targeting using tumor-specific ligands or macromolecular carriers are discussed as well as release strategies that are based on tumor-specific characteristics such as low pH or the expression of tumor-associated enzymes. Furthermore, other strategies such as ADEPT (antibody-directed enzyme prodrug therapy) and the design of self-eliminating structures are introduced. Chemical realization of prodrug approaches is illustrated by drug candidates that have or may have clinical importance.

Development of albumin-binding camptothecin prodrugs using a Peptide positional scanning library.

Designing truly tumor-specific prodrugs remains a challenge in the field of cancer chemotherapy. As a new strategy, we incubated homogenates of a spectrum of human colon tumor xenografts with a fluorogenic positional scanning tetrapeptide library in order to identify peptide sequences that are preferentially cleaved by colon tumors. Our screening experiments at pH 7.4 revealed that Met, Leu, and Lys were preferred amino acids in the position P(1) and Tyr, Phe, and Met in P(2), whereas in P(3) and P(4), the cleavage profiles were less characteristic. However, similar results were obtained when testing breast tumor material and homogenates from healthy murine organs. On the basis of these results, we developed albumin-binding camptothecin (CPT) prodrugs of the general formula EMC-Arg-P(4)-P(3)-P(2)-P(1)-Ala-CPT (EMC = 6-maleimidocaproic acid) that incorporated two peptide linkers: H-Arg-Ala-Phe-Met-OH and H-Arg-Phe-Tyr-Met-OH (P(4)-P(3)-P(2)-P(1)). The incorporation of two arginine residues rendered the prodrugs water-soluble (>7 mg/mL), while the use of alanine as an amino acid spacer proved to be beneficial for the release of the active agent. Incubation studies with homogenates of HT-29 colon tumor tissue and murine spleen, liver, and kidneys demonstrated cleavage of the peptide linker with CPT-peptide derivatives and CPT being the major cleavage products. Although the peptide sequence is not selectively cleaved in colon tumors, an in vivo study in a HT-29 xenograft model showed that the prodrug EMC-Arg-Arg-Ala-Phe-Met-Ala-CPT demonstrated enhanced antitumor efficacy when compared to CPT [( T/ C max: 17% for the prodrug (2 x 12.5 mg/kg CPT equivalents) and 40% for CPT (3 x 12.5 mg/kg)].

Synthesis, cleavage profile, and antitumor efficacy of an albumin-binding prodrug of methotrexate that is cleaved by plasmin and cathepsin B.

Cathepsin B and plasmin are intra- or extracellular proteases that are overexpressed by several solid tumors. In order to exploit both proteases as molecular targets for tumor-specific cleavage of prodrugs, an albumin-binding formulation of methotrexate was developed that incorporated the peptide sequence D-Ala-Phe-Lys as the protease substrate. Albumin is a suitable carrier for cytostatic agents due to passive accumulation in solid tumors. Synthesis was performed by coupling the peptide linker EMC-D-Ala-Phe-Lys(Boc)-Lys-OH (EMC = epsilon-maleimidocaproic acid) to the gamma-COOH group of alpha-tert-butyl protected methotrexate. After cleavage of the protective groups and purification on reverse phase HPLC, a highly water-soluble methotrexate-peptide derivative was obtained that binds rapidly and selectively to human serum albumin. The albumin-bound form of the prodrug was shown to be efficiently cleaved by cathepsin B and plasmin as well as in an ovarian carcinoma homogenate (OVCAR-3) liberating a methotrexate-lysine derivative. In an OVCAR-3 xenograft model, the prodrug at a dose of 4x15 mg/kg methotrexate equivalents demonstrated distinctly superior antitumor efficacy compared to free methotrexate at a dose of 4x100 mg/kg [T/C(%) for MTX = 69; T/C(%) for MTX prodrug = 29]. The data provide a further proof of concept for the development of albumin-binding, enzymatically cleavable prodrugs of anticancer drugs.

Anticancer carrier-linked prodrugs in clinical trials.

Coupling of low molecular weight anticancer drugs to antibodies, serum proteins or polymers through a cleavable linker has been an effective method for improving the therapeutic index of cytotoxic established agents. Modern drug-antibody conjugates that have recently entered clinical trials have primarily used highly potent drugs such as calicheamicin or maytansins. Gemtuzumab ozogamicin, a conjugate of calicheamicin and an anti-CD33 humanized antibody, is the first drug-antibody conjugate to receive market approval. Drug conjugates that have undergone clinical assessment include N-(2-hydroxypropyl)methacrylamide (HPMA) copolymer conjugates with doxorubicin, camptothecin, paclitaxel and Pt(II) complexes, poly(ethylene glycol) conjugates with camptothecin and paclitaxel, polyglutamate conjugates with paclitaxel and camptothecin, a methotrexate-albumin conjugate and an albumin-binding doxorubicin prodrug. This review summarizes the Phase I-III studies that have been performed with these macromolecular prodrugs.

Albumin-binding prodrugs of camptothecin and doxorubicin with an Ala-Leu-Ala-Leu-linker that are cleaved by cathepsin B: synthesis and antitumor efficacy.

We have recently validated a macromolecular prodrug strategy for improved cancer chemotherapy based on two features: (a) rapid and selective binding of thiol-reactive prodrugs to the cysteine-34 position of endogenous albumin and (b) acid-sensitive promoted or enzymatic release of the drug at the tumor site [Kratz, F., Warnecke, A., Scheuemann, K., Stockmar, C., Schwab, J., Lazar, P., Druckes, P., Esser, N., Drevs, J., Rognan, D., Bissantz, C., Hinderling, C., Folkers, G., Fichtner, I., and Unger, C. (2002) J. Med. Chem. 45, 5523-33]. In the present work, we developed water-soluble camptothecin (CPT) and doxorubicin (DOXO) prodrugs that incorporate the peptide linker Ala-Leu-Ala-Leu that serves as a substrate for the tumor-associated protease, cathepsin B, which is overexpressed in several solid tumors. Consequently, two albumin-binding prodrugs were synthesized [EMC-Arg-Arg-Ala-Leu-Ala-Leu-Ala-CPT (1) and EMC-Arg-Arg-Ala-Leu-Ala-Leu-DOXO (2) (EMC = 6-maleimidocaproic acid)]. Both prodrugs exhibited excellent water-solubility and bound rapidly and selectively to the cysteine-34 position of endogenous albumin. Further in vitro studies showed that the albumin-bound form of the prodrugs was cleaved specifically by cathepsin B as well as in human tumor homogenates. Major cleavage products were CPT-peptide derivatives and CPT for the CPT prodrug and H-Leu-Ala-Leu-DOXO, H-Leu-DOXO, and DOXO for the doxorubicin prodrug. In vivo, 1 was superior to free camptothecin in an HT-29 human colon xenograft model; the antitumor efficacy of prodrug 2 was comparable to that of free doxorubicin in the M-3366 mamma carcinoma xenograft model at equimolar doses.

Development of albumin-binding doxorubicin prodrugs that are cleaved by prostate-specific antigen.

Prostate-specific antigen (PSA) is a serine protease that is overexpressed in prostate carcinoma and represents a molecular target for selectively releasing an anticancer agent from a prodrug formulation. In this work, we developed albumin-binding prodrugs with the structures MT-Ser-Ser-Tyr-Tyr- Ser-Gly-DOXO, MT-Asn-Ser-Ser-Tyr-Phe-Gln-DOXO (MT = maleimidotriethyleneglycol acid; DOXO = Doxorubicin) or EMC-Arg-Arg-Ser-Ser-Tyr-Tyr-Ser-Gly-DOXO (EMC = epsilon-maleimidocaproic acid; X = amino acid). The maleimide Doxorubicin derivatives bound rapidly to the cysteine-34 position of endogenous and exogenous albumin and were efficiently cleaved by PSA at the P(1)-P'(1) scissile bond, releasing a respective Doxorubicin dipeptide (Ser-Gly-DOXO or Phe-Gln-DOXO). The derivative containing arginine residues (EMC-Arg-Arg-Ser-Ser-Tyr-Tyr-Ser-Gly-DOXO) exhibited excellent water solubility for intravenous administration. Subsequent biological evaluation was focused on a PSA-negative xenograft model (PC 3) and a PSA-positive xenograft model (CWR22) in order to assess the selectivity of our therapeutic approach. EMC-Arg-Arg-Ser-Ser-Tyr-Tyr-Ser-Gly-DOXO showed no in vivo activity in the PSA-negative PC 3 model, but good activity in the CWR22 PSA-positive model that was comparable to Doxorubicin.

Synthesis and biological activity of water-soluble maleimide derivatives of the anticancer drug carboplatin designed as albumin-binding prodrugs.

Four platinum (II) complexes (13-16) were synthesized by reacting either [Pt trans-DACH](NO(3))(2) with a 6-maleimidocaproic acid, a 15-maleimido-4,7,10,13-tetroxapentadecanoic acid, and a 6-maleimido-4-oxacaproic ester derivative of cyclobutane-1,1-dicarboxylic acid (CDBA) or [Pt(NH(3))(2)](NO(3))(2) with a 6-maleimido-4-oxacaproic ester derivative of CBDA. Both complexes containing the 6-maleimido-4-oxacaproic ester (15, 16) showed good water solubility (>/=8 mg/mL) and CE experiments revealed rapid binding to human serum albumin and the formation of biadducts with dGMP and dAMP. In the MaTu xenograft model in nude mice, both complexes showed an improved antitumor effect at their maximum tolerated dose (2 x 50 mg/kg carboplatin equivalents) compared to therapy with carboplatin at equimolar dose or at its optimal dose (2 x 75 mg/kg).

Maleimide-oligo(ethylene glycol) derivatives of camptothecin as albumin-binding prodrugs: synthesis and antitumor efficacy.

In situ binding of thiol-reactive prodrugs to the cysteine-34 position of circulating albumin is a new approach in drug delivery. Therefore, five maleimide-bearing derivatives of the anticancer drug camptothecin (CPT) were developed as albumin-binding prodrugs. These compounds were synthesized by reacting heterobifunctional cross-linkers based on oligo(ethylene glycols) [3-6 (O-CH(2)-CH(2)) units] bearing a maleimide group on one end and a carboxylic acid group on the other with camptothecin 20-O-glycinate. Incorporating oligo(ethylene glycol) chains into the prodrugs enhanced their water-solubility when compared to the parent compound (up to 27-fold). HPLC studies showed that the prodrugs react almost quantitatively with the cysteine-34 position of endogenous albumin within a few minutes after incubation of the CPT derivatives with human blood plasma. The therapeutic potential of two of the prodrugs was assessed in nude mice bearing a colon xenograft (HT-29). Both albumin-binding derivatives of camptothecin were well-tolerated and showed enhanced antitumor efficacy when compared to CPT.

Probing the cysteine-34 position of endogenous serum albumin with thiol-binding doxorubicin derivatives. Improved efficacy of an acid-sensitive doxorubicin derivative with specific albumin-binding properties compared to that of the parent compound.

We have recently proposed a macromolecular prodrug strategy for improved cancer chemotherapy based on two features (Kratz, F.; et al. J. Med. Chem 2000, 43, 1253-1256.): (a) rapid and selective binding of thiol-reactive prodrugs to the cysteine-34 position of endogenous albumin after intravenous administration and (b) release of the albumin-bound drug in the acidic environment at the tumor site due to the incorporation of an acid-sensitive bond between the drug and the carrier. To investigate this therapeutic strategy in greater depth, four (maleinimidoalkanoyl)hydrazone derivatives of doxorubicin were synthesized differing in the length of the aliphatic spacer (1, -(CH(2))(2)-; 2, -(CH(2))(3)-; 3, -(CH(2))(5)-; 4, -(CH(2))(7)-). The albumin-binding doxorubicin prodrugs, especially the (6-maleimidocaproyl)hydrazone derivative of doxorubicin (3), are rapidly and selectively bound to the cysteine-34 position of endogenous albumin. 3 was distinctly superior to the parent compound doxorubicin in three animal tumor models (RENCA, MDA-MB 435, and MCF-7) with respect to antitumor efficacy and toxicity.