Thiotepa
Thiotepa, sold under the brand name Tepadina among others, is an anti-cancer medication.
Thiotepa is an organophosphorus compound with the formula 3PS.
History
Thiotepa and its synthesis were patented in 1952 by the American Cyanamid company. It was made for use in the textile industry and in the production process of plastics. However, thiotepa entered human trials in 1953 and was found to be effective against acute myeloid leukemia, chronic myelogenous leukemia, and Hodgkin's lymphoma. The first clinical trial noted a "reasonable margin for safety" between the apparent dose and undesired bone marrow suppressionIn January 2007, the European Medicines Agency designated thiotepa as an orphan drug. In April 2007, the United States FDA designated thiotepa as a conditioning treatment for use prior to hematopoietic stem cell transplantation.
In June 2024, the FDA approved a ready-to-dilute liquid formulation of thiotepa to treat breast and ovarian cancer.
Structure
Thiotepa consists of three aziridine rings, which are cyclic compounds containing two carbon atoms and one nitrogen atom, all bonded to a phosphine sulfide group. The phosphine sulfide acts as an activating group, activating the aziridine groups.Reactivity
Thiotepa is a reactive compound that, under acidic, neutral, or alkaline conditions, undergoes solvolysis, leading to potential side reactions such as polymerization and dimerization into piperazines. During acidic degradation, thiotepa reacts with chloride ions to produce monochloro, dichloro, and trichloro derivatives. Acidic conditions also result in the formation of tepa, the first identified and more reactive metabolite of thiotepa.In alkaline media, thiotepa undergoes degradation, though no detectable byproducts were identified. Like other aziridine-containing compounds, hydroxyl substitution reactions may release aziridine. This degradation pathway has also been reported for tepa. The stability of thiotepa in biological samples is dependent on pH. In plasma, the monochloro derivative of thiotepa is formed, while in urine, both monochloro and dichloro derivatives have been found. Thiotepa is most stable between pH 7 and 11. In plasma under physiological conditions, the compound has a half-life of five days, whereas in urine at 37 °C, the half-life is 16 minutes at pH 4 and 21 hours at pH 6.
Synthesis
Two separate syntheses of thiotepa have been described in literature. The most prevalent method involves the addition of an excess of aziridine to thiophosphoryl chloride in the presence of a base such as triethylamine and a suitable solvent. The first molecule of aziridine reacts with thiophosphoryl chloride to produce dichloridophosphorothionate, which is sufficiently reactive due to the poor overlap of the nitrogen lone pair with the P=S bond, allowing it to react with another two molecules of aziridineThiotepa has also been synthesized from phosphorus trichloride and six molar equivalents of aziridine. The trivalent triamide formed reacts with octasulfur in benzene.
Medical uses
Thiotepa is used in combination with other chemotherapy agents to treat cancer. It can be given with or without total body irradiation to prepare the body for allogeneic or autologous hematopoietic progenitor cell transplantation, which replaces damaged blood-forming cells with donor cells. This treatment is used in both adults and children for blood cancers such as Hodgkin lymphoma and leukemia. Thiotepa is also used with high-dose chemotherapy and HPCT support to treat certain solid tumors in adults and children.Thiotepa is used in palliative care for several types of cancer, including breast cancer, ovarian cancer, papillary thyroid cancer, and bladder cancer. It is also used to control intracavitary effusions caused by serosal neoplastic deposits, which refers to fluid buildup resulting from cancer spreading to the lining of body cavities.
In Japan, a widely used regimen consisting of high-dose thiotepa and melphalan, followed by autologous peripheral blood stem cell rescue, is used to treat high-risk neuroblastoma.
Administration
Thiotepa is mainly administered intravenously and intravesically. The administered dose regarding different types of cancer variates between 3 mg/kg/day to 13 mg/kg/day. Thiotepa is unreliably absorbed from the gastrointestinal tract: acid instability prevents thiotepa from being administered orally. Thiotepa is also used in the treatment of bladder cancer during this treatment thiotepa is used as intravesical chemotherapy. Thiotepa is frequently administered in combination with other chemotherapeutic agents such as busulfan and carboplatin.Clinical outcomes
In clinical trials the outcome of different types of treatment is compared to identify if a compound or regimen is favourable for the patient. The choice of treatment in the conditioning therapy can have a profound impact on progression-free survival, overall survival, relapse incidence and non-relapse mortality. The studies mentioned summarize key findings comparing various conditioning regimens.Studies on conditioning regimens for hematopoietic cell transplant in primary central nervous system lymphoma have shown that thiotepa based therapies thiotepa/busulfan/cyclophosphamide and thiotepa/carmustine improve progression-free survival of PCNSL compared to traditional therapies carmustine/etoposide/cytarabine/melphalan. Research also suggests that in BEAM if carmustine is exchanged for thiotepa no statistical difference was found in PFS, OS and RI. Furthermore, the capacity of thiotepa to pass the blood-brain barrier may allow optimizing the therapy for patients with Central Nervous System involvement of increased CNS relapse risk. Another study compared total body irradiation and thiotepa, busulfan and cyclophosphamide/fludarabine as a conditioning regiment of patients with acute lymphoblastic leukemia undergoing allogenic hematopoietic stem cell transplantation. No statistical difference was found in the overall survival but the RI was higher in the TBI regimen but the NRM was lower with TTB suggesting that TBB might be a viable alternative to TBI.
Metabolism
The metabolism of thiotepa primarily takes place in the liver, following both phase 1 and phase 2 metabolic pathways. Phase 1 involves reactions which change chemical moieties such as oxidation, reduction, and hydrolysis, while phase 2 includes the addition of endogenous groups to foreign compounds.Phase 1 metabolism of thiotepa is predominantly mediated by the cytochrome P450 enzyme system, major CYP2B6 and minor CYP3A4. In this phase an oxidation and desulfuration reactions convert thiotepa into its more active metabolite tepa. Tepa itself exhibits a longer plasma half-life than thiotepa and contributes to the overall pharmacological activity of the drug.
In phase 2 thiotepa is detoxified via the conjugation with glutathione by glutathione S-transferase. This is followed by the removal of the glutamyl and glycine moieties, and concludes with the N-acetylation of the cysteine conjugate by N-acetylase to form thiotepa-mercapturate. This derivative is more water-soluble, facilitating urinary excretion. Tepa is not conjugated to glutathione but reacts further in the urine and plasma to monochloro tepa. The conversion to a β-chloroethyl moiety depends on the pH and the chloride concentration. The formation of monochloride tepa mainly occurs in the urine.
Enzymes responsible for metabolising compounds can show varying efficiency in different individuals or populations, this is called polymorphism. In a study regarding thiotepa metabolism by Ekhart et al., it was found that glutathione S-transferase shows polymorphism. This variation resulted in some patients in slower glutathione conjugation and consequently, to a 45% increase in combined exposure to thiotepa and tepa.
The volume of distribution has been reported to range from 40,8 L/m2 to 75,0 L/m2. This high value is due to the highly lipophilic character of thiotepa and can therefore easily cross cell membranes and distribute into fatty tissues. In addition, thiotepa can easily cross the blood brain barrier and can rapidly penetrate the central nervous system. In plasma, 70 to 90% of the compound remains unbound to proteins, while the remaining 10–30% is primarily bound to gamma globulin, with minimal binding to albumin. Gamma globulin primarily functions as antibodies for the immune system, while albumin serves as a transport protein.
All metabolites are excreted in the urine, which is nearly complete in 6 to 8 hours, with tepa and thiotepa-mercapturate each accounting for approximately 11.1% of the excretion. In contrast, the excretion of monochloride tepa and thiotepa is significantly lower, at only 0.5% each. The total clearance of thiotepa ranged from 11,4 to 23,2 L/h/m2. The total excretion of thiotepa and its identified metabolites accounts for 54 to 100% of the total alkylating activity, suggesting the existence of other alkylating metabolites. During the conversion of glutathione conjugates into N-acetylcysteine conjugates, intermediates such as glutathione, cysteinyl glycine, and cysteine conjugates are formed. These metabolites are not detected in urine and, if formed, are likely excreted in bile or rapidly converted into thiotepa-mercapturate. Additionally, due to its high lipophilicity, thiotepa is excreted in minor amounts by the skin via sweat.