Cyclophosphamide remains one of the most successful and widely utilized antineoplastic drugs. Moreover, it is also a potent immunosuppressive agent and the most commonly used drug in blood and marrow transplantation (BMT). It was initially synthesized to selectively target cancer cells, although the hypothesized mechanism of tumor specificity (activation by cancer cell phosphamidases) transpired to be irrelevant to its activity. Nevertheless, cyclophosphamide's unique metabolism and inactivation by aldehyde dehydrogenase is responsible for its distinct cytotoxic properties. Differential cellular expression of aldehyde dehydrogenase has an effect on the anticancer therapeutic index and immunosuppressive properties of cyclophosphamide. This Review highlights the chemistry, pharmacology, clinical toxic effects and current clinical applications of cyclophosphamide in cancer and autoimmune disorders. We also discuss the development of high-dose cyclophosphamide for BMT and the treatment of autoimmune diseases.
Cyclophosphamide is an inactive prodrug that requires enzymatic and chemical activation; the resultant nitrogen mustard produces the interstrand and intrastrand DNA crosslinks that account for its cytotoxic properties
The major mechanism of cyclophosphamide detoxification involves aldehyde dehydrogenase; cells with high proliferative potential express high levels of aldehyde dehydrogenase and as a consequence are relatively resistant to cyclophosphamide
Cyclophosphamide, in combination with other antineoplastic agents, is used for the treatment of various cancers, including breast, lymphoid and pediatric malignancies
Cyclophosphamide is also widely used in bone marrow transplantation 'conditioning' and 'mobilization' regimens, and for the treatment of different autoimmune conditions
The toxic effects of cyclophosphamide include bone marrow suppression, cardiac and gonadal toxicity, hemorrhagic cystitis and carcinogenesis, with cumulative dose being the principal risk factor
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Brock, N. & Wilmanns, H. Effect of a cyclic nitrogen mustard-phosphamidester on experimentally induced tumors in rats; chemotherapeutic effect and pharmacological properties of B518 ASTA [German]. Dtsch. Med. Wochenschr. 83, 453–458 (1958).
Gross, R. & Wulf, G. Klinische und experimentelle Erfahrungen mit zyk lischen und nichtzyklischen Phosphamidestern des N-Losl in der Chemotherapie von Tumoren [German]. Strahlentherapie 41, 361–367 (1959).
Friedman, O. M. & Seligman, A. M. Preparation of N-phosphorylated derivatives of bis-P-chloroethylamine. J. Amer. Chem. Soc. 76, 655–658 (1954).
Arnold, H., Bourseaux, F. & Brock, N. Chemotherapeutic action of a cyclic nitrogen mustard phosphamide ester (B 518-ASTA) in experimental tumours of the rat. Nature 181, 931 (1958).
Dong, Q. et al. A structural basis for a phosphoramide mustard-induced DNA interstrand cross-link at 5'-d(GAC). Proc. Natl Acad. Sci. USA 92, 12170–12174 (1995).
Boddy, A. V. & Yule, S. M. Metabolism and pharmacokinetics of oxazaphosphorines. Clin. Pharmacokinet. 38, 291–304 (2000).
Chen, T. L. et al. Nonlinear pharmacokinetics of cyclophosphamide and 4-hydroxycyclophosphamide/aldophosphamide in patients with metastatic breast cancer receiving high-dose chemotherapy followed by autologous bone marrow transplantation. Drug Metab. Dispos. 25, 544–551 (1997).
Silverman, R. B. The Organic Chemistry of Enzyme-catalyzed Reactions (Academic Press, 2002).
Russo, J. E., Hilton, J. & Colvin, O. M. The role of aldehyde dehydrogenase isozymes in cellular resistance to the alkylating agent cyclophosphamide. Prog. Clin. Biol. Res. 290, 65–79 (1989).
Joqueviel, C. et al. Urinary excretion of cyclophosphamide in humans, determined by phosphorus-31 nuclear magnetic resonance spectroscopy. Drug Metab. Dispos. 26, 418–428 (1998).
Duester, G. Genetic dissection of retinoid dehydrogenases. Chem. Biol. Interact. 130–132, 469–480 (2001).
Sladek, N. E., Kollander, R., Sreerama, L. & Kiang, D. T. Cellular levels of aldehyde dehydrogenases (ALDH1A1 and ALDH3A1) as predictors of therapeutic responses to cyclophosphamide-based chemotherapy of breast cancer: a retrospective study. Rational individualization of oxazaphosphorine-based cancer chemotherapeutic regimens. Cancer Chemother. Pharmacol. 49, 309–321 (2002).
Jones, R. J. et al. Assessment of aldehyde dehydrogenase in viable cells. Blood 85, 2742–2746 (1995).
Gordon, M. Y., Goldman, J. M. & Gordon-Smith, E. C. 4-Hydroperoxycyclophosphamide inhibits proliferation by human granulocyte-macrophage colony-forming cells (GM-CFC) but spares more primitive progenitor cells. Leuk. Res. 9, 1017–1021 (1985).
Ozer, H., Cowens, J. W., Colvin, M., Nussbaum-Blumenson, A. & Sheedy, D. In vitro effects of 4-hydroperoxycyclophosphamide on human immunoregulatory T subset function. I. Selective effects on lymphocyte function in T–B cell collaboration. J. Exp. Med. 155, 276–290 (1982).
Santos, G. W. et al. The use of cyclophosphamide for clinical marrow transplantation. Transplant. Proc. 4, 559–564 (1972).
Sharkis, S. J., Santos, G. W. & Colvin, M. Elimination of acute myelogenous leukemic cells from marrow and tumor suspensions in the rat with 4-hydroperoxycyclophosphamide. Blood 55, 521–523 (1980).
Jones, R. J. Purging with 4-hydroperoxycyclophosphamide. J. Hematother. 1, 343–348 (1992).
Sladek, N. E. Leukemic cell insensitivity to cyclophosphamide and other oxazaphosphorines mediated by aldehyde dehydrogenase(s). Cancer Treat. Res. 112, 161–175 (2002).
Tanner, B. et al. Glutathione, glutathione S-transferase alpha and pi, and aldehyde dehydrogenase content in relationship to drug resistance in ovarian cancer. Gynecol. Oncol. 65, 54–62 (1997).
Banker, D. E., Groudine, M., Norwood, T. & Appelbaum, F. R. Measurement of spontaneous and therapeutic agent-induced apoptosis with BCL-2 protein expression in acute myeloid leukemia. Blood 89, 243–255 (1997).
Zhang, J., Tian, Q., Chan, S. Y., Duan, W. & Zhou, S. Insights into oxazaphosphorine resistance and possible approaches to its circumvention. Drug Resist. Updat. 8, 271–297 (2005).
Ayash, L. J. et al. Cyclophosphamide pharmacokinetics: correlation with cardiac toxicity and tumor response. J. Clin. Oncol. 10, 995–1000 (1992).
Slattery, J. T. et al. Conditioning regimen-dependent disposition of cyclophosphamide and hydroxycyclophosphamide in human marrow transplantation patients. J. Clin. Oncol. 14, 1484–1494 (1996).
Nieto, Y. et al. Nonpredictable pharmacokinetic behavior of high-dose cyclophosphamide in combination with cisplatin and 1,3-bis(2-chloroethyl)-1-nitrosourea. Clin. Cancer Res. 5, 747–751 (1999).
Anderson, L. W. et al. Cyclophosphamide and 4-hydroxycyclophosphamide/aldophosphamide kinetics in patients receiving high-dose cyclophosphamide chemotherapy. Clin. Cancer Res. 2, 1481–1487 (1996).
Chen, T. L. et al. Nonlinear pharmacokinetics of cyclophosphamide in patients with metastatic breast cancer receiving high-dose chemotherapy followed by autologous bone marrow transplantation. Cancer Res. 55, 810–816 (1995).
Busse, D. et al. Dose escalation of cyclophosphamide in patients with breast cancer: consequences for pharmacokinetics and metabolism. J. Clin. Oncol. 15, 1885–1896 (1997).
Forrester, L. M. et al. Relative expression of cytochrome P450 isoenzymes in human liver and association with the metabolism of drugs and xenobiotics. Biochem. J. 281, 359–368 (1992).
Gilbert, C. J. et al. Pharmacokinetic interaction between ondansetron and cyclophosphamide during high-dose chemotherapy for breast cancer. Cancer Chemother. Pharmacol. 42, 497–503 (1998).
Williams, M. L. et al. Enantioselective induction of cyclophosphamide metabolism by phenytoin. Chirality 11, 569–574 (1999).
Deeg, H. J. et al. Marrow graft rejection and veno-occlusive disease of the liver in patients with aplastic anemia conditioned with cyclophosphamide and cyclosporine. Transplantation 42, 497–501 (1986).
Hassan, M. et al. The effect of busulphan on the pharmacokinetics of cyclophosphamide and its 4-hydroxy metabolite: time interval influence on therapeutic efficacy and therapy-related toxicity. Bone Marrow Transplant. 25, 915–924 (2000).
Chang, T. K., Yu, L., Maurel, P. & Waxman, D. J. Enhanced cyclophosphamide and ifosfamide activation in primary human hepatocyte cultures: response to cytochrome P-450 inducers and autoinduction by oxazaphosphorines. Cancer Res. 57, 1946–1954 (1997).
Tosi, P. et al. Safety of autologous hematopoietic stem cell transplantation in patients with multiple myeloma and chronic renal failure. Leukemia 14, 1310–1313 (2000).
Haubitz, M. et al. Cyclophosphamide pharmacokinetics and dose requirements in patients with renal insufficiency. Kidney Int. 61, 1495–1501 (2002).
Brodsky, R. A., Chen, A. R., Brodsky, I. & Jones, R. J. High-dose cyclophosphamide as salvage therapy for severe aplastic anemia. Exp. Hematol. 32, 435–440 (2004).
Dussan, K. B., Magder, L., Brodsky, R. A., Jones, R. J. & Petri, M. High dose cyclophosphamide performs better than monthly dose cyclophosphamide in quality of life measures. Lupus 17, 1079–1085 (2008).
Murdych, T. & Weisdorf, D. J. Serious cardiac complications during bone marrow transplantation at the University of Minnesota, 1977–1997. Bone Marrow Transplant. 28, 283–287 (2001).
Cazin, B. et al. Cardiac complications after bone marrow transplantation. A report on a series of 63 consecutive transplantations. Cancer 57, 2061–2069 (1986).
Hertenstein, B. et al. Cardiac toxicity of bone marrow transplantation: predictive value of cardiologic evaluation before transplant. J. Clin. Oncol. 12, 998–1004 (1994).
Watson, A. R., Rance, C. P. & Bain, J. Long term effects of cyclophosphamide on testicular function. Br. Med. J. (Clin. Res. Ed.) 291, 1457–1460 (1985).
Boumpas, D. T. et al. Risk for sustained amenorrhea in patients with systemic lupus erythematosus receiving intermittent pulse cyclophosphamide therapy. Ann. Intern. Med. 119, 366–369 (1993).
Sanders, J. E. et al. Ovarian function following marrow transplantation for aplastic anemia or leukemia. J. Clin. Oncol. 6, 813–818 (1988).
Cigni, A. et al. Hormonal strategies for fertility preservation in patients receiving cyclophosphamide to treat glomerulonephritis: a nonrandomized trial and review of the literature. Am. J. Kidney Dis. 52, 887–896 (2008).
Dooley, M. A. & Nair, R. Therapy Insight: preserving fertility in cyclophosphamide-treated patients with rheumatic disease. Nat. Clin. Pract. Rheumatol. 4, 250–257 (2008).
Stillwell, T. J. & Benson, R. C. Jr Cyclophosphamide-induced hemorrhagic cystitis. A review of 100 patients. Cancer 61, 451–457 (1988).
Cox, P. J. Cyclophosphamide cystitis—identification of acrolein as the causative agent. Biochem. Pharmacol. 28, 2045–2049 (1979).
Haselberger, M. B. & Schwinghammer, T. L. Efficacy of mesna for prevention of hemorrhagic cystitis after high-dose cyclophosphamide therapy. Ann. Pharmacother. 29, 918–921 (1995).
Bedi, A. et al. Association of BK virus with failure of prophylaxis against hemorrhagic cystitis following bone marrow transplantation. J. Clin. Oncol. 13, 1103–1109 (1995).
Apperley, J. F. et al. Late-onset hemorrhagic cystitis associated with urinary excretion of polyomaviruses after bone marrow transplantation. Transplantation 43, 108–112 (1987).
Miyamura, K. et al. Adenovirus-induced late onset hemorrhagic cystitis following allogeneic bone marrow transplantation. Bone Marrow Transplant. 2, 109–110 (1987).
Knowles, W. A. Discovery and epidemiology of the human polyomaviruses BK virus (BKV) and JC virus (JCV). Adv. Exp. Med. Biol. 577, 19–45 (2006).
Blume, K. G. et al. Total body irradiation and high-dose etoposide: a new preparatory regimen for bone marrow transplantation in patients with advanced hematologic malignancies. Blood 69, 1015–1020 (1987).
Kondo, M., Kojima, S., Kato, K. & Matsuyama, T. Late-onset hemorrhagic cystitis after hematopoietic stem cell transplantation in children. Bone Marrow Transplant. 22, 995–998 (1998).
Yamamoto, R. et al. Late hemorrhagic cystitis after reduced-intensity hematopoietic stem cell transplantation (RIST). Bone Marrow Transplant. 32, 1089–1095 (2003).
Stillwell, T. J., Benson, R. C. Jr, DeRemee, R. A., McDonald, T. J. & Weiland, L. H. Cyclophosphamide-induced bladder toxicity in Wegener's granulomatosis. Arthritis Rheum. 31, 465–470 (1988).
Kempen, J. H. et al. Long-term risk of malignancy among patients treated with immunosuppressive agents for ocular inflammation: a critical assessment of the evidence. Am. J. Ophthalmol. 146, 802–812 (2008).
Vlaovic, P. & Jewett, M. A. Cyclophosphamide-induced bladder cancer. Can. J. Urol. 6, 745–748 (1999).
Levine, E. G. & Bloomfield, C. D. Leukemias and myelodysplastic syndromes secondary to drug, radiation, and environmental exposure. Semin. Oncol. 19, 47–84 (1992).
Stone, R. M. Myelodysplastic syndrome after autologous transplantation for lymphoma: the price of progress. Blood 83, 3437–3440 (1994).
Jayachandran, N. V., Chandrasekhara, P. K., Thomas, J., Agrawal, S. & Narsimulu, G. Cyclophosphamide-associated complications: we need to be aware of SIADH and central pontine myelinolysis. Rheumatology (Oxford) 48, 89–90 (2008).
Magrath, I. et al. Adults and children with small non-cleaved-cell lymphoma have a similar excellent outcome when treated with the same chemotherapy regimen. J. Clin. Oncol. 14, 925–934 (1996).
Burkitt, D. Long-term remissions following one and two-dose chemotherapy for African lymphoma. Cancer 20, 756–759 (1967).
Fisher, R. I. et al. Comparison of a standard regimen (CHOP) with three intensive chemotherapy regimens for advanced non-Hodgkin's lymphoma. N. Engl. J. Med. 328, 1002–1006 (1993).
Keating, M. J. et al. Early results of a chemoimmunotherapy regimen of fludarabine, cyclophosphamide, and rituximab as initial therapy for chronic lymphocytic leukemia. J. Clin. Oncol. 23, 4079–4088 (2005).
Wierda, W. et al. Chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab for relapsed and refractory chronic lymphocytic leukemia. J. Clin. Oncol. 23, 4070–4078 (2005).
Lamanna, N. et al. Pentostatin, cyclophosphamide, and rituximab is an active, well-tolerated regimen for patients with previously treated chronic lymphocytic leukemia. J. Clin. Oncol. 24, 1575–1581 (2006).
Kay, N. E. et al. Cyclophosphamide remains an important component of treatment in CLL patients receiving pentostatin and rituximab based chemoimmunotherapy. Blood 112, 43 (2008).
Gokbuget, N. & Hoelzer, D. Treatment of adult acute lymphoblastic leukemia. Semin. Hematol. 46, 64–75 (2009).
Fisher, B. et al. Two months of doxorubicin-cyclophosphamide with and without interval reinduction therapy compared with 6 months of cyclophosphamide, methotrexate, and fluorouracil in positive-node breast cancer patients with tamoxifen-nonresponsive tumors: results from the National Surgical Adjuvant Breast and Bowel Project B-15. J. Clin. Oncol. 8, 1483–1496 (1990).
Fisher, B. et al. Tamoxifen and chemotherapy for axillary node-negative, estrogen receptor-negative breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-23. J. Clin. Oncol. 19, 931–942 (2001).
Mamounas, E. P. et al. Paclitaxel after doxorubicin plus cyclophosphamide as adjuvant chemotherapy for node-positive breast cancer: results from NSABP B-28. J. Clin. Oncol. 23, 3686–3696 (2005).
Jones, S. et al. Extended follow-up and analysis by age of the US Oncology Adjuvant Trial 9735: docetaxel/cyclophosphamide is associated with an overall survival benefit compared to doxorubicin/cyclophoshamide and is well tolerated in women 65 or older [abstract]. San Antonio Breast Cancer Symposium a12 (2007).
Martin, M. et al. Adjuvant docetaxel for node-positive breast cancer. N. Engl. J. Med. 352, 2302–2313 (2005).
McGuire, W. P. et al. Cyclophosphamide and cisplatin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer. N. Engl. J. Med. 334, 1–6 (1996).
Piccart, M. J. et al. Randomized intergroup trial of cisplatin–paclitaxel versus cisplatin–cyclophosphamide in women with advanced epithelial ovarian cancer: three-year results. J. Natl Cancer Inst. 92, 699–708 (2000).
International Collaborative Ovarian Neoplasm Group. Paclitaxel plus carboplatin versus standard chemotherapy with either single-agent carboplatin or cyclophosphamide, doxorubicin, and cisplatin in women with ovarian cancer: the ICON3 randomised trial. Lancet 360, 505–515 (2002).
Slayton, R. E. et al. Vincristine, dactinomycin, and cyclophosphamide in the treatment of malignant germ cell tumors of the ovary. A Gynecologic Oncology Group Study (a final report). Cancer 56, 243–248 (1985).
Rubie, H. et al. Localised and unresectable neuroblastoma in infants: excellent outcome with primary chemotherapy. Neuroblastoma Study Group, Societe Francaise d'Oncologie Pediatrique. Med. Pediatr. Oncol. 36, 247–250 (2001).
Sandberg, J. S., Owens, A. H. Jr & Santos, G. W. Clinical and pathologic characteristics of graft-versus-host disease produced in cyclophosphamide-treated adult mice. J. Natl Cancer Inst. 46, 151–160 (1971).
Thomas, E. D. et al. Aplastic anaemia treated by marrow transplantation. Lancet 1, 284–289 (1972).
Brodsky, R. A. & Jones, R. J. Aplastic anaemia. Lancet 365, 1647–1656 (2005).
Thomas, E. D. et al. Bone-marrow transplantation (first of two parts). N. Engl. J. Med. 292, 832–843 (1975).
Bensinger, W. I. et al. Transplantation of bone marrow as compared with peripheral-blood cells from HLA-identical relatives in patients with hematologic cancers. N. Engl. J. Med. 344, 175–181 (2001).
Vose, J. M. et al. Autologous transplantation for aggressive non-Hodgkin's lymphoma: results of a randomized trial evaluating graft source and minimal residual disease. J. Clin. Oncol. 20, 2344–2352 (2002).
Russell, N. H., McQuaker, G., Stainer, C., Byrne, J. L. & Haynes, A. P. Stem cell mobilisation in lymphoproliferative diseases. Bone Marrow Transplant. 22, 935–940 (1998).
Jayne, D. et al. Autologous stem cell transplantation for systemic lupus erythematosus. Lupus 13, 168–176 (2004).
Moore, J. et al. A pilot randomized trial comparing CD34-selected versus unmanipulated hemopoietic stem cell transplantation for severe, refractory rheumatoid arthritis. Arthritis Rheum. 46, 2301–2309 (2002).
Tyndall, A. & Furst, D. E. Adult stem cell treatment of scleroderma. Curr. Opin. Rheumatol. 19, 604–610 (2007).
Fassas, A. et al. Hematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study. J. Neurol. 249, 1088–1097 (2002).
Lowenthal, R. M., Cohen, M. L., Atkinson, K. & Biggs, J. C. Apparent cure of rheumatoid arthritis by bone marrow transplantation. J. Rheumatol. 20, 137–140 (1993).
Passweg, J. & Tyndall, A. Autologous stem cell transplantation in autoimmune diseases. Semin. Hematol. 44, 278–285 (2007).
Brodsky, R. A. et al. Immunoablative high-dose cyclophosphamide without stem-cell rescue for refractory, severe autoimmune disease. Ann. Intern. Med. 129, 1031–1035 (1998).
Krishnan, C. et al. Reduction of disease activity and disability with high-dose cyclophosphamide in patients with aggressive multiple sclerosis. Arch. Neurol. 65, 1044–1051 (2008).
Sensenbrenner, L. L., Steele, A. A. & Santos, G. W. Recovery of hematologic competence without engraftment following attempted bone marrow transplantation for aplastic anemia: report of a case with diffusion chamber studies. Exp. Hematol. 5, 51–58 (1977).
Brodsky, R. A. et al. Durable treatment-free remission after high-dose cyclophosphamide therapy for previously untreated severe aplastic anemia. Ann. Intern. Med. 135, 477–483 (2001).
Korbling, M. et al. 4-Hydroperoxycyclophosphamide: a model for eliminating residual human tumour cells and T-lymphocytes from the bone marrow graft. Br. J. Haematol. 52, 89–96 (1982).
Moyo, V. M. et al. High-dose cyclophosphamide for refractory autoimmune hemolytic anemia. Blood 100, 704–706 (2002).
Petri, M., Jones, R. J. & Brodsky, R. A. High-dose cyclophosphamide without stem cell transplantation in systemic lupus erythematosus. Arthritis Rheum. 48, 166–173 (2003).
Drachman, D. B., Adams, R. N., Hu, R., Jones, R. J. & Brodsky, R. A. Rebooting the immune system with high-dose cyclophosphamide for treatment of refractory myasthenia gravis. Ann. NY Acad. Sci. 1132, 305–314 (2008).
Schwartzman, R. J. et al. High-dose cyclophosphamide in the treatment of multiple sclerosis. CNS Neurosci. Ther. 15, 118–127 (2009).
Mayumi, H., Umesue, M. & Nomoto, K. Cyclophosphamide-induced immunological tolerance: an overview. Immunobiology 195, 129–139 (1996).
Luznik, L., Engstrom, L. W., Iannone, R. & Fuchs, E. J. Posttransplantation cyclophosphamide facilitates engraftment of major histocompatibility complex-identical allogeneic marrow in mice conditioned with low-dose total body irradiation. Biol. Blood Marrow Transplant. 8, 131–138 (2002).
Luznik, L. et al. HLA-haploidentical bone marrow transplantation for hematologic malignancies using nonmyeloablative conditioning and high-dose, posttransplantation cyclophosphamide. Biol. Blood Marrow Transplant. 14, 641–650 (2008).
The authors thank Dr. M. J. Higgins for her helpful discussion about the breast cancer section.
Under a licensing agreement between Accentia Pharmaceuticals and the Johns Hopkins University, R. A. Brodsky and R. J. Jones are entitled to share royalty received by the University on sales of a method of administering high-dose cyclophosphamide. The study described in this article could impact the value of this method of administering the drug. The terms of this agreement are being managed by the Johns Hopkins University in accordance with its conflict of interest policies. A. Emadi declares no competing interests.
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Emadi, A., Jones, R. & Brodsky, R. Cyclophosphamide and cancer: golden anniversary. Nat Rev Clin Oncol 6, 638–647 (2009). https://doi.org/10.1038/nrclinonc.2009.146
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