Abstract
Nitroglycerin (NTG) is a prodrug that has long been used in clinical practice for the treatment of angina pectoris. The biotransformation of NTG and subsequent release of nitric oxide (NO) is responsible for its vasodilatating property. Because of the remarkable ambivalence of NO in cancer disease, either protumorigenic or antitumorigenic (partly dependent on low or high concentrations), harnessing the therapeutic potential of NTG has gain interest to improve standard therapies in oncology. Cancer therapeutic resistance remains the greatest challenge to overcome in order to improve the management of cancer patients. As a NO releasing agent, NTG has been the subject of several preclinical and clinical studies used in combinatorial anticancer therapy. Here, we provide an overview of the use of NTG in cancer therapy in order to foresee new potential therapeutic avenues.
Similar content being viewed by others
Facts
-
Nitroglycerin is a vasodilatating agent used to treat or prevent angina.
-
Nitroglycerin increases the effects of various cancer treatments in preclinical studies.
-
Variable results so far for combination therapy with nitroglycerin in clinical trials.
Open questions
-
What is the role of NTG-mediated ERP effect in the antitumor response of nitroglycerin?
-
Which NTG-based combination therapy would more appropriate to improve the outcome of patients?
-
Can NTG may regulate other TNF receptors via NO-dependent post-translational modifications?
-
Can tumor microenvironment components be utilized as biomarkers to predict the clinical benefit of nitroglycerin in combinatorial therapies?
Introduction
Nitroglycerin (NTG), also called glyceryl trinitrate (GTN), is an organic nitrate molecule that has entered the medicinal world for more than 170 years. Just like its chemical properties, the scientific history of NTG is remarkable and astonishing.
NTG was synthetized by the Italian chemist Ascanio Sobrero in 1847 via the nitration of glycerol using a mixture of nitric and sulfuric acids causing a highly explosive reaction unless the mixture is cooled. Some years later, Alfred Nobel patented and manufactured dynamite, a stabilized form of NTG. In the late 1860s, some factory workers in explosives industry, suffering from angina pectoris or heart failure, reported a significant relief of pain only on workdays thus attributed to NTG exposure. In the meantime, the development of homeopathic medicine (based on the principle of cure by the similitude “like cures like”) was the cornerstone for the entry of NTG in the Pharmacopoeia and Medicine. In parallel, Brunton discovered the ability of a nitric-containing compound, amyl nitrite, to lower blood pressure and relieve anginal pain [1, 2]. Based on all these observations, William Murrel successfully treated angina pectoris for the first time with NTG in 1878. NTG-induced smooth muscle relaxation was further established [3] and still remains to date the milestone therapy for the relief of anginal pain. The molecular mechanism involved was then attributed to nitric oxyde (NO). Ferid Murad, Robert Furchgott and Louis Ignarro were awarded the 1998 Nobel Prize in Physiology/Medicine for their discoveries concerning NO as a signaling molecule in the cardiovascular system [4].
NO-released by NTG is known as a direct activator of soluble guanylyl cyclase (sGC), which activates the production of guanosine monophosphate cyclic (GMPc) and ultimately results in a signaling pathway that causes vascular smooth muscle relaxation [5]. The biological properties of NO have led to the search for new therapeutic uses of NTG. For several decades, numerous randomized clinical trials examined the effectiveness of NTG in a wide spectrum of human disorders including anal fissures [6,7,8] tendinopathies [9], cervical ripening [10], the prevention of mastectomy skin flap necrosis (MSFN) [11], and the prevention of acute pancreatitis post-endoscopic retrograde choliangiopancreatography (ERCP) [12,13,14].
Since the entry of NTG in the medicine, the understanding of the molecular mechanism of NTG bioactivation and the biological action of NO or NO-containing metabolite continues to intrigue and fuel research for novel potential therapeutic avenues.
Either produced by NO synthases or delivered by NO donors, NO plays a role in a broad spectrum of physiological and pathophysiological processes. NO exists as a free radical gaseous molecule (•NO) highly reactive on molecular oxygen (O2), iron, superoxide anion (O2•−) characterized with the production of subsequent reactive nitrogen species, nitrogen dioxide (•NO2) then nitrite (NO2−), nitrate (NO3−) and peroxynitrite (ONOO-) respectively [15]. Important NO biological effects (•NO or NO-derived from RNS) are mediated by protein post-translation modifications such as metal-nitrosylation, the reaction of NO with a transition metal (e.g. heme group), nitrosation the NO-dependent covalent modification of a tyrosine residue (i.e. hydroxyl group) and S-nitrosylation the NO-dependent non-covalent modification of a cysteine residue (i.e. thiol group) [16].
The biological outcome of NO has been shown to be cytoprotective or cytotoxic depending on various factors including concentration, subcellular location, the chemical redox state of the cellular microenvironment and time of NO exposure [17]. The dichotomous effects of NO have been well established in tumor cells. High concentration of NO (of the order of µM) has a cytotoxic/antitumoral effect whereas low concentration of NO (of the order of nM) has a cytoprotective/carcinogenic effect [17, 18]. Increase in the concentration of NO using NO donors represent an interesting novel therapeutic strategy. Many preclinical and clinical studies have examined the therapeutic potential of NTG to treat different types of cancer yet. Whether NTG may provide a clinical benefit for cancer patients have been investigated for several decades and is still a matter of clinical research. In this review, we aim to provide an updated insight on the use of NTG in cancer therapy.
Pharmacokinetic of NTG
NTG formulations
NTG exists under various formulations for oral and sublingual use (tablets and sprays), transdermal use (ointments and patches), and intravenous use (liquid) [19]. The routes of administration of NTG have a significant impact on its biotransformation and pharmacokinetic. When administered orally, NTG undergoes an exhaustive first-pass hepatic extraction with a plasma concentration frequently below the detection threshold (~0.1 ng/ml) [20, 21]. Sublingual administration of NTG has a short-lived effect and prevents the first-pass hepatic metabolism which results in greater NTG plasma concentrations (concentrations reached within 2–5 min with 0.5 mg NTG sublingual tablet: 1.4 ± 0.1 ng/ml [22]; 0.8 mg NTG sublingual spray: 3.96 ng/ml)) [23]. Transdermal administration of NTG provide a longer-lasting effect [24]. It also offers the advantage of avoiding first-pass hepatic extraction and constitutes a controlled-delivery system with steady plasma concentration even though the patch is replaced [25]. When given intravenously (like sublingually) NTG has a short plasma half-life of 2–3 min [24, 26].
Nitrate tolerance
The attenuation or full loss of the NO-dependent hemodynamic and anti-ischemic effects of NTG, often known as “nitrate tolerance,” severely restricts the therapeutic effectiveness of continuous NTG administration regardless the route of administration [27]. Vascular tolerance is thought to be multifactorial due to the depletion of intracellular thiols, inhibition of nitrate bioactivation enzymes, decreased NO bioavailability caused by changes in eNOS expression and activity and/or increased phosphodiesterase (PDE) activity, and the reduction in cGMP-dependent protein kinase (cGK) activity [28, 29].
Adverse effects
The systemic toxicity of NTG is minimal. Headache is the most frequent negative effect of nitrate therapy. Dizziness and syncope are less frequently reported because nitrate-induced hypotension frequently rises heart rate, which offsets a decline in stroke volume. Flushing, palpitations, and hypotension with reflex tachycardia are the most frequent cardiovascular side effects linked to NTG [30].
Bioactivation of NTG
NTG metabolites
NTG biotransformation was first defined by Bennett et al. as two mechanisms. The first one is a mechanism-based biotransformation (or bioactivation) in which NTG is denitrated and transformed into the vasoactive compound NO that activates the soluble guanylate cyclase, which subsequently upregulates intracellular cyclic guanosine 3′,5′- monophosphate (cGMP) and causing muscles to relax. NO generation is coupled with the production of primarily of 1,2-glyceryl dinitrate (1,2-GDN) and a considerably lower amount of 1,3-glyceryl dinitrate (1,3-GDN). The second mechanism is a clearance-based biotransformation (or metabolic clearance) in which NTG is metabolized into 1,3-GDN and a nitrite (NO2−) with poor vasodilatory capabilities [31].
Regardless of the method of administration, NTG metabolism generates dinitrate metabolites 1, 2- and 1, 3-GDN, which in turn generate 1- and 2-glyceryl mononitrate (1- and 2-GMN). When compared to NTG, the GDNs and GMNs plasma concentrations are often 10 times and 100 times higher respectively [26]. The metabolites have substantially longer half-lives than NTG with 30–60 min for GDNs and 5–6 h for GMNs, which explains their higher plasma concentration [26]. It was found that 1, 2-GDN plasma levels are always greater than 1, 3-GDN levels, and that 2-GMN concentrations are always higher than 1-GMN concentrations. When administered by a transdermally route, 1,2-GDN was shown to be typically 4 times more concentrated than 1,3-GDN and 2-GMN was ~6 times more concentrated than 1-GMN [32]. Following sublingual (0.4 mg) and intravenous administration (10, 20, and 40 μg/min) of NTG, the concentration of 1, 2-GDN may be 4.6–7.4 times greater than that of 1, 3-GDN, respectively [33].
Mechanisms of NTG bioactivation
For many years, the process by which NTG undergoes biotransformation to release NO and its dinitrate metabolites remains not fully understood. Hence, numerous NTG biotransforming enzyme-dependent and independent mechanisms have been proposed (Fig. 1) [34]. Four enzymes, including cytochrome P450 (CYP450), glutathione-S-transferase (GST), xanthine oxidoreductase (XOR), and aldehyde dehydrogenase (ALDH), have been associated with the biotransformation of NTG [35,36,37,38].
ALDH2 is a key NTG bioactivator and it is also involved in detoxification of ethanol. It exhibits many enzymatic activities including dehydrogenase, esterase and denitration. Of note, an inactive mutant of ALDH2 (Glu504Lys) is found in about 40% of the East Asian population which is responsible for defective alcohol metabolism. The vascular response to NTG metabolism investigated in ALDH2 Glu504Lys versus ALDH2 wild-type individuals has shown contradictory clinical results: either no effects [39] or a lack of an efficacious response [40] associated to ALDH2 Glu504Lys. This suggests the existence of alternative pathways for NTG biotransformation. Furthermore, site directed mutagenesis of ALDH2 suggests three distinct pathways of NTG biotransformation that involve different active site residues (Cys302, Cys301/303, Glu268) [41]. Although the mechanism for ALDH2-catalysed NTG denitration is not fully understood, at least Cys302 and Glu268 appear essential in this process reported for vascular bioactivation of NTG [42, 43]. ALDH2 polymorphisms (Glu504Lys) is also correlated with occurrence and progression of cancer but the role is only partially understood [44]. Altogether, given the existence of alternative pathways, it is much likely that the influence of ALDH2 polymorphisms on NTG biotransformation in cancer cells may be rather limited.
Polymorphisms exist within GST and CYP450 genes which may affect their enzyme catalytic activity. For example, GSTM1, GSTT1-null genotypes and GSTP1 rs1695 polymorphism have been correlated as an increased risk factor for a variety of cancer type [45, 46].
We can still speculate that mutation/defective expression of wild type gene or upregulation of a defective catalytic variant in cancer of the enzyme responsible of NTG biotransformation may affect NO delivery and post-translational modification. Further investigations are required to clearly define this point.
Preclinical studies for the combination of antitumor therapies and nitroglycerin
Effect of nitroglycerin on the tumor microenvironment
Nitroglycerin and Cytokine signaling
Tumor necrosis factor (TNF)/TNF receptors superfamily members
Tumor necrosis factor (TNF) and TNF receptors superfamily members play a role in the pathogenesis of various diseases including cancer. The TNF ligands consist of 19 members, well-documented for their engagement in signaling pathways resulting in inflammation, proliferation, cell death, migration/invasion, angiogenesis, and metastasis [47]. In particular, TNFα/TNF-R1, FasL/Fas and TRAIL/DR4 or DR5 systems exert pleiotropic effects, associated with both tumor-promoting and tumor-suppressing effects in the tumor microenvironment (TME). TNF ligand/TNF receptor trimeric assembly and secondary formation of clusters (for category II TNF receptors such as transmembrane Fas, DR4 and DR5) is required for the full activation of the system [48]. NTG has been shown to significantly enhance FasL-mediated cell death by apoptosis in mammary and colon cancer cell lines [49]. S-nitrosylation of Fas in its cytoplasmic part (S-nitrosylation of cysteine residues 199 and 304) was found associated with this process. Particularly, S-nitrosylation at cysteine 304 promotes redistribution of Fas to lipid rafts, formation of the death-inducing signal complex and induction of cell death by apoptosis [49].
An increase in understanding the mode of action of NTG in tumor-suppressive effects brings to the fore a NO-dependent regulation of the TNF ligands/TNF receptors superfamily signaling pathways [50]. In mammary and colon cancer cells (from human and murine origin), NTG induces a switch of the TNFα/TNF-R1 signaling pathway from the classical survival NF-ƙB pathway to a pro-apoptotic cell death pathway [51]. The switch occurs in a NO-dependent molecular mechanism via the S-nitrosylation and inactivation of the cIAP1 E3 ligase activity (cysteine at position 571). In absence of K63 ubiquitinated RIP1, the TNFα/TNF-R1 system NTG mediates a cell death signaling pathway involving the formation of a complex II [51]. The E3 ligases cIAP1/2 are long-time active targets for drug development. Smac-Mimetic (SM) compounds have been extensively studied and developed to counteract cIAPs by inducing their autoubiquitination and proteasomal degradation [52]. As SM, NTG induces TNFα-dependent cancer cell death by apoptosis due to the loss of cIAP1 E3 ligase activity by a distinct molecular mechanism.
To date no study has explored whether NTG might display a cellular function via other TNF receptors. Only one study reported the S-nitrosylation of DR4 (not for DR5), specifically by the NO donor nitrosylcobalamin and its role in sensitizing ovarian cancer cell lines to TRAIL-induced apoptosis [53].
IL-6-dependent migration/invasion
Interleukin-6 (IL-6) is a critical cytokine and key inflammatory mediator within the TME that is strongly implicated in almost all hallmarks of cancer such as inflammation, cell proliferation/inhibition of cell death, migration/invasiveness, and metastasis formation [54]. The consideration of IL-6 levels detected in the serum of various type of cancer patients as potential diagnostic and predictive biomarker has been discussed in the literature [55,56,57]. Whether NTG may modulate the level of inflammatory mediators in blood has been investigated. Interestingly, continuous therapy with transdermal NTG (0.6 mg/h, 24 h/day for 7 days) or no therapy in healthy volunteers was not associated with changes in IL-6, TNFα and other vascular inflammation biomarkers [58]. While NTG therapy does not appear to have an impact on the level of IL-6 in human serum, it does affect IL-6 signaling. The IL6/JAK/STAT3 signaling pathway is frequently activated in various human cancers driving cell proliferation, migration/invasion, and cancer metastatic dissemination. As one of the most dysregulated signaling pathway in cancer, especially in breast cancer, many therapies targeting the IL6/JAK/STAT3 signaling pathway have been developed and studied [59]. More recently, it has been demonstrated that NTG has an inhibitory effect on the IL6/JAK/STAT3 signaling and consequently can prevent the migration and invasion of triple-negative breast cancer (TNBC) cells examined in vitro. Mechanistically, NTG mediates the S-nitrosylation of JAK2 which inhibits the phosphorylation of JAK2 and subsequent activation to phosphorylate its downstream substrate STAT3 [60].
Nitroglycerin and hypoxia-mediated immune escape
Hypoxia contributes to the escape of both innate and adaptative immunity which contributes to malignant progression. There is a growing body of evidence that suggests that NO donors, such as NTG, could immunosensitize tumor cells (Fig. 2).
The expression of MHC class I chain-related molecules (MICA and MICB) plays an important role in tumor surveillance by natural killer (NK) cells, lymphokine-activated killer (LAK) cells and cytotoxic T (T) cells [61]. Hypoxia-mediated shedding of MICA at the surface of human DU-145 prostate cancer cells, and subsequent resistance to killing by immune cells, is linked to an impaired NO signaling. In hypoxic conditions (0.5 % O2), low concentration of NTG (10 nM) significantly immunosensitize DU-145 cancer cells, most likely by restoring NO/cGMP signaling [62, 63]. Mechanistically, NTG interferes with the hypoxia-induced accumulation of ADAM10 (a disintegrin and metalloproteinase domain-containing protein 10), a gene target of the transcription factor HIF-1α (Hypoxia-inducible factor 1-alpha) that encodes for a metalloproteinase required for the shedding of MICA (Fig. 2). An antitumoral and immunotherapeutic effect of NTG (continuous administration of patch, 1.8 µg/h) further support the finding [64]. In addition, hypoxia-mediated up-regulation of PD-L1 (programmed death-ligand 1), evidenced in human breast and prostate cancer cells, and in murine melanoma and mammary carcinoma cells, leads to resistance to CTL (cytotoxic T lymphocyte)-mediated lysis (Fig. 2). Low dose of NTG counteracts this effect and sensitizes tumor cells to CTL-mediated lysis [65].
Nitroglycerin and angiogenesis
Peripheral circulation of bone marrow-derived stem cell population, endothelial progenitor cells (EPCs), plays a critical role in sustaining angiogenesis by their differentiation into endothelial cells and secretion of proangiogenic factors [66]. The impact of continuous exposure of various doses of NTG on human peripheral blood-derived EPCs was investigated. Transdermal administration of NTG (0.6 mg/h) given continuously for 7 days to healthy volunteer significantly increased the percentage of circulating cells expressing the EPC marker [67]. Ex vivo, exposure of NTG dose range (100–1000 nM) to human peripheral blood-derived EPCs (isolated from healthy individuals) was associated with increased EPCs apoptosis in a NTG-dose-dependently manner [67]. Ex vivo, continuous exposure of moderate concentrations of NTG (≤7.5 mg/l) increases the proliferative capacity of EPCs (isolated from patients with coronary artery disease) whereas exposure of higher concentration of NTG (≥15 mg/l) inhibits the proliferation of EPCs [68].
Interestingly, the adverse effect of continuous exposure of high doses of NTG on endothelial dysfunction represents an opportunity in cancer therapy to disrupt tumor angiogenesis. From a mechanistic point of view, it has been demonstrated that NTG-induced endothelial dysfunction may be due to phosphorylation and S-glutathionylation of eNOS [69]. In support to these studies, long-term exposure of NTG is linked to Akt S-nitrosylation and inactivation in endothelial cells and further impairment of angiogenesis [70].
Nitroglycerin and metastasis
Some insights indicate that NTG may contribute to counteract the shaping of metastasis (Fig. 2). The anti-metastatic effects of NTG have been examined on aggressive subtypes of metastatic breast and melanoma cancers. Basal-like TNBC is the most aggressive subtype of breast cancer associated with a poor prognosis, invasiveness, and distant metastasis [71, 72]. Recently, it was shown that in vivo metastatic potential of 4T1 murine TNBC cells to form lung nodules was delay following NTG therapy [60]. In that study, in vitro migration and invasion assays carried out with both 4T1 murine and MDA-MB-31 human TNBC cells were significantly inhibited by NTG treatment (250 µM) [60]. A previous study has shown that experimentally induced hypoxia (0.5% O2) increased the in vitro invasiveness of MDA-MB-231 cells which was prevented with low concentration of NTG (1 pM and 0.1 µM) [73]. In support of this finding, the anti-metastatic effect of low concentration of NTG (20 pM) was observed in vivo in hypoxia-mediated lung nodule formation using B16F10 murine metastatic melanoma cells. The experimental metastasis assay was established using C57Bl/6 mice injected intravenously with B16F10 cells that were pre-incubated for 12 h in hypoxic (1% O2) versus normoxic (20% O2) conditions, and treated with or without NTG [74].
Nitroglycerin as a sensitizing agent in cancer therapies
Chemosensitization
The chemosensitizing ability of NO has been demonstrated in different cellular contexts. Tumor hypoxia is known to increase resistance to chemotherapeutic agents and also radiotherapy (Fig. 2). One of the mechanisms associated with hypoxia-induced drug resistance is the inhibition of endogenous NO production (molecular O2 being required for NOS activity) also referred as “hyponitroxia” [75]. This finding supported the rationale for the use of NO donor to compensate for the loss of NO production in order to alleviate chemoresistance acquired in tumor hypoxia. In vitro studies have demonstrated that low concentrations of NTG (0.1 nM to 1 µM) significantly reduce hypoxia-induced chemoresistance of MDA-MB-231 TNBC cell line to doxorubicin [75] and to paclitaxel [76]; B16F10 melanoma cell line to doxorubicin [75]; DU-145 and PC-3 prostate cancer cell lines to doxorubicin [77] and to paclitaxel [76]. The chemosensitizing effect of NTG (by continuous transdermal delivery) to doxorubicin was also evidenced in vivo using a xenograft mouse model of human prostate cancer cell. Multicellular resistance, observed when cancer cells grown in spheroids, to doxorubicin is attenuated in MDA-MB-231 spheroids treated by NTG [78].
Further studies reported by the same team indicated that NTG induces the chemosensitization of hypoxic tumor cells in a cGMP-dependent signaling manner in both monolayer culture and spheroids [76, 78]. Acquired resistance to docetaxel is frequently observed in metastatic castration resistant prostate cancer (mCRPC). Interestingly, established docetaxel-resistant mCRPC cell lines (DU145-DR and PC3-D12) were found more sensitive to NTG-induced cytotoxicity than the parental cell line (DU-145 and PC-3) [79].
In addition, NTG was shown to enhance cisplatin-induced cytotoxicity in human NSCLC cell lines A549 and H1703 in vitro [80]. In human colon carcinoma cells SW480, cytotoxity-induced by M1 macrophage-derived conditioned medium pre-treated by the standard chemotherapies 5-fluorouracil/oxaliplatin is significantly enhanced by NTG. TNFα-induced by 5-fluorouracil/oxaliplatin-induced is associated with the enhanced cytotoxicity mediated by NTG [51]. The activity of NTG on the TNF signaling pathways has been described above (section Tumor necrosis factor (TNF)/TNF receptors superfamily members).
Photo-sensitization
One preclinical study supports the potential benefit of combining photodynamic therapy (PDT) and NTG on human retinoblastoma tumors xenografted subcutaneaously on mice [81]. A low dose of NTG ointment was applied on the skin of tumor-bearing animals one hour before the PDT treatment (two photosensitizing agent injection). In mice treated with NTG, a significant increase in light intensity detected by Magnetic resonance imaging (MRI) in tumor tissue was observed after PDT compared to the control group (without NTG treatment). The combination of PDT with NTG decreased the tumor volume below its initial value [81].
Sensitization toward other molecules
The combination of NTG with a nonspecific kinase inhibitor, H89, synergistically induces apoptosis in colon cancer cells. Such effect is dependent of ROS production and protein kinase G activation and also the P2-purinergic receptors P2X3, P2Y1, and P2Y6 [82].
In another study, when combined with the valproic acid (an inhibitor of histone deacetylase) NTG decreases cell viability and induces apoptosis of human leukemia cells [83].
More recently, it has been reported that NTG can synergistically enhance the cytotoxicity and cell growth inhibition triggered by the anti-cancer drug pemetrexed (an anti-folate) in non-small-cell lung cancer (NSCLC) cells. This effect is associated with Akt and ERK1/2 inactivation and radiation-sensitive 52 (Rad52) (playing a crucial role in DNA repair) downregulation [84]. The antitumor effect of pemetrexed was shown to be enhanced by NTG in a xenograft model of lung cancer in mice. This synergistic effect was significantly reversed by a selective inhibitor of the NO-sensitive guanylyl cyclase, 1H[1,2,4] oxadiazolo[4,3-a]quinoxaline-1-one (ODQ), suggesting that the anticancer effect is dependent on the cGMP signaling pathway [85].
Recently, in vivo investigation of the effect of NTG associated to metformin (an anti-diabetes drug) in hamsters-bearing fibrosarcoma tumors has been conducted. The combination of NTG and metformin significantly inhibited fibrosarcoma cell growth without toxicity, compared to monotherapy or control. This antitumor effect is also associated with the inhibition of tumor vasculature, the increase of apoptosis, the inhibition of glucose metabolism and the inhibition of NO metabolism [86].
Clinical studies for the combination of antitumor therapies and nitroglycerin
Non-small cell lung cancer
Chemotherapeutic treatment
Docetaxel and carboplatin
The first clinical trial to test the anticancer effect of NTG in combined therapy was conducted by Yasuda et al. in 2006 [87]. Seventeen patients with lung adenocarcinoma and stable angina pectoris were treated with NTG patches (25 mg daily) during 3 months before surgery. The patients were all suffering from angina pectoris and likely to receive NTG for the treatment of this pathology. However, the continuous NTG treatment without chemotherapy did not have a clinical benefit in the prolongation of time to progression (TTP) after surgery [87]. During this study, the long-term effects of NTG on different proteins (HIF-1α, P-gp, VEGF, p53, and activated p53) were studied. The treatment with NTG decreases the rates of immunoreactive cells for HIF-1α protein and the level of VEGF (vascular endothelial growth factor) protein was closely associated with HIF-1α and P-gp (P-glycoprotein) protein levels in cancer tissues after operation. These results suggest that NTG-induced reduction of HIF-1α level leads to a reduction in VEGF level and subsequent reduction of angiogenesis.
In parallel, 29 patients with non-operable advanced lung adenocarcinoma were treated with NTG patches (25 mg daily for 5 days between 3 days before and 2 days after each cycle of chemotherapy) associated with docetaxel (on day 1) and carboplatin (on day 1) for four cycles maximum. The authors showed that the NTG may improve chemosensitivity to docetaxel and carboplatin in patients with lung adenocarcinoma. This effect of NTG treatment was strongly associated with the decreasing of the level of VEGF and P-gp via the reduction of HIF-1α [87]. In 2016, He and colleagues have also investigated the efficacy and the safety of the combination of NTG with docetaxel (on day 1) and carboplatin (on day 2) for the treatment of 70 elderly patients (≥65 years) with advanced NSCLC complicated with coronary heart disease (CHD). NTG was administrated via intravenous micro-pump during 24 h in continuous from the start of the chemotherapy. The injection speed was gradually increased from 20 to 50 µg/min and maintained at 50 µg/min. The authors observed a significant increase of tumor response rate (25.00% vs 52.63%), of disease control rate (40.60% vs 65.80%) and a median Overall Survival significantly longer (OS, 10.8 vs 8.3 months) in the treatment group compared with the control group. Moreover, the incidence of angina pectoris and myocardial infarction were significantly lower in the treated group [88]. So, this combination can be considered as a safe and effective option to improve the efficacy of docetaxel and carboplatin and treated NSCLC patients with CHD.
Vinorelbine and cisplatin
In 2006, Yasuda et al. conducted a randomized phase II clinical trial to investigate the efficacy and safety of NTG combined with vinorelbine and cisplatin in 120 patients with previously untreated stage IIIB/IV NSCLC [89]. The combination improved the response rate (72% vs 42%), the TTP (327 vs 185 days) and the median survival time (413 vs 289 days) in the NTG compared with the placebo arms, without the appearance of major adverse effects [89]. These results were confirmed by Reinmuth et al. with a study evaluating the effects of NTG combined with oral vinorelbine and cisplatin in 66 Caucasian patients with stage IIIB/IV NSCLC [90]. In this study, the addition of NTG increased numerically but no significatively, the objective response rate (ORR, 35.3% vs 18.8%) and the disease control rate (DCR, 61.8% vs 53.1%) compared to placebo group. However, there were no differences in the median time to progression (TTP) and the median overall survival (OS) between NTG and placebo groups. The results seem to confirm the previous results reported by Yasuda et al. in Asian cohort [89] despite the low sample size.
In 2014, a new phase II clinical trial combining with vinorelbine and cisplatin with concurrent NTG and radiotherapy for treatment of locally advanced NSCLC (35 patients) has been realized. The NTG patch was administrated for 5 days (25 mg 1 day before and 4 days after chemotherapy induction and consolidation) and all-day during chemo-radiotherapy for a total of six cycles of chemotherapy. This study demonstrated that 63% of patients present an overall response (OS) after induction of chemotherapy and 75% an OS after chemo-radiotherapy. Moreover, the improved OS was associated with reduced VEGF levels. Thus, the addition of NTG to chemotherapy and radiotherapy can be used for the treatment of locally advanced NSCLC without toxicity [91].
Carboplatin, paclitaxel and bevacizumab
In parallel, a randomized phase II clinical trial combining NTG with carboplatin, paclitaxel, and bevacizumab was realized on 223 chemo-naïve patients with stage IV nonsquamous NSCLC. The patients were randomized to receive four cycles of chemotherapy every 3 weeks with or without NTG patches (15 mg daily for 5 days between 2 days before, the day of, and 2 days after each cycle). Unfortunately, the association of NTG with carboplatin, paclitaxel, and bevacizumab did not increase the response rate (38% vs 54%), the progression-free survival (PFS, 5.1 vs 6.8 months) and the overall survival (OS, 9.4 vs 11.6 months) in patients with stage IV nonsquamous NSCLC treated with NTG patch compared to placebo group [92]. So, the dramatically decrease of the VEGF levels by the bevacizumab could be responsible of the loss of NTG enhancement potential in patients with stage IV nonsquamous NSCLC.
While the clinical trial by Dingemans et al. [92] shows that NTG does not improve treatment efficacy (carboplatin, paclitaxel and bevacizumab), Jong et al. investigated whether a predicted outcome could be based on early response assessment using [18F] FDG PET imaging from available data [93]. The addition of NTG did not reduce FDG uptake. However, this method identified more tumor responders than chemotherapy-based response assessment, but this was not correlated to progression-free survival (PFS) or overall survival (OS). These results could be due to a lower NTG dose than the one used in Yasuda’s study or to the timing of the [18F] FDG PET shortly after the bevacizumab infusion and so to an interference with bevacizumab [93].
The combined effect of NTG with chemotherapies against the NSCLC seems to depend on the type of chemotherapy used. A rigorous, multicenter, phase III clinical trial was completed in 2015, on 372 advanced NSCLC patients treated with one of five prespecified platinum-based doublets as first-line chemotherapy (carboplatin and gemcitabine (79%) or carboplatin and paclitaxel (18%) or vinorelbine and cisplatin (2%)). The patients were treated with NTG patches (25 mg) two days before, the day of, and two days after, each chemotherapy infusion. Chemotherapies were injected every 3 weeks for a maximum of four to six cycles in the absence of progressive disease or prohibitive toxicity. Unfortunately, this study was stopped because, during the first interim analysis (270 patients), the NTG had no demonstrable effect either on progression-free survival (PFS, 5.0 vs 4.8 months) or overall survival (OS, 11.0 vs 10.3 months) or tumor response rate (31% vs 30%) compared to placebo group.
Radiotherapy
Reymen et al. investigated the potential of NTG as a radio-sensitizer on 42 patients with stage IB-IV NSCLC. A NTG patch (25 mg) was applied at least 2 h before the first radiation session of the day and removed only after the last session in case of bi-daily treatments. The clinical trial was stopped prematurely because the NTG did not improve overall survival (OS) and could not reduce tumor hypoxia in association with radiotherapy. The small sample size (42 patients) combined with the heterogeneity of patient characteristics and treatments modalities have complicated the analysis of the results in particular the overall survival in subgroup [94].
Prostate cancer
A phase II clinical trial was completed in 2009 on prostate cancer by Siemens et al. [95]. A preclinical study indicated that NO plays a significant role in the hypoxia and in the development of the prostate cancer [77]. This clinical trial was realized on 29 men who experienced an increase in prostate-specific antigen (PSA) level after surgery or radiotherapy. Patients were treated continuously with slow-release NTG patches delivering a low-dose of NTG (0.033 mg/h) for 24 months. The primary evaluation criteria were PSA doubling time (PSADT). Before treatment, the PSADT was 13.3 months and after NTG treatment 31.8 months [95]. This clinical trial showed that the NTG can improve the PSADT by attenuating hypoxia-induced progression of prostate cancer. NTG has a beneficial antitumor effect in patients with relapsed prostate cancer.
Liver cancer
In 2012, a randomized study was carried out to investigate potential benefit of NTG on the delivery and effectiveness Lipiodol (lymphographic agent) or Lipiodol/Doxorubicin emulsion after TAE (transcatheter arterial embolization) or TACE (transcatheter arterial (chemoembolization) respectively in patients with hepatocellular carcinoma (HCC). Lipiodol is selectively deposited in HCC tumors and used to visualize tumor-patient response by computerized tomography (CT). NTG improved the ability of Lipiodol to deposit in HCC tumors after TAE or TACE and GTN/TACE resulted in a greater reduction in tumor size compared to control groups [96]. Importantly, doxorubicin delivery may be enhanced because of the known NTG-mediated enhanced permeability and retention (EPR) effect [97].
Rectal cancer
Recently, an open-label, nonrandomized, multicohort, dose escalation, phase I clinical trial was completed on 13 patients with locoregionally advanced operable rectal cancer [98]. The goal of this study was to evaluate the safety, the tolerability, the feasibility, the dose-limiting toxicity, and the maximum tolerated dose of NTG patch associated with 5-fluorouracil and radiation therapy. Three sequential doses of NTG were studied: 0.2, 0.4, and 0.6 mg/h (3 patients by dose). All patients received radiation therapy with continuous infusion of 5-fluorouracil per day for the duration of the radiation therapy. The NTG patch was applied 2 h before the radiation therapy and then during 12 h on days of radiation therapy (monday to friday). Overall, NTG patches were well tolerated by the patients and a complementary phase II clinical trial can be investigated with a dose of 0.6 mg/h of NTG [98].
The different association of therapeutic agents with NTG investigated in NSCLC, prostate, liver, and rectal cancer is summarized in Table 1.
Ongoing clinical trials
Three clinical trials intended to evaluate the antitumor potential of NTG in combination with other therapies have been conducted although the results not available yet (Table 2). The first study (NCT00616031) was a randomized phase II clinical trial realized by Yasuda et al. and investigated the effects of NTG in addition with carboplatin and paclitaxel for the treatment of previously untreated stage IIIB/IV NSCLC. This study would allow to verify if the poor results obtained by Dingemans et al. [92] are due to the interference of Bevacizumab with NTG or to the combination of chemotherapy used. The second study (NCT04338867) was a phase II clinical trial realized on 96 NSCLC patients with brain metastases. It investigated the effect of NTG combined with whole-brain radiation therapy (WBRT), the standard treatment for multiple brain metastases. The results were published recently but the article was temporally removed. In parallel, a phase III clinical trial (NCT01704274) was completed on 60 prostate cancer patients with biochemical recurrence after primary therapy (surgery or radiotherapy). This study seems to follow the first phase II trial published in 2009, demonstrating a beneficial effect of a low dose of NTG on PSADT in patients with biochemical recurrence after surgery or radiotherapy [95]. In this new study, the authors compared the efficacy of a low dose (0.0285 mg/h) and a high dose (0.057 mg/h) of NTG on the prostate cancer.
Conclusion
The putative repurposing of NTG in cancer therapy in order to overcome resistance to standard therapies is a recent strategy currently under investigation that aims to improve the management of cancer patients. A growing body of preclinical studies found clear evidence for the sensitizing effect of NTG on various anticancer therapies. Despite some significant outcomes in the field of clinical trials, much remains to be done to determine the best combination of therapies to use with NTG. How to combine NTG considering standard therapies, i.e., timing, frequency and for which type of cancer patient is still an open question. Better understanding the mode of action of NTG regarding its concentration, due to potential ambivalence of NO released, and effects within the temporal dynamics of TME would help to delineate the best responsive cancer patients most likely associated to a tumor-specific molecular signature.
References
Marsh N, Marsh A. A short history of nitroglycerine and nitric oxide in pharmacology and physiology. Clin Exp Pharm Physiol. 2000;27:313–9.
Pearson R, Butler A. Glyceryl trinitrate: history, mystery, and alcohol intolerance. Mol Basel Switz. 2021;26:6581.
Murad F, Arnold WP, Mittal CK, Braughler JM. Properties and regulation of guanylate cyclase and some proposed functions for cyclic GMP. Adv Cycl Nucleotide Res. 1979;11:175–204.
Ignarro LJ. After 130 years, the molecular mechanism of action of nitroglycerin is revealed. Proc Natl Acad Sci USA. 2002;99:7816–7.
Ignarro LJ, Lippton H, Edwards JC, Baricos WH, Hyman AL, Kadowitz PJ, et al. Mechanism of vascular smooth muscle relaxation by organic nitrates, nitrites, nitroprusside and nitric oxide: evidence for the involvement of S-nitrosothiols as active intermediates. J Pharm Exp Ther. 1981;218:739–49.
Mathur N, Qureshi W. Anal fissure management by the gastroenterologist. Curr Opin Gastroenterol. 2020;36:19–24.
Jin JZ, Hardy MO, Unasa H, Mauiliu-Wallis M, Weston M, Connolly A, et al. A systematic review and meta-analysis of the efficacy of topical sphincterotomy treatments for anal fissure. Int J Colorectal Dis. 2022;37:1–15.
Mustafa G, Hossain MS, Sheikh SH, Faruk I, Taher MA, Ferdaus AM, et al. Clinical Outcome of 0.2% Glyceryl Trinitrate Topical Ointment Compared to Lateral Internal Sphincterotomy in the Treatment of Patient with Chronic Anal Fissure: A Randomized Control Trial. Mymensingh Med J. 2022;31:1034–9.
Saltychev M, Johansson J, Kemppi V, Juhola J. Effectiveness of topical glyceryl trinitrate in treatment of tendinopathy - systematic review and meta-analysis. Disabil Rehabil. 2022;44:5804–10.
Morgan PJ, Kung R, Tarshis J. Nitroglycerin as a uterine relaxant: a systematic review. J Obstet Gynaecol Can. 2002;24:403–9.
Vania R, Pranata R, Irwansyah D. Budiman null. Topical nitroglycerin is associated with a reduced mastectomy skin flap necrosis-systematic review and meta-analysis. J Plast Reconstr Aesthetic Surg. 2020;73:1050–9.
Du F, Zhang Y, Yang X, Zhang L, Yuan W, Fan H, et al. Efficacy of combined management with nonsteroidal anti-inflammatory drugs for prevention of pancreatitis after endoscopic retrograde cholangiography: a Bayesian network meta-analysis. J Gastrointest Surg J Soc Surg Aliment Trac. 2022;26:1982–97.
Ding J, Jin X, Pan Y, Liu S, Li Y. Glyceryl trinitrate for prevention of post-ERCP pancreatitis and improve the rate of cannulation: a meta-analysis of prospective, randomized, controlled trials. PLoS ONE. 2013;8:e75645.
Shi QQ, Huang GX, Li W, Yang JR, Ning XY. Rectal nonsteroidal anti-inflammatory drugs, glyceryl trinitrate, or combinations for prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis: a network meta-analysis. World J Clin Cases. 2022;10:7859–71.
Lancaster JR. Nitric oxide: a brief overview of chemical and physical properties relevant to therapeutic applications. Future Sci OA. 2015;1:FSO59.
Martínez-Ruiz A, Lamas S. Two decades of new concepts in nitric oxide signaling: from the discovery of a gas messenger to the mediation of nonenzymatic posttranslational modifications. IUBMB Life. 2009;61:91–8.
Thomas DD, Ridnour LA, Isenberg JS, Flores-Santana W, Switzer CH, Donzellie S, et al. The chemical biology of nitric oxide. implications in cellular signaling. Free Radic Biol Med. 2008;45:18–31.
Khan FH, Dervan E, Bhattacharyya DD, McAuliffe JD, Miranda KM, Glynn SA. The role of nitric oxide in cancer: master regulator or NOt? Int J Mol Sci. 2020;21:9393.
Curry SH, Lopez LM, Lambert CR, Kwon HR, Stack RK. Plasma concentrations and hemodynamic effects of intravenous, sublingual, and aerosolized nitroglycerin in patients undergoing cardiac catheterization. Biopharm Drug Dispos. 1993;14:107–18.
Yu DK, Williams RL, Benet LZ, Lin ET, Giesing DH. Pharmacokinetics of nitroglycerin and metabolites in humans following oral dosing. Biopharm Drug Dispos. 1988;9:557–65.
Noonan PK, Benet LZ. The bioavailability of oral nitroglycerin. J Pharm Sci. 1986;75:241–3.
Bashir A, Lewis MJ, Henderson AH. Pharmacokinetic studies of various preparations of glyceryl trinitrate. Br J Clin Pharm. 1982;14:779–84.
Jensen KM, Mikkelsen S. Studies on the bioavailability of glyceryl trinitrate after sublingual administration of spray and tablet. Arzneimittelforschung. 1997;47:716–8.
Bogaert MG. Clinical pharmacokinetics of glyceryl trinitrate following the use of systemic and topical preparations. Clin Pharmacokinet. 1987;12:1–11.
Sh C, Sm A. Analysis, disposition and pharmacokinetics of nitroglycerin. Biopharm Drug Dispos. 1985 Sep [cited 2022 Nov 30];6. Available from: https://pubmed.ncbi.nlm.nih.gov/3929851/
Hashimoto S, Kobayashi A. Clinical pharmacokinetics and pharmacodynamics of glyceryl trinitrate and its metabolites. Clin Pharmacokinet. 2003;42:205–21.
Thadani U. Challenges with nitrate therapy and nitrate tolerance: prevalence, prevention, and clinical relevance. Am J Cardiovasc Drugs. 2014;14:287–301.
Münzel T, Li H, Mollnau H, Hink U, Matheis E, Hartmann M, et al. Effects of long-term nitroglycerin treatment on endothelial nitric oxide synthase (NOS III) gene expression, NOS III–mediated superoxide production, and vascular NO bioavailability. Circ Res. 2000;86:e7–12.
Kim D, Rybalkin SD, Pi X, Wang Y, Zhang C, Munzel T, et al. Upregulation of phosphodiesterase 1A1 expression is associated with the development of nitrate tolerance. Circulation. 2001;104:2338–43.
Thadani U, Rodgers T. Side effects of using nitrates to treat angina. Expert Opin Drug Saf. 2006;5:667–74.
Bennett BM, McDonald BJ, Nigam R, Simon WC. Biotransformation of organic nitrates and vascular smooth muscle cell function. Trends Pharm Sci. 1994;15:245–9.
Han C, Jung P, Sanders SW, Lin ET, Benet LZ. Pharmacokinetics of nitroglycerin and its four metabolites during nitroglycerin transdermal administration. Biopharm Drug Dispos. 1994;15:179–83.
Noonan PK, Benet LZ. Variable glyceryl dinitrate formation as a function of route of nitroglycerin administration. Clin Pharm Ther. 1987;42:273–7.
Daiber A, Münzel T. Organic nitrate therapy, nitrate tolerance, and nitrate-induced endothelial dysfunction: emphasis on redox biology and oxidative stress. Antioxid Redox Signal. 2015;23:899–942.
Servent D, Delaforge M, Ducrocq C, Mansuy D, Lenfant M. Nitric oxide formation during microsomal hepatic denitration of glyceryl trinitrate: involvement of cytochrome P-450. Biochem Biophys Res Commun. 1989;163:1210–6.
Lau DT, Benet LZ. Nitroglycerin metabolism in subcellular fractions of rabbit liver. Dose dependency of glyceryl dinitrate formation and possible involvement of multiple isozymes of glutathione S-transferases. Drug Metab Dispos Biol Fate Chem. 1990;18:292–7.
Millar TM, Stevens CR, Benjamin N, Eisenthal R, Harrison R, Blake DR. Xanthine oxidoreductase catalyses the reduction of nitrates and nitrite to nitric oxide under hypoxic conditions. FEBS Lett. 1998;427:225–8.
Chen Z, Zhang J, Stamler JS. Identification of the enzymatic mechanism of nitroglycerin bioactivation. Proc Natl Acad Sci USA. 2002;99:8306–11.
Miura T, Nishinaka T, Terada T, Yonezawa K. Vasodilatory effect of nitroglycerin in Japanese subjects with different aldehyde dehydrogenase 2 (ALDH2) genotypes. Chem Biol Interact. 2017;276:40–5.
Li Y, Zhang D, Jin W, Shao C, Yan P, Xu C, et al. Mitochondrial aldehyde dehydrogenase-2 (ALDH2) Glu504Lys polymorphism contributes to the variation in efficacy of sublingual nitroglycerin. J Clin Invest. 2006;116:506–11.
Wenzl MV, Beretta M, Griesberger M, Russwurm M, Koesling D, Schmidt K, et al. Site-directed mutagenesis of aldehyde dehydrogenase-2 suggests three distinct pathways of nitroglycerin biotransformation. Mol Pharm. 2011;80:258–66.
Opelt M, Eroglu E, Waldeck-Weiermair M, Russwurm M, Koesling D, Malli R, et al. Formation of nitric oxide by aldehyde dehydrogenase-2 Is necessary and sufficient for vascular bioactivation of nitroglycerin. J Biol Chem. 2016;291:24076–84.
Lang BS, Gorren ACF, Oberdorfer G, Wenzl MV, Furdui CM, Poole LB, et al. Vascular bioactivation of nitroglycerin by aldehyde dehydrogenase-2: reaction intermediates revealed by crystallography and mass spectrometry. J Biol Chem. 2012;287:38124–34.
Zhang H, Fu L. The role of ALDH2 in tumorigenesis and tumor progression: targeting ALDH2 as a potential cancer treatment. Acta Pharm Sin B. 2021;11:1400–11.
Al-Eitan LN, Rababa’h DM, Alghamdi MA, Khasawneh RH. Association of GSTM1, GSTT1 And GSTP1 polymorphisms with breast cancer among Jordanian women. OncoTargets Ther. 2019;12:7757–65.
Sørensen M, Autrup H, Tjønneland A, Overvad K, Raaschou-Nielsen O. Glutathione S-transferase T1 null-genotype is associated with an increased risk of lung cancer. Int J Cancer. 2004;110:219–24.
Dostert C, Grusdat M, Letellier E, Brenner D. The TNF family of ligands and receptors: communication modules in the immune system and beyond. Physiol Rev. 2019;99:115–60.
Kucka K, Wajant H. Receptor oligomerization and its relevance for signaling by receptors of the tumor necrosis factor receptor superfamily. Front Cell Dev Biol. 2020;8:615141.
Leon-Bollotte L, Subramaniam S, Cauvard O, Plenchette-Colas S, Paul C, Godard C, et al. S-nitrosylation of the death receptor fas promotes fas ligand-mediated apoptosis in cancer cells. Gastroenterology. 2011;140:2009–18. 2018.e1-4
Plenchette S, Romagny S, Laurens V, Bettaieb A. S-Nitrosylation in TNF superfamily signaling pathway: implication in cancer. Redox Biol. 2015;6:507–15.
Romagny S, Bouaouiche S, Lucchi G, Ducoroy P, Bertoldo JB, Terenzi H, et al. S-nitrosylation of cIAP1 switches cancer cell fate from TNFα/TNFR1-mediated cell survival to cell death. Cancer Res. 2018;78:1948–57.
Morrish E, Brumatti G, Silke J. Future therapeutic directions for Smac-mimetics. Cells. 2020;9:406.
Tang Z, Bauer JA, Morrison B, Lindner DJ. Nitrosylcobalamin promotes cell death via S nitrosylation of Apo2L/TRAIL receptor DR4. Mol Cell Biol. 2006;26:5588–94.
Heinrich PC, Behrmann I, Haan S, Hermanns HM, Müller-Newen G, Schaper F. Principles of interleukin (IL)-6-type cytokine signalling and its regulation. Biochem J. 2003;374:1–20.
Liu C, Yang L, Xu H, Zheng S, Wang Z, Wang S, et al. Systematic analysis of IL-6 as a predictive biomarker and desensitizer of immunotherapy responses in patients with non-small cell lung cancer. BMC Med. 2022;20:187.
Vainer N, Dehlendorff C, Johansen JS. Systematic literature review of IL-6 as a biomarker or treatment target in patients with gastric, bile duct, pancreatic and colorectal cancer. Oncotarget. 2018;9:29820–41.
Dethlefsen C, Højfeldt G, Hojman P. The role of intratumoral and systemic IL-6 in breast cancer. Breast Cancer Res Treat. 2013;138:657–64.
Thomas GR, DiFabio JM, Gori T, Jenkins DJA, Parker JD. Continuous therapy with transdermal nitroglycerin does not affect biomarkers of vascular inflammation and injury in healthy volunteers. Can J Physiol Pharm. 2009;87:455–9.
Bournazou E, Bromberg J. Targeting the tumor microenvironment: JAK-STAT3 signaling. JAK-STAT. 2013;2:e23828.
Bouaouiche S, Ghione S, Sghaier R, Burgy O, Racoeur C, Derangère V, et al. Nitric oxide-releasing drug glyceryl trinitrate targets JAK2/STAT3 signaling, migration and invasion of triple-negative breast cancer cells. Int J Mol Sci. 2021;22:8449.
Kato N, Tanaka J, Sugita J, Toubai T, Miura Y, Ibata M, et al. Regulation of the expression of MHC class I-related chain A, B (MICA, MICB) via chromatin remodeling and its impact on the susceptibility of leukemic cells to the cytotoxicity of NKG2D-expressing cells. Leukemia. 2007;21:2103–8.
Siemens DR, Hu N, Sheikhi AK, Chung E, Frederiksen LJ, Pross H, et al. Hypoxia increases tumor cell shedding of MHC class I chain-related molecule: role of nitric oxide. Cancer Res. 2008;68:4746–53.
Kim J, Barsoum IB, Loh H, Paré JF, Siemens DR, Graham CH. Inhibition of hypoxia-inducible factor 1α accumulation by glyceryl trinitrate and cyclic guanosine monophosphate. Biosci Rep. 2020;40:BSR20192345.
Barsoum IB, Hamilton TK, Li X, Cotechini T, Miles EA, Siemens DR, et al. Hypoxia induces escape from innate immunity in cancer cells via increased expression of ADAM10: role of nitric oxide. Cancer Res. 2011;71:7433–41.
Barsoum IB, Smallwood CA, Siemens DR, Graham CH. A mechanism of hypoxia-mediated escape from adaptive immunity in cancer cells. Cancer Res. 2014;74:665–74.
Marçola M, Rodrigues CE. Endothelial progenitor cells in tumor angiogenesis: another brick in the wall. Stem Cells Int. 2015;2015:832649.
DiFabio JM, Thomas GR, Zucco L, Kuliszewski MA, Bennett BM, Kutryk MJ, et al. Nitroglycerin attenuates human endothelial progenitor cell differentiation, function, and survival. J Pharm Exp Ther. 2006;318:117–23.
Wang X, Zeng C, Gong H, He H, Wang M, Hu Q, et al. The influence of nitroglycerin on the proliferation of endothelial progenitor cells from peripheral blood of patients with coronary artery disease. Acta Biochim Biophys Sin. 2014;46:851–8.
Knorr M, Hausding M, Kröller-Schuhmacher S, Steven S, Oelze M, Heeren T, et al. Nitroglycerin-induced endothelial dysfunction and tolerance involve adverse phosphorylation and S-Glutathionylation of endothelial nitric oxide synthase: beneficial effects of therapy with the AT1 receptor blocker telmisartan. Arterioscler Thromb Vasc Biol. 2011;31:2223–31.
Li XY, Zhang HM, An GP, Liu MY, Han SF, Jin Q, et al. S-Nitrosylation of Akt by organic nitrate delays revascularization and the recovery of cardiac function in mice following myocardial infarction. J Cell Mol Med. 2021;25:27–36.
Yin L, Duan JJ, Bian XW, Yu SC. Triple-negative breast cancer molecular subtyping and treatment progress. Breast Cancer Res. 2020;22:61.
Bianchini G, Balko JM, Mayer IA, Sanders ME, Gianni L. Triple-negative breast cancer: challenges and opportunities of a heterogeneous disease. Nat Rev Clin Oncol. 2016;13:674–90.
Postovit LM, Adams MA, Lash GE, Heaton JP, Graham CH. Oxygen-Mediated Regulation of Tumor Cell invasiveness: involvement of a nitric oxide signaling pathway. J Biol Chem. 2002;277:35730–7.
Postovit LM, Adams MA, Lash GE, Heaton JPW, Graham CH. Nitric oxide-mediated regulation of hypoxia-induced B16F10 melanoma metastasis. Int J Cancer. 2004;108:47–53.
Matthews NE, Adams MA, Maxwell LR, Gofton TE, Graham CH. Nitric oxide-mediated regulation of chemosensitivity in cancer cells. J Natl Cancer Inst. 2001;93:1879–85.
Frederiksen LJ, Sullivan R, Maxwell LR, Macdonald-Goodfellow SK, Adams MA, Bennett BM, et al. Chemosensitization of cancer in vitro and in vivo by nitric oxide signaling. Clin Cancer Res. 2007;13:2199–206.
Frederiksen LJ, Siemens DR, Heaton JP, Maxwell LR, Adams MA, Graham CH. Hypoxia induced resistance to doxorubicin in prostate cancer cells is inhibited by low concentrations of glyceryl trinitrate. J Urol. 2003;170:1003–7.
Muir CP, Adams MA, Graham CH. Nitric oxide attenuates resistance to doxorubicin in three-dimensional aggregates of human breast carcinoma cells. Breast Cancer Res Treat. 2006;96:169–76.
Bouaouiche S, Magadoux L, Dondaine L, Reveneau S, Isambert N, Bettaieb A, et al. Glyceryl trinitrate‑induced cytotoxicity of docetaxel‑resistant prostatic cancer cells is associated with differential regulation of clusterin. Int J Oncol. 2019;1446–1456. https://doi.org/10.3892/ijo.2019.4708.
Ko JC, Chen JC, Yen TC, Chen TY, Ma PF, Lin YC, et al. Nitroglycerin enhances cisplatin-induced cytotoxicity via AKT inactivation and thymidylate synthase downregulation in human lung cancer cells. Pharmacology. 2020;105:209–24.
Thomas CD, Lupu M, Poyer F, Maillard P, Mispelter J. Increased PDT efficacy when associated with nitroglycerin: a study on retinoblastoma xenografted on mice. Pharm Basel Switz. 2022;15:985.
Cortier M, Boina-Ali R, Racoeur C, Paul C, Solary E, Jeannin JF, et al. H89 enhances the sensitivity of cancer cells to glyceryl trinitrate through a purinergic receptor-dependent pathway. Oncotarget. 2015;6:6877–86.
Aalaei S, Mohammadzadeh M, Pazhang Y. Synergistic induction of apoptosis in a cell model of human leukemia K562 by nitroglycerine and valproic acid. EXCLI J. 2019;18:619–30.
Ko JC, Chen JC, Tseng PY, Hsieh JM, Chiang CS, Liu LL, et al. Nitroglycerin-induced downregulation of AKT- and ERK1/2-mediated radiation-sensitive 52 expression to enhance pemetrexed-induced cytotoxicity in human lung cancer cells. Toxicol Res. 2022;11:299–310.
Nagai H, Yasuda H, Hatachi Y, Xue D, Sasaki T, Yamaya M, et al. Nitric oxide (NO) enhances pemetrexed cytotoxicity via NO‑cGMP signaling in lung adenocarcinoma cells in vitro and in vivo. Int J Oncol. 2012;41:24–30.
Popović KJ, Popović DJ, Miljković D, Popović JK, Lalošević D, Čapo I. Co-treatment with nitroglycerin and metformin exhibits physicochemically and pathohistologically detectable anticancer effects on fibrosarcoma in hamsters. Biomed Pharmacother. 2020;130:110510.
Yasuda H, Nakayama K, Watanabe M, Suzuki S, Fuji H, Okinaga S, et al. Nitroglycerin treatment may enhance chemosensitivity to docetaxel and carboplatin in patients with lung adenocarcinoma. Clin Cancer Res. 2006;12:6748–57.
He Z, Wu Y, Sun Q, Zhang M, Wu G, Chen X, et al. Efficacy and safety of nitroglycerin combined with chemotherapy in the elderly patients with advanced non-small cell lung cancer complicated with coronary heart disease. 2016;9:13021–7.
Yasuda H, Yamaya M, Nakayama K, Sasaki T, Ebihara S, Kanda A, et al. Randomized phase II trial comparing nitroglycerin plus vinorelbine and cisplatin with vinorelbine and cisplatin alone in previously untreated stage IIIB/IV non-small-cell lung cancer. J Clin Oncol. 2006;24:688–94.
Reinmuth N, Meyer A, Hartwigsen D, Schaeper C, Huebner G, Skock-Lober R, et al. Randomized, double-blind phase II study to compare nitroglycerin plus oral vinorelbine plus cisplatin with oral vinorelbine plus cisplatin alone in patients with stage IIIB/IV non-small cell lung cancer (NSCLC). Lung Cancer. 2014;83:363–8.
Arrieta O, Blake M, de la Mata-Moya MD, Corona F, Turcott J, Orta D, et al. Phase II study. Concurrent chemotherapy and radiotherapy with nitroglycerin in locally advanced non-small cell lung cancer. Radiother Oncol. 2014;111:311–5.
Dingemans AMC, Groen HJM, Herder GJM, Stigt JA, Smit EF, Bahce I, et al. A randomized phase II study comparing paclitaxel-carboplatin-bevacizumab with or without nitroglycerin patches in patients with stage IV nonsquamous nonsmall-cell lung cancer: NVALT12 (NCT01171170). Ann Oncol. 2015;26:2286–93.
de Jong EEC, van Elmpt W, Leijenaar RTH, Hoekstra OS, Groen HJM, Smit EF, et al. [18F]FDG PET/CT-based response assessment of stage IV non-small cell lung cancer treated with paclitaxel-carboplatin-bevacizumab with or without nitroglycerin patches. Eur J Nucl Med Mol Imaging. 2017;44:8–16.
Reymen BJT, van Gisbergen MW, Even AJG, Zegers CML, Das M, Vegt E, et al. Nitroglycerin as a radiosensitizer in non-small cell lung cancer: Results of a prospective imaging-based phase II trial. Clin Transl Radiat Oncol. 2020;21:49–55.
Siemens DR, Heaton JPW, Adams MA, Kawakami J, Graham CH. Phase II study of nitric oxide donor for men with increasing prostate-specific antigen level after surgery or radiotherapy for prostate cancer. Urology. 2009;74:878–83.
Liu YS, Chuang MT, Tsai YS, Tsai HM, Lin XZ. Nitroglycerine use in transcatheter arterial (chemo)embolization in patients with hepatocellular carcinoma and dual-energy CT assessment of Lipiodol retention. Eur Radio. 2012;22:2193–200.
Maeda H. Nitroglycerin enhances vascular blood flow and drug delivery in hypoxic tumor tissues: analogy between angina pectoris and solid tumors and enhancement of the EPR effect. J Control Release. 2010;142:296–8.
Illum H, Wang DH, Dowell JE, Hittson WJ, Torrisi JR, Meyer J, et al. Phase I dose escalation trial of nitroglycerin in addition to 5-fluorouracil and radiation therapy for neoadjuvant treatment of operable rectal cancer. Surgery. 2015;158:460–5.
Page NA, Fung HL. Organic nitrate metabolism and action: toward a unifying hypothesis and the future-a dedication to Professor Leslie Z. Benet. J Pharm Sci. 2013;102:3070–81.
Zhang J, Chen Z, Cobb FR, Stamler JS. Role of mitochondrial aldehyde dehydrogenase in nitroglycerin-induced vasodilation of coronary and systemic vessels. Circulation. 2004;110:750–5.
Yasuda H. Solid tumor physiology and hypoxia-induced chemo/radio-resistance: novel strategy for cancer therapy: nitric oxide donor as a therapeutic enhancer. Nitric oxide. Biol Chem. 2008;19:205–16.
Acknowledgements
The authors acknowledge the financial support from “Région Bourgogne-Franche-Comté”, “Université de Bourgogne” and “EPHE-PSL”. This work was supported by the Fondation pour la Recherche Médicale, grant number “ECO202106013771”, to “Mélina Meunier”.
Author information
Authors and Affiliations
Contributions
MM wrote the clinical section and contributed to write the preclinical sections; AY wrote the pharmacokinetic section; AB contributed to write the preclinical section; SP and MM designed the organization of the review. SP wrote the introduction, conclusion, abstract, contributed to write the preclinical section. All the authors revised the manuscript.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Edited by Pier Giorgio
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Meunier, M., Yammine, A., Bettaieb, A. et al. Nitroglycerin: a comprehensive review in cancer therapy. Cell Death Dis 14, 323 (2023). https://doi.org/10.1038/s41419-023-05838-5
Received:
Revised:
Accepted:
Published:
DOI: https://doi.org/10.1038/s41419-023-05838-5