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BioMed Research International
Volume 2019, Article ID 6146972, 13 pages
https://doi.org/10.1155/2019/6146972
Research Article

Effect of Chemotherapeutics and Tocopherols on MCF-7 Breast Adenocarcinoma and KGN Ovarian Carcinoma Cell Lines In Vitro

Department of Medical Biotechnology, College of Medicine and Public Health, Flinders University, Adelaide, SA, 5052, Australia

Correspondence should be addressed to Daniela Figueroa; ua.ude.srednilf@zelaznogaoreugif.aleinad

Received 7 June 2018; Revised 28 November 2018; Accepted 30 December 2018; Published 15 January 2019

Guest Editor: Claudio Tabolacci

Copyright © 2019 Daniela Figueroa et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The combination of doxorubicin and cyclophosphamide commonly used to treat breast cancer can cause premature ovarian failure and infertility. α-Tocopherol is a potent antioxidant whereas γ-tocopherol causes apoptosis in a variety of cancer models in vitro including breast cancer. We hypothesised that the combination of doxorubicin (Dox) and 4-hydroperoxycyclophosphamide (4-Cyc) would be more cytotoxic in vitro than each agent alone, and that α-tocopherol would reduce and γ-tocopherol would augment the cytotoxicity of the combined chemotherapeutics. Human MCF-7 breast cancer and KGN ovarian cells were exposed to Dox, 4-Cyc, combined Dox and 4-Cyc, α-tocopherol, γ-tocopherol, or a combination of Dox and 4-Cyc with α-tocopherol or γ–tocopherol. Cell viability was assessed using a crystal violet assay according to four schedules: 24h exposure, 24h exposure + 24h culture in medium, 24h exposure + 48h culture in medium, or 72h continuous exposure. Supernatants from each separate KGN culture experiment (n=3) were examined using an estradiol ELISA. Dox was cytotoxic to both MCF-7 and KGN cells, but 4-Cyc only killed MCF-7 cells. γ-Tocopherol significantly decreased MCF-7 but not KGN cell viability. The combined chemotherapeutics and γ-tocopherol were more cytotoxic to MCF-7 than KGN cells, and α-tocopherol reduced the cytotoxicity of the combined chemotherapeutics towards KGN ovarian cells, but not MCF-7 cells. The addition of both γ-tocopherol and α-tocopherol to the chemotherapeutic combination of Dox and cyclophosphamide has the potential to increase in vitro chemotherapeutic efficacy against breast cancer cells whilst decreasing cytotoxicity towards ovarian granulosa cells.

1. Introduction

In Asia, approximately 25% of all breast cancer patients are premenopausal and younger than 35 years old [1]. Worldwide, up to 90% of breast cancer patients can survive for 5 years following diagnosis [2, 3] but it was found that chemotherapy-induced premature ovarian failure and infertility reduce the survivors quality of life [410].

Many types of breast cancer are treated with a combination of chemotherapeutic agents such as doxorubicin (adriamycin) and cyclophosphamide [3, 11, 12]. Clinical administration [13, 14] resulted in plasma concentrations of 1.8±0.4μM doxorubicin within 24h of infusion [15] and serum concentrations of 4-hydroxycyclophosphamide to be approximately 0.02uM 2-4h after administration [16].

Cyclophosphamide, an alkylating agent, requires hepatic activation to form 4-hydroxycyclophosphamide and aldophosphamide, which coexist in equilibrium and diffuse freely into cells. Aldophosphamide is metabolised into phosphoramide mustard [17, 18] which causes intra- and interstrand crosslinking in DNA. This interferes with DNA replication [19] and stimulates apoptosis [17]. A synthetic compound, 4-hydroperoxycyclophosphamide (4-Cyc), is metabolised to 4-hydroxycyclophosphamide in vitro [13, 20] and in vivo [21, 22]. Aldehyde dehydrogenase oxidises aldophosphamide to an inactive metabolite instead of the active phosphoramide mustard, and hence cells with different levels of aldehyde dehydrogenase respond differently to 4-Cyc [18].

Doxorubicin (Dox), an anthracycline agent, intercalates at double strand DNA breaks in a topoisomerase-II dependent manner and inhibits DNA replication, synthesis, and mitosis [23, 24]. Dox also induces the production of reactive oxygen species (ROS) which cause lipid peroxidation and apoptosis [25]. The combined administration of both drugs caused therapeutic synergism in a mouse model [26] that was attributed to these different mechanisms of action: cyclophosphamide crosslinking of DNA strands and Dox prevention of DNA repair [27].

The chemotherapeutic combination of Dox and cyclophosphamide causes premature ovarian failure in premenopausal breast cancer patients [10, 18, 28]. Ovaries contain follicles, a spherical structure consisting of a single oocyte (egg) surrounded by layers of dividing granulosa cells. Granulosa cells produce anti-Müllerian hormone (AMH) which inhibits activation of small, quiescent primordial follicles [29]. It is thought that chemotherapeutics cause granulosa cell death [30, 31], which reduces AMH and results in the activation of primordial follicles [10]. The granulosa cells in the activated follicles proliferate and the follicles grow, but subsequent cycles of Dox and cyclophosphamide therapy cause granulosa cell death and loss of these follicles [32, 33]. Hence chemotherapy to treat breast cancer reduces serum concentrations of AMH, depletes the ovary of its reservoir of quiescent primordial follicles, and advances infertility through premature ovarian failure [10, 34]. The administration of cyclophosphamide to rodents caused a dose-dependent loss of small follicles [32, 35, 36] with DNA double strand breaks in the oocytes [37]. Dox caused apoptosis in mature murine oocytes [38, 39] and the in vivo administration of Dox to mice significantly reduced the numbers of follicles, whilst increasing ovarian apoptosis [40, 41]. It is clear that cyclophosphamide alone, or Dox alone, has adverse effects on the follicular granulosa cells of the ovary, but there are no reports describing the cytotoxic effects of the combined regime (which is used to treat breast cancer patients) on ovarian granulosa cells.

Dox-induced ROS damage was significantly lower in mice administered vitamin E [42, 43], and vitamin E decreased the toxicity of Dox without reducing its effectiveness as chemotherapeutic agent [4449]. Vitamin E consists of eight structurally distinct compounds classified as tocopherols (alpha, beta, gamma, and delta) and tocotrienols (alpha, beta, gamma, and delta) [5053]. Tocopherols have antioxidant activity against ROS-induced lipid peroxidation [54, 55], and gamma tocopherol (γToc) is the prominent form in the human diet [56].

The administration of α-tocopherol (αToc) to 21 breast cancer patients prior to chemotherapy significantly elevated serum concentrations of αToc but did not augment efficacy of the chemotherapeutics and did not decrease toxic side-effects, although ovarian function was not assessed in this study [57]. It seems that long-term dietary supplementation with antioxidant vitamins reduces the incidence, but not the severity, of cancer [58, 59]. Klein et al. [60] reported that αToc did not have anticancer properties in vivo, but when the human breast cancer MCF-7 cell line was used to generate tumours in mice, the dietary administration of either αToc or γToc reduced tumour growth [53]. Delta and γToc increased the levels of proapoptotic proteins, inhibited expression of antiapoptotic proteins in vivo, and also had antitumour activity in animal models of colon and prostate cancer [52]. γToc inhibited the proliferation of human breast cancer cells in vitro [52, 61], delayed the formation of breast cancer tumours in rodent models [52], and induced apoptosis in breast cancer cells via upregulation of DR5 expression [60]. Estrogen metabolism can generate ROS and this may contribute to the pathogenesis of breast cancer [53]. This also suggests that antioxidant tocopherols may have more anticancer activity in vivo than in estrogen-free in vitro systems.

We hypothesised that the combination of Dox and cyclophosphamide would be more cytotoxic in vitro to the human MCF-7 breast cancer cell line and the human ovarian granulosa tumour-derived KGN cell line than each chemotherapeutic agent alone [26]. Both alpha and gamma tocopherol are antioxidants with the potential to reduce chemotherapeutic-induced ROS damage and consequently reduce cytotoxicity, but γToc additionally has anticancer activity. We therefore hypothesised that γToc, but not αToc, would augment the cytotoxic activity of the combined Dox and cyclophosphamide regime in vitro.

2. Materials and Methods

2.1. Chemicals and Reagents

All chemicals and reagents used in this study were obtained from Sigma-Aldrich (Australia), unless specified otherwise.

2.2. Preparation of Solutions

Stock solutions of 100μM doxorubicin (Dox) and 1000μM 4-hydroperoxycyclophosphamide (4-Cyc, ThermoFisher Scientific, Victoria, Australia) were prepared in RPMI media and 10% foetal calf serum (FCS, DKSH, Victoria, Australia) for MCF-7 cells or in DMEM/F12 media and 10% FCS for KGN cells. These solutions were kept at 4°C and -20°C, respectively, for a maximum of 3 months and were diluted immediately before use, because these conditions maintain activity and stability [62, 63]. Stock solutions of alpha and gamma tocopherol (αToc and γToc) were prepared by diluting the compounds in dimethyl sulfoxide (DMSO) to yield solutions of 1000μM. These were stored for a maximum of 3 months at 4°C. Further dilutions in the appropriate cell culture medium were prepared immediately before use, and cells were exposed to 0.8% DMSO. The 0.5% crystal violet stain was prepared in a 50% methanol (99.9% pure). 100% acetic acid was diluted to 33% with demineralised water, to be used as a destaining solution in the crystal violet assay.

2.3. Cell Culture

The MCF-7 human epithelial breast adenocarcinoma cell line was obtained from the America Type Culture Collection (ATCC) and maintained in RPMI media, supplemented with 10% FCS and 1% v/v of 10,000 units/mL penicillin + 10mg/mL streptomycin. Media were replaced every 2-3 days and cells were harvested with 0.1% trypsin/EDTA solution and subcultured twice a week. The KGN human granulosa carcinoma cell line [64] was kindly donated by Dr. Theresa Hickey, Research Centre for Reproductive Health, Department of Obstetrics and Gynaecology, University of Adelaide, and maintained in DMEM/F12 supplemented with insulin (5μg/mL), transferrin (5μg/mL), selenium (5ng/mL, ITS), 10% FCS, and 1% v/v of 10,000 units/mL penicillin + 10mg/mL streptomycin. Although the KGN cell line was derived from an ovarian granulosa cell carcinoma, it can be used as a model for human ovarian granulosa cell growth, apoptosis, and steroid hormone production [64]. Media were replaced every 2-3 days and both cell lines were subcultured twice a week. Cell culture flasks containing 80% confluent cells in exponential growth phase were used for all experiments.

2.4. Effect of Doxorubicin, 4-Hydroperoxycyclophosphamide, and α- and γ-Tocopherol on MCF-7 and KGN Cell Viability

MCF-7 cells (20,000 cells per well) and KGN cells (25,000 cells per well) were added to 96-well microplates. After a 24h adherence period, supernatants were removed and cells were exposed to 100μL of chemotherapeutics or tocopherols (Table 1). The chemotherapeutic doses selected for this in vitro study bracket the clinical, in vivo serum concentrations of Dox [15] and 4-hydroxycyclophosphamide [16] (Table 1). Cells were exposed to chemotherapeutics and tocopherols according to four different schedules: 24h exposure, 24h exposure + 24h culture in media, 24h exposure + 48h culture in media, or 72h continuous exposure where reagents in medium + 10% FCS were replenished every 24h. After exposure to chemotherapeutics and tocopherols, media containing reagents were collected and frozen, and the cell viability was assessed by the crystal violet (CV) assay. Each test condition was examined in three replicate wells and each experiment was repeated on 3 separate occasions (n=3) for the two cell types.

Table 1: Concentrations of chemotherapeutics and tocopherols. Dox: doxorubicin, 4-Cyc: 4-hydroperoxycyclophosphamide, αToc: α-tocopherol, γToc: γ-tocopherol.
2.5. Crystal Violet (CV) Cell Viability Assay

Cell culture supernatants were replaced with 50μL of crystal violet stain (0.5%). The cells were stained and fixed for 10min at room temperature. Excess stain was rinsed away with demineralised water, and cells were left to air-dry overnight. 50μL of destaining solution was added for 10min. The optical density was read at 570nm with correction at 630nm [65]. A crystal violet standard plot was produced in each replicate experiment in which MCF-7 cell densities ranged from 0 to 80,000 and KGN cell densities from 0 to 100,000 cells per well in replicates of 6 for each cell density. Absorbance readings were plotted against cell densities with an average linear correlation of R2 = 0.99 (n=3) replicate experiments for MCF-7 cells and R2 = 0.97 (n=3) replicate experiments for KGN cells. Numbers of viable cells after exposure to chemotherapeutics and/or tocopherols were determined by comparison with the CV standard curve for the same experimental replicate.

2.6. Estradiol Enzyme-Linked Immunosorbent Assay (ELISA)

Supernatants from each KGN culture experiment (n=3) were examined in a competitive estradiol ELISA (Cayman Chemical ELISA, Ann Arbor, MI, USA) that uses a mouse anti-rabbit IgG and an acetylcholinesterase estradiol tracer. Detection ranges from 6.6 to 4000 pg/mL, and the intra-assay coefficient of variation (CoV) ranges from 7.8 to 18.8%. For this study, the estradiol standard was diluted in the DMEM/F12 cell culture medium to give concentrations that ranged from 6.6 to 4000 pg/mL. A separate standard plot was constructed for each experimental replicate (n=3) and the lowest R2 value was 0.99. Concentration of estrogen was determined by comparison with the standard curve. Estrogen/cell concentration was calculated by dividing pg/mL of estrogen for each culture well by the numbers of viable cells in the same well.

3. Statistical Analysis

To examine the dose-dependent effect of chemotherapeutics and/or tocopherols, a one-way ANOVA with Tukey HSD and Bonferroni post hoc was conducted. To examine the effect of the four different exposure schedules on cell viability, an ANOVA was conducted that used the periods of culture as independent factors. Statistical significance was assessed by Tukey HSD and Bonferroni post hoc tests. A one-way ANOVA with Tukey HSD post hoc was conducted to examine estrogen production. These statistical analyses were performed using SPSS statistics software (V22.0 IBM, Australia). Statistical significance was set at p ≤ 0.05. All experiments were performed as three independent replicates, and all data expressed as mean ± standard deviation.

4. Results

KGN (25,000) and MCF-7 (20,000) cells were added to each well, and after 24h adherence and 24h culture in control conditions, there were 113,600±15,600 KGN cells/well and 38,100±4400 MCF-7 cells/well. After 24h adherence and 72h in culture there were 119072±8750 KGN and 83383±13546 MCF-7 cells per well in control medium.

Doxorubicin killed both MCF-7 and KGN cells (Figure 1). A 24h exposure to 5μM Dox significantly decreased MCF-7 to 46±22% (p<0.0001) and KGN to 65±3% (p<0.01) percent of control (n=3, Figure 1(a)). Cells were exposed to Dox for 24h, then the cells were washed and cultured for an additional 24 or 48h in medium alone (Figures 1(b) and 1(c)) with media replenished at 24h intervals. There was a time-dependent decrease in the numbers of viable cells during the subsequent 48h culture (Figures 1(b) and 1(c)). There were similar numbers of viable cells after 72h continuous exposure to Dox (with media replenishment every 24h, Figure 1(d)) as those after 24h exposure and a further 48h culture (Figure 1(c)).

Figure 1: Doxorubicin-induced cytotoxicity. MCF-7 and KGN cells were exposed to Dox 0, 5, 10, 25μM for (a) 24h (24H+), (b) 24h exposure and 24h culture with medium (24H+24H-), (c) 24h exposure and 48h culture with medium (24H+48H-), or (d) 72h continuous exposure (72H+). Complete RPMI (MCF-7) or DMEM/F12 (KGN) without Dox (0μM) was used as a control. Cell viability was assessed by a crystal violet assay, in which cell number was obtained by comparison with a standard curve and % cell viability was calculated from medium control. Means ± SD of 3 independent experiments shown. Data analysed by one-way ANOVA with Tukey’s post hoc test. p ≤ 0.05; p ≤ 0.01, p ≤ 0.0001 compared to control.

4-Cyc had no effect on KGN cell viability (Figure 2(a)) and only the longest 72h exposure to the highest concentration (2.5μM) of 4-Cyc significantly reduced the numbers of viable MCF-7 cells to 56354±1657 cells per well (p<0.05).

Figure 2: Effect of 4-Cyc on cell viability. (a) MCF-7 and (b) KGN cells were exposed to 4-Cyc 0, 0.5, 1, 2.5μM for 24h exposure (24H+), 24h exposure and 24h culture with media (24H+24H-), 24h exposure and 48h culture with media (24H+48H-), or 72h continuous exposure (72H+). Complete RPMI or DMEM/F12 without 4-Cyc (0μM) was used as a control. Cell viability was assessed by a crystal violet assay, in which cell number was obtained by comparison with a standard curve and % cell viability was calculated from medium control. Means ± SD of 3 independent experiments shown. Data analysed by one-way ANOVA with Tukey’s post hoc test.

Exposure to αToc had no significant effect on MCF-7 or KGN cell viability (Figure 3) but γ-Toc was significantly more cytotoxic to MCF-7 cells than to KGN cells (Figure 4). A dose- and time-dependent decrease in MCF-7 cell viability were observed after a 24h or a 72h continuous exposure to γToc (Figure 4), but increasing concentrations of γToc had no significant effects on KGN cell viability compared to the vehicle control (Figure 4). The percentage of viable KGN cells after 24h exposure to 100μM γToc was 113±16% per cells/well, similar to the percentage of viable cells after exposure to the same concentration of αToc (109±13% cells/well, Figure 3).

Figure 3: Effect of αToc on cell viability. MCF-7 and KGN cells were exposed to αToc 0, 50, 75, 100μM for 24h exposure (24H+), 24h exposure and 24h culture with media (24H+24H-), 24h exposure and 48h culture with media (24H+48H-), or 72h continuous exposure (72H+). Culture media containing 0.8% DMSO was used as a control. Cell viability was assessed by a crystal violet assay, in which cell number was obtained by comparison with a standard curve and % cell viability was calculated from vehicle control. Means ± SD of 3 independent experiments shown. Data analysed by one-way ANOVA with Tukey’s post hoc test.
Figure 4: Effect of γToc on cell viability. MCF-7 and KGN cells were exposed to γToc 0, 50, 75, 100μM for 24h exposure (24H+), 24h exposure and 24h culture with media (24H+24H-), 24h exposure and 48h culture with media (24H+48H-), or 72h continuous exposure (72H+). 0.8% DMSO in RPMI or DMEM/F12 was used as a control. Cell viability was assessed by a crystal violet assay, in which cell number was obtained by comparison with a standard curve and % cell viability was calculated from vehicle control. Means ± SD of 3 independent experiments shown. Data analysed by one-way ANOVA with Tukey’s post hoc test. p ≤ 0.05; p ≤ 0.01, p ≤ 0.0001 compared to control.

The viability of MCF-7 cells was reduced to 31±7% percent of control by a 24h exposure to the low concentration combination of Dox (10μM) and 4-Cyc (1μM), similar to that observed with the same (10μM) concentration of Dox alone (data not shown). When the MCF-7 cells were exposed to the combination of higher concentrations of Dox (25μM) and 4-Cyc (2.5μM) for 24h, the combination also had the same effect as Dox (25μM) alone; viable MCF-7 cells were reduced to 16±6% of control (Figure 5(a)). Adding αToc to this combination had no effect on cell viability (23±7% of control), but the addition of γToc (75μM) to the combination decreased MCF-7 cell viability to 9±3% cells per well after 24h exposure, significantly lower than Dox alone (p<0.05, Figure 5(a)) or 4-Cyc alone (2.5μM, Figure 2(a), 95±13% of control), or compared to the combination of Dox and 4-Cyc (Figure 5(a)).

Figure 5: Cytotoxicity of combined chemotherapeutic regime. (a) MCF-7 and (b) KGN cells were exposed to a combination of chemotherapeutics (25μM Dox + 2.5μM 4-Cyc), or a combination of chemotherapeutics + 75μM αToc, or a combination of chemotherapeutics + 75μM γToc for 24h (24H+); 24h exposure and 24h culture with media (24H+24H-); 24h exposure and 48h culture with media (24H+48H-); or 72h continuous exposure (72H+). Cell viability was assessed by a crystal violet assay, in which cell number was obtained by comparison with a standard cue and % cell viability was calculated from vehicle control. Means ± SD of 3 independent experiments shown. Data analysed by one-way ANOVA with Tukey’s post hoc test. p ≤ 0.05; p ≤ 0.01, p ≤ 0.0001 compared to control same concentration of doxorubicin alone (25μM).

The combination of Dox (25μM) and 4-Cyc (2.5μM) caused significantly more KGN cell death than Dox alone (Figure 5(b)). After 72h exposure to this combination there were 1763±1494 KGN cells per well (1.4±1 % of control, Figure 5(b)), significantly lower than those after a 72h exposure to Dox alone (10555±4797, p<0.01), equivalent to 8.7±3.4 percent of control (Figure 5(b)). The addition of αToc to this combination reduced KGN cell death so that it was the similar to Dox alone, 7305±1823 cells per well, equivalent to 7.9±1 percent of control (Figure 5(b)). The addition of γToc to the combination did not augment the cytotoxicity of Dox and 4-Cyc in KGN cells (Figure 5(a)). Overall, γToc combined with Dox and 4-Cyc was more cytotoxic towards MCF-7 than KGN cells in the first 24h of culture (Figure 5).

After 24h culture KGN cells produced 1.2±0.1 pg/cell of estrogen and 0.8±0.08 pg/cell in the last 24h of a 72h culture under control conditions (Figures 6(a) and 6(b)). A 24h exposure to 5μM Dox significantly reduced KGN cell viability (Figure 1(a)) but had no effect on estrogen per cell production, which was 1.2±0.03 pg/cell (Figure 6(a)). However, a continuous 72h exposure to Dox, during which media were replenished every 24h and the number of viable cells decreased (Figure 1(d)), caused a significant increase to 13±3 pg/cell (p<0.01, Figure 6(a)) in the last 24h culture period. The same 72h continuous exposure to 2.5μM 4-Cyc had no effect on cell viability (Figure 2(b)) and no effect on estrogen production, which was 0.81±0.08 pg/cell in the last 24h culture period (Figure 6(b)).

Figure 6: Effect of chemotherapeutics and tocopherols on estrogen production. KGN cells were exposed to Dox (0, 5, 10, 25μM), 4-Cyc (0, 0.5, 1, 2.5μM), αToc (0, 50, 75, 100μM) or γToc (0, 50, 75, 100μM) for 24h exposure (24h+), 24h exposure and 24h culture with fresh DMEM/F-12 complete medium (24h+24h-), 24h exposure and 48h culture with DMEM/F-12 complete medium (24h+48h-), or 72h continuous exposure where reagents in medium + 10% FCS were replenished every 24h (72h+). Estrogen production was assessed in supernatant at the end of each exposure using an estradiol Enzyme-Linked Immunoassay, in which concentration of estrogen (pg/mL) was obtained by comparison with a standard curve, and estrogen/cell concentration was calculated by dividing pg/mL of estrogen by the number of viable cells in the same well. Means ± SD of 3 independent experiments shown. Data analysed by one-way ANOVA with Tukey’s post hoc test. p ≤ 0.05; p ≤ 0.01, p ≤ 0.0001 compared to the same exposure control.

When KGN cells were exposed to tocopherols, the 24h+48h- control KGN cells were exposed to almost the same conditions as the 72h+ control cells, 72h in vitro with media replenished every 24h. The only difference was that the 72h+ continuously exposed cells were cultured with 0.8% DMSO throughout, whereas the 24h+48h- control KGN cells were only cultured in the presence of 0.8% DMSO for the first 24h. The 72h+ exposure to 0.8% DMSO did not significantly affect KGN cell viability (Figure 3(b)), but it stimulated significantly more estrogen production (1.32±0.07 pg/cell) in the last 24h period of culture than the 24h+48h- exposure which supported production of 0.76±0.14 pg/cell (p< 0.05, Figures 6(c) and 6(d)).

KGN cells in the 0.8% DMSO control produced 1.1±0.4 pg/cell after 24h in vitro. The same 24h exposure to αToc had no effect on estrogen per cell production (Figure 6(c)) whereas 100μM γToc stimulated the production of 1.6±0.5 pg/cell (Figure 6(d)). A 72h continuous exposure to either αToc or γToc significantly reduced estrogen per cell production compared to control medium containing 0.8% DMSO (Figures 6(c) and 6(d)). The highest (100μM) concentration of αToc and γToc supported higher levels of estrogen synthesis than the lowest (50μM) concentrations of the tocopherols.

A continuous 72h exposure to the combination of Dox and 4-Cyc reduced cell viability (Figure 5(b)) but stimulated the highest recorded estrogen per cell production; 39±22 pg/cell in the last 24h culture period (Figure 7). This was also higher than the estrogen per cell concentration caused by 72h exposure to Dox alone (Figure 6(a)). The addition of αToc or γToc to the combination of Dox and 4-Cyc had no statistically significant effect on estrogen per cell production (Figure 7), although it was noted that 72h exposure to the combination of Dox and 4-Cyc with 75μM αToc resulted in 13±2 pg/cell.

Figure 7: Effect of chemotherapeutics and tocopherols on estrogen production. Combined chemotherapeutic regime (25μM Dox with 2.5μM 4-Cyc), combined regime + 75μM αToc, or combined regime + 75μM γToc for 24h exposure (24h+), 24h exposure and 24h culture with fresh DMEM/F-12 complete medium (24h+24h-), 24h exposure and 48h culture with DMEM/F-12 complete medium (24h+48h-), or 72h continuous exposure where reagents in medium + 10% FCS were replenished every 24h (72h+). Estrogen production was assessed in supernatant at the end of each exposure by using an estradiol ELISA, in which concentration of estrogen (pg/mL) was obtained by comparison with a standard curve, and estrogen/cell concentration was calculated by dividing pg/mL of estrogen by the number of viable cells in the same well. Means ± SD of 3 independent experiments shown. Data analysed by one-way ANOVA with Tukey’s post hoc test. p ≤ 0.05; p ≤ 0.01, p ≤ 0.0001 compared to control same concentration of doxorubicin alone (10μM).

5. Discussion

The combination of Dox and cyclophosphamide has been used as a standard chemotherapy option for breast cancer patients since 1975 [3, 66]. Although it is a successful treatment for breast cancer [2], it causes premature ovarian failure and infertility [10]. This study showed for the first time that the combination of Dox and 4-Cyc caused the same cytotoxicity to MCF-7 breast cancer cells in vitro as Dox alone, but there were different cytotoxic effects towards the KGN ovarian granulosa cell line; the Dox and 4-Cyc combination was significantly more cytotoxic than Dox alone. Similarly, γToc affected the two cell lines differently; it augmented the cytotoxicity of the Dox and 4-Cyc combination towards MCF-7 cells but did not affect cytotoxicity of the combination towards the KGN cells.

Breast cancer patients are administered multiple cycles of Dox and cyclophosphamide [3], and although this can result in 90% survival for 5y [2], chemotherapeutic-resistant cells are known to cause recurrence of the cancer. The exposure and culture schedules used in this in vitro study resulted in only 54% of MCF-7 and 35% of KGN cells being killed in the first 24h of exposure. In our in vitro model ‘viable’ meant cells were adherent to the floor of the culture vessel, whereas nonadherent dead cells were washed away. Cells with damaged DNA may still function and adhere to the culture vessel, and it is likely that DNA damage is only manifested as cell death or loss in the crystal violet assay when the cell attempts to go through mitosis. Since the doubling time for MCF-7 is 29h [67] and was originally reported as being 46h for the KGN cell line [64], we expected to see further cell loss in the 48–72h following removal of the chemotherapeutics, and this proved to be the case; fewer than 10% of the cells were viable after 72h in vitro. We conclude that additional time in culture, sufficient for the MCF-7 to undergo mitosis, would be needed to be able to determine if this surviving ≤10% would give rise to Dox-resistant cells or if these would also die. Further development is required to determine if this in vitro system can be used to derive chemoresistant cells.

Resistance or sensitivity to chemotherapeutics in vivo is affected by a number of interacting factors including the hepatic clearance of the chemotherapeutics and intracellular levels of metabolising enzymes such as glutathione S-transferase [68] or aldehyde dehydrogenase, which in vitro metabolises 4-Cyc to its inactive form [18]. KGN cells were more sensitive to Dox but less sensitive to 4-Cyc than MCF-7 cells. We concluded this because a 72h continuous exposure to 4-Cyc reduced the number of viable MCF-7 cells but had no effect on KGN cells. It is possible that KGN cells express higher levels of aldehyde dehydrogenase than MCF-7 cells and hence metabolised 4-Cyc to its inactive form [62].

A relatively short 24h in vitro exposure to 2.5μM 4-Cyc had no effect on MCF-7 cells, although this concentration is two orders of magnitude higher than the plasma concentration (0.02μM) of the pharmacologically equivalent 4-hydroxycyclophosphamide 2-24h after administration of cyclophosphamide in vivo. The pharmacokinetics of cyclophosphamide has been well characterised [6971], but much less is known about the kinetics of the metabolites of cyclophosphamide. The hepatic metabolite 4-hydroxycyclophosphamide has a plasma half-life of only a few minutes in vivo [71] because it undergoes spontaneous alteration into phosphoramide mustard [17, 18]. However, phosphoramide mustard may be ionised at physiological pH with a consequent reduction in cytotoxicity, and the oxidation of 4-hydroxycyclophosphamide can produce inactive metabolites [71]. Therefore, the clinically relevant dose of cyclophosphamide necessary to treat breast cancer patients might differ from the in vitro effective concentration.

Dox was more cytotoxic to MCF-7 cells than 4-Cyc. Although 2.5μM 4-Cyc did kill MCF-7 cells after 72h continuous exposure, when the same 2.5μM concentration of 4-Cyc was combined with Dox for 72h, the numbers of surviving cells were comparable to those recorded after exposure to Dox alone, suggesting that in this in vitro model 4-Cyc did not potentiate the in vitro effect of Dox in the MCF-7 cells. Corbett et al. [26] found that the growth of murine mammary adenocarcinomas in vivo was slower after administration of Dox as a single agent than after cyclophosphamide alone, meaning that the Dox was more cytotoxic than cyclophosphamide in vivo. However, the combination of Dox and cyclophosphamide delayed the in vivo development of mammary adenocarcinomas for longer than after the administration of each single agent [26] which suggested therapeutic synergism between the two chemotherapeutics in vivo.

The combination of Dox and 4-Cyc reduced MCF-7 viability by 85% whereas exposure to 75μM γToc for 24h caused a 20% reduction in viable cell numbers. The addition of 75μM γToc to Dox and 4-Cyc for 24h reduced cell viability by 91%, less than the amount of cytotoxicity predicted by adding the activity of γToc to Dox and 4-Cyc. More studies using lower concentrations of reagents are needed to determine if there are synergistic interactions between γToc, Dox, and 4-Cyc.

A long 72h continuous exposure to 2.5μM 4-Cyc had no effect on KGN cell viability nor estrogen per cell production, a 72h exposure to Dox was cytotoxic, and exposure to the combination of Dox and 2.5μM 4-Cyc was more cytotoxic than exposure to Dox alone. This result suggested synergism between Dox and 4-Cyc, but a mechanism for that synergism cannot be deduced from this study. It is possible that 4-Cyc caused DNA crosslinking [18], but this damage was repaired in KGN cells exposed to 4-Cyc alone, whereas the addition of Dox to 4-Cyc prevented the damage from being repaired [27] and hence caused KGN cell death.

In a previous study, KGN cells incubated with androstenedione for 72h synthesised and secreted significant amounts of estrogen into the culture medium [64]. In the present study, a 24h culture in DMEM/F-12 medium containing 10% FCS and ITS resulted in the production of 1.2±0.1 pg/cell, and that rate of production was maintained for 72h when the culture medium was replenished every 24h. Foetal calf serum is rich in fatty acids and cholesterol, the substrate for the whole steroidogenic pathway [72]. Fatty acids, like arachidonic acid, play an essential role in StAR protein expression [73] and the in vitro synthesis of steroid hormones such as progesterone and estrogen. In this study, the use of DMEM/F12 with 10% FCS and ITS was enough to support steroidogenesis; androstenedione was not required to support estrogen synthesis and secretion.

Bak et al. [53] reported that estrogen induced the expression of cyclin D1 and c-myc and hence increased mitosis in MCF-7 cells in vitro, and that γToc, but not αToc, inhibited expression of these cell-cycle genes and reduced estrogen-stimulated MCF-7 cell proliferation. The MCF-7 cells in our study were not exposed to estrogen; therefore this was not the cause of the significant cell death caused by γToc in our study, suggesting that γToc is cytotoxic through another estrogen-independent mechanism of action. Lee et al. [61] showed that γToc was cytotoxic to breast cancer cells because it enhanced the transactivation of PPARγ which caused apoptosis and inhibited cell-cycle progression. γToc has also shown anticancer activity in numerous cancer models, including colon [74], prostate [75], and lung cancer [76] in the absence of estrogen. KGN cells synthesised estrogen, which raises the possibility that there may have been interactions between estrogen and γToc, but γToc alone did not cause cytotoxicity towards KGN cells in the presence of 75 to 183 pg/mL estrogen, and neither did γToc increase the cytotoxicity of the combination of Dox and 4-Cyc, which suggests that the proapoptotic effect that Bak et al. [53] reported in estrogen-stimulated MCF-7 exposed to γToc does not apply to KGN cells.

Exposure to Dox for 72h caused significant KGN cell death and, counterintuitively, also caused a significant increase in estrogen production per KGN cell. This effect has been reported in other steroid hormone-synthesising reproductive cell lines in vitro. An extract from a marine snail was significantly cytotoxic to a human Jar choriocarcinoma placental cell line. As the number of viable cells decreased, secreted progesterone increased [77]. Gross et al. [78] also described dying primary-derived granulosa cells increasing progesterone production. It is possible that the cytotoxic mechanisms of action in these cases disrupted membranes and dysregulated steroidogenesis, resulting in massive overproduction of steroid hormones. This confounding effect might be avoided in future by measuring production of another nonsteroid hormone, AMH, which is important for fertility.

Four test reagents (γToc, αToc, Dox, and 4-Cyc) were each tested at several different concentrations in four exposure schedules. This generated a relatively high number of test conditions which justified the use of human cell lines. Further studies examining ROS generation and cell death will support the selection of a reduced number of test conditions. At this point MCF-7 cells could be replaced with heterogeneous populations of primary-derived breast cancer cells from different tumour types, and the KGNS could be replaced with 3D primary-derived ovarian follicle culture [79] to better model the effects of chemotherapeutics with or without tocopherols on breast cancer and the ovary.

In summary, 4-Cyc was active because a 72h continuous exposure killed MCF-7 cells and reduced KGN estrogen per cell production. Both γToc and Dox (applied as single agents) significantly reduced the numbers of viable MCF-7 and KGN cells within 24h of exposure, whilst αToc reduced the cytotoxic effects of the Dox and 4-Cyc combination in KGN cells. The 4-Cyc concentration, despite two orders of magnitude higher than effective clinical plasma concentrations, may have been too low for this in vitro model; hence we do not exclude the possibility of therapeutic synergism of the Dox and 4-Cyc combination in MCF-7 cells too. Our hypotheses were partially supported: although the Dox and 4-Cyc combination was not more cytotoxic than Dox alone towards MCF-7 cells, the combination displayed therapeutic synergism towards the ovarian KGN granulosa cells. γToc, but not αToc, augmented the cytotoxic activity of Dox and 4-Cyc in the MCF-7 cells, but not the KGN cells. This study supports further work to explore the potential of γToc to increase the chemotherapeutic efficacy of Dox and 4-Cyc against breast cancer cells in vitro.

Abbreviations

Dox:Doxorubicin
4-Cyc:4-Hydroperoxycyclophosphamide
ROS:Reactive oxygen species
AMH:Anti-Müllerian hormone
:Alpha tocopherol
:Gamma tocopherol.

Data Availability

The raw data for cell viability assay and ELISA, used to support the findings of this study, may be released upon reasonable request to the corresponding author, who can be contacted at daniela.figueroa@flinders.edu.au. The graphs used to support the findings of this study are included within the article.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors’ Contributions

Daniela Figueroa and Mohammad Asaduzzaman contributed equally to this work.

References

  1. V. Tiong, A. M. Rozita, N. A. Taib, C. H. Yip, and C. H. Ng, “Incidence of chemotherapy-induced ovarian failure in premenopausal women undergoing chemotherapy for breast cancer,” World Journal of Surgery, vol. 38, no. 9, pp. 2288–2296, 2014. View at Publisher · View at Google Scholar · View at Scopus
  2. J. Ferlay, I. Soerjomataram, R. Dikshit et al., “Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012,” International Journal of Cancer, vol. 136, no. 5, 2015. View at Publisher · View at Google Scholar
  3. D. A. Yardley, E. R. Arrowsmith, B. R. Daniel et al., “TITAN: phase III study of doxorubicin/cyclophosphamide followed by ixabepilone or paclitaxel in early-stage triple-negative breast cancer,” Breast Cancer Research and Treatment, vol. 164, no. 3, pp. 649–658, 2017. View at Publisher · View at Google Scholar · View at Scopus
  4. V. Mor, M. Malin, and S. Allen, “Age differences in the psychosocial problems encountered by breast cancer patients.,” Journal of the National Cancer Institute Monographs, no. 16, pp. 191–197, 1994. View at Google Scholar · View at Scopus
  5. P. A. Ganz, J. H. Rowland, K. Desmond, B. E. Meyerowitz, and G. E. Wyatt, “Life after breast cancer: understanding women's health-related quality of life and sexual functioning,” Journal of Clinical Oncology, vol. 16, no. 2, pp. 501–514, 1998. View at Publisher · View at Google Scholar · View at Scopus
  6. P. A. Ganz, G. A. Greendale, L. Petersen, B. Kahn, and J. E. Bower, “Breast cancer in younger women: Reproductive and late health effects of treatment,” Journal of Clinical Oncology, vol. 21, no. 22, pp. 4184–4193, 2003. View at Publisher · View at Google Scholar · View at Scopus
  7. P. A. Ganz, “Breast cancer, menopause, and long-term survivorship: Critical issues for the 21st century,” American Journal of Medicine, vol. 118, no. 12, pp. 136–141, 2005. View at Publisher · View at Google Scholar · View at Scopus
  8. D. H. Baucom, L. S. Porter, J. S. Kirby, T. M. Gremore, and F. J. Keefe, “Psychosocial issues confronting young women with breast cancer,” Breast Disease, vol. 23, pp. 103–113, 2005. View at Publisher · View at Google Scholar · View at Scopus
  9. A. B. Mariotto, J. H. Rowland, L. A. G. Ries, S. Scoppa, and E. J. Feuer, “Multiple cancer prevalence: A growing challenge in long-term survivorship,” Cancer Epidemiology, Biomarkers & Prevention, vol. 16, no. 3, pp. 566–571, 2007. View at Publisher · View at Google Scholar · View at Scopus
  10. S. Morgan, R. A. Anderson, C. Gourley, W. H. Wallace, and N. Spears, “How do chemotherapeutic agents damage the ovary?” Human Reproduction Update, vol. 18, no. 5, pp. 525–535, 2012. View at Publisher · View at Google Scholar · View at Scopus
  11. J.-M. Nabholtz, C. Falkson, D. Campos et al., “Docetaxel and doxorubicin compared with doxorubicin and cyclophosphamide as first-line chemotherapy for metastatic breast cancer: results of a randomized, multicenter, phase III trial,” Journal of Clinical Oncology, vol. 21, no. 6, pp. 968–975, 2003. View at Publisher · View at Google Scholar · View at Scopus
  12. J. Bray, J. Sludden, M. J. Griffin et al., “Influence of pharmacogenetics on response and toxicity in breast cancer patients treated with doxorubicin and cyclophosphamide,” British Journal of Cancer, vol. 102, no. 6, pp. 1003–1009, 2010. View at Publisher · View at Google Scholar · View at Scopus
  13. E. Claire Dees, S. O'Reilly, S. N. Goodman et al., “A prospective pharmacologic evaluation of age-related toxicity of adjuvant chemotherapy in women with breast cancer,” Cancer Investigation, vol. 18, no. 6, pp. 521–529, 2000. View at Publisher · View at Google Scholar · View at Scopus
  14. S. E. Jones, M. A. Savin, F. A. Holmes et al., “Phase III trial comparing doxorubicin plus cyclophosphamide with docetaxel plus cyclophosphamide as adjuvant therapy for operable breast cancer,” Journal of Clinical Oncology, vol. 24, no. 34, pp. 5381–5387, 2006. View at Publisher · View at Google Scholar · View at Scopus
  15. C. E. Swenson, L. E. Bolcsak, G. Batist et al., “Pharmacokinetics of doxorubicin administered i.v. as Myocet (TLC D-99; liposome-encapsulated doxorubicin citrate) compared with conventional doxorubicin when given in combination with cyclophosphamide in patients with metastatic breast cancer,” Anti-Cancer Drugs, vol. 14, no. 3, pp. 239–246, 2003. View at Publisher · View at Google Scholar · View at Scopus
  16. R. F. Struck, D. S. Alberts, K. Horne, J. G. Phillips, Y.-M. Peng, and D. J. Roe, “Plasma Pharmacokinetics of Cyclophosphamide and Its Cytotoxic Metabolites after Intravenous versus Oral Administration in a Randomized, Crossover Trial,” Cancer Research, vol. 47, no. 10, pp. 2723–2726, 1987. View at Google Scholar · View at Scopus
  17. A. V. Boddy and S. M. Yule, “Metabolism and pharmacokinetics of oxazaphosphorines,” Clinical Pharmacokinetics, vol. 38, no. 4, pp. 291–304, 2000. View at Publisher · View at Google Scholar · View at Scopus
  18. A. Emadi, R. J. Jones, and R. A. Brodsky, “Cyclophosphamide and cancer: golden anniversary,” Nature Reviews Clinical Oncology, vol. 6, no. 11, pp. 638–647, 2009. View at Publisher · View at Google Scholar · View at Scopus
  19. Q. Dong, D. Barskt, M. E. Colvin et al., “A structural basis for a phosphoramide mustard-induced DNA interstrand cross-link at 5-d(GAC),” Proceedings of the National Acadamy of Sciences of the United States of America, vol. 92, no. 26, pp. 12170–12174, 1995. View at Publisher · View at Google Scholar · View at Scopus
  20. H. Ozer, J. W. Cowens, M. Colvin, A. Nussbaum-Blumenson, and D. Sheedy, “In vitro effects of 4-hydroperoxycyclophosphamide on human immunoregulatory T subset function. I. Selective effects on lymphocyte function in T-B cell collaboration,” The Journal of Experimental Medicine, vol. 155, no. 1, pp. 276–290, 1982. View at Publisher · View at Google Scholar · View at Scopus
  21. B. A. Teicher, S. A. Holden, D. A. Goff, J. E. Wright, O. Tretyakov, and L. J. Ayash, “Antitumor efficacy and pharmacokinetic analysis of 4-hydroperoxycyclophosphamide in comparison with cyclophosphamide ± hepatic enzyme effectors,” Cancer Chemotherapy and Pharmacology, vol. 38, no. 6, pp. 553–560, 1996. View at Publisher · View at Google Scholar · View at Scopus
  22. A. Yuksel, G. Bildik, F. Senbabaoglu et al., “The magnitude of gonadotoxicity of chemotherapy drugs on ovarian follicles and granulosa cells varies depenDing upon the category of the drugs and the type of granulosa cells,” Human Reproduction, vol. 30, no. 12, pp. 2926–2935, 2015. View at Publisher · View at Google Scholar · View at Scopus
  23. K. M. Tewey, T. C. Rowe, L. Yang, B. D. Halligan, and L. F. Liu, “Adriamycin-induced DNA damage mediated by mammalian DNA topoisomerase II,” Science, vol. 226, no. 4673, pp. 466–468, 1984. View at Publisher · View at Google Scholar · View at Scopus
  24. C. F. Thorn, C. Oshiro, S. Marsh et al., “Doxorubicin pathways: pharmacodynamics and adverse effects,” Pharmacogenetics and Genomics, vol. 21, no. 7, pp. 440–446, 2011. View at Publisher · View at Google Scholar · View at Scopus
  25. D. A. Gewirtz, “A critical evaluation of the mechanisms of action proposed for the antitumor effects of the anthracycline antibiotics adriamycin and daunorubicin,” Biochemical Pharmacology, vol. 57, no. 7, pp. 727–741, 1999. View at Publisher · View at Google Scholar · View at Scopus
  26. T. H. Corbett, D. P. Griswold, J. G. Mayo, W. R. Laster, and F. M. Schabel, “Cyclophosphamide-Adriamycin Combination Chemotherapy of Transplantable Murine Tumors,” Cancer Research, vol. 35, no. 6, pp. 1568–1573, 1975. View at Google Scholar · View at Scopus
  27. J. S. Tobias, L. M. Parker, M. H. Tattersall, and E. Frei, “Adriamycin/cyclophosphamide and adriamycin/melphalan in advanced L1210 leukaemia,” British Journal of Cancer, vol. 32, no. 2, pp. 199–207, 1975. View at Publisher · View at Google Scholar · View at Scopus
  28. D. Meirow, H. Biederman, R. A. Anderson, and W. H. B. Wallace, “Toxicity of chemotherapy and radiation on female reproduction,” Clinical Obstetrics and Gynecology, vol. 53, no. 4, pp. 727–739, 2010. View at Publisher · View at Google Scholar · View at Scopus
  29. A. L. L. Durlinger, P. Kramer, B. Karels et al., “Control of primordial follicle recruitment by anti-mullerian hormone in the mouse ovary,” Endocrinology, vol. 140, no. 12, pp. 5789–5796, 1999. View at Publisher · View at Google Scholar · View at Scopus
  30. S. M. Downs and A. M. Utecht, “Metabolism of radiolabeled glucose by mouse oocytes and oocyte-cumulus cell complexes,” Biology of Reproduction, vol. 60, no. 6, pp. 1446–1452, 1999. View at Publisher · View at Google Scholar · View at Scopus
  31. X.-J. Zhao, Y.-H. Huang, Y.-C. Yu, and X.-Y. Xin, “GnRH antagonist cetrorelix inhibits mitochondria-dependent apoptosis triggered by chemotherapy in granulosa cells of rats,” Gynecologic Oncology, vol. 118, no. 1, pp. 69–75, 2010. View at Publisher · View at Google Scholar · View at Scopus
  32. O. Oktem and K. Oktay, “Quantitative assessment of the impact of chemotherapy on ovarian follicle reserve and stromal function,” Cancer, vol. 110, no. 10, pp. 2222–2229, 2007. View at Publisher · View at Google Scholar · View at Scopus
  33. R. Soleimani, E. Heytens, Z. Darzynkiewicz, and K. Oktay, “Mechanisms of chemotherapy-induced human ovarian aging: double strand DNA breaks and microvascular compromise.,” AGING, vol. 3, no. 8, pp. 782–793, 2011. View at Publisher · View at Google Scholar · View at Scopus
  34. M. S. Yucebilgin, M. C. Terek, A. Ozsaran et al., “Effect of chemotherapy on primordial follicular reserve of rat: An animal model of premature ovarian failure and infertility,” Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 44, no. 1, pp. 6–9, 2004. View at Publisher · View at Google Scholar · View at Scopus
  35. D. Meirow, H. Lewis, D. Nugent, and M. Epstein, “Subclinical depletion of primordial follicular reserve in mice treated with cyclophosphamide: Clinical importance and proposed accurate investigative tool,” Human Reproduction, vol. 14, no. 7, pp. 1903–1907, 1999. View at Publisher · View at Google Scholar · View at Scopus
  36. P. Desmeules and P. J. Devine, “Characterizing the ovotoxicity of cyclophosphamide metabolites on cultured mouse ovaries,” Toxicological Sciences, vol. 90, no. 2, pp. 500–509, 2006. View at Publisher · View at Google Scholar · View at Scopus
  37. S. K. Petrillo, P. Desmeules, T.-Q. Truong, and P. J. Devine, “Detection of DNA damage in oocytes of small ovarian follicles following phosphoramide mustard exposures of cultured rodent ovaries in vitro,” Toxicology and Applied Pharmacology, vol. 253, no. 2, pp. 94–102, 2011. View at Publisher · View at Google Scholar · View at Scopus
  38. G. I. Perez, C. M. Knudson, L. Leykin, S. J. Korsmeyer, and J. L. Tilly, “Apoptosis-associated signaling pathways are required for chemotherapy- mediated female germ cell destruction,” Nature Medicine, vol. 3, no. 11, pp. 1228–1232, 1997. View at Publisher · View at Google Scholar · View at Scopus
  39. A. Jurisicova, H.-J. Lee, S. G. D'Estaing, J. Tilly, and G. I. Perez, “Molecular requirements for doxorubicin-mediated death in murine oocytes,” Cell Death & Differentiation, vol. 13, no. 9, pp. 1466–1474, 2006. View at Publisher · View at Google Scholar · View at Scopus
  40. I. Ben-Aharon, H. Bar-Joseph, G. Tzarfaty et al., “Doxorubicin-induced ovarian toxicity,” Reproductive Biology and Endocrinology, vol. 8, article no. 20, 2010. View at Publisher · View at Google Scholar · View at Scopus
  41. E. C. Roti Roti, S. K. Leisman, D. H. Abbott, and S. M. Salih, “Acute doxorubicin insult in the mouse ovary is cell- and follicle-type dependent,” PLoS ONE, vol. 7, no. 8, Article ID e42293, 2012. View at Google Scholar · View at Scopus
  42. Y. Nagata, J. Takata, A. Yoshiharu Karube, and Y. Matsushima, “Effects of a water-soluble prodrug of vitamin E on doxorubicin-induced toxicity in mice,” Biological & Pharmaceutical Bulletin, vol. 22, no. 7, pp. 698–702, 1999. View at Publisher · View at Google Scholar · View at Scopus
  43. M. I. Thabrew, N. Samarawickrema, L. G. Chandrasena, and S. Jayasekera, “Effect of oral supplementation with vitamin E on the oxido-reductive status of red blood cells in normal mice and mice subject to oxidative stress by chronic administration of Adriamycin,” Annals of Clinical Biochemistry, vol. 36, no. 2, pp. 216–220, 1999. View at Publisher · View at Google Scholar · View at Scopus
  44. C. E. Myers, W. McGuire, and R. Young, “Adriamycin: amelioration of toxicity by α tocopherol,” Cancer Treatment Reports, vol. 60, no. 7, pp. 961-962, 1976. View at Google Scholar · View at Scopus
  45. W. Krivit, “Adriamycin cardiotoxicity amelioration by α-tocopherol,” Journal of Pediatric Hematology/Oncology, vol. 1, no. 2, pp. 151–153, 1979. View at Google Scholar · View at Scopus
  46. W. C. Lubawy, J. Whaley, and L. H. Hurley, “Coenzyme Q10 or α-tocopherol reduce the acute toxicity of anthramycin in mice,” Research Communications in Chemical Pathology and Pharmacology, vol. 24, no. 2, pp. 401–404, 1979. View at Google Scholar · View at Scopus
  47. E. H. Herman and V. J. Ferrans, “Influence of vitamin E and ICRF-187 on chronic doxorubicin cardiotoxicity in miniature swine,” Laboratory Investigation, vol. 49, no. 1, pp. 69–77, 1983. View at Google Scholar · View at Scopus
  48. J. Milei, A. Boveris, S. Llesuy et al., “Amelioration of adriamycin-induced cardiotoxicity in rabbits by prenylamine and vitamins A and E,” American Heart Journal, vol. 111, no. 1, pp. 95–102, 1986. View at Publisher · View at Google Scholar · View at Scopus
  49. A. Geetha, R. Sankar, T. Marar, and C. S. Shyamala Devi, “α-Tocopherol reduces doxorubicin-induced toxicity in rats - histological and biochemical evidences,” Indian Journal of Physiology and Pharmacology, vol. 34, no. 2, pp. 94–100, 1990. View at Google Scholar · View at Scopus
  50. R. Brigelius-Flohé, F. J. Kelly, J. T. Salonen, J. Neuzil, J. Zingg, and A. Azzi, “The European perspective on vitamin E: current knowledge and future research,” American Journal of Clinical Nutrition, vol. 76, no. 4, pp. 703–716, 2002. View at Publisher · View at Google Scholar
  51. G. Lu, H. Xiao, G.-X. Li et al., “A γ-tocopherol-rich mixture of tocopherols inhibits chemically induced lung tumorigenesis in A/J mice and xenograft tumor growth,” Carcinogenesis, vol. 31, no. 4, pp. 687–694, 2010. View at Publisher · View at Google Scholar · View at Scopus
  52. A. K. Smolarek and N. Suh, “Chemopreventive activity of vitamin e in breast cancer: A focus on γ- and δ-tocopherol,” Nutrients, vol. 3, no. 11, pp. 962–986, 2011. View at Publisher · View at Google Scholar · View at Scopus
  53. M. J. Bak, S. Das Gupta, J. Wahler et al., “Inhibitory Effects of γ- and δ-Tocopherols on Estrogen-Stimulated Breast Cancer,” Cancer Prevention Research, vol. 10, no. 3, pp. 188–197, 2017. View at Publisher · View at Google Scholar
  54. M. G. Traber, “Vitamin E regulatory mechanisms,” Annual Review of Nutrition, vol. 27, no. 1, pp. 347–362, 2007. View at Publisher · View at Google Scholar · View at Scopus
  55. M. G. Traber and J. Atkinson, “Vitamin E, antioxidant and nothing more,” Free Radical Biology & Medicine, vol. 43, no. 1, pp. 4–15, 2007. View at Publisher · View at Google Scholar · View at Scopus
  56. R. B.-F. Brigelius-Flohé and M. G. Traber, “Vitamin E: function and metabolism,” The FASEB Journal, vol. 13, no. 10, pp. 1145–1155, 1999. View at Publisher · View at Google Scholar · View at Scopus
  57. S. S. Legha, R. S. Benjamin, B. Mackay et al., “Reduction of doxorubicin cardiotoxicity by prolonged continuous intravenous infusion,” Annals of Internal Medicine, vol. 96, no. 2, pp. 133–139, 1982. View at Publisher · View at Google Scholar · View at Scopus
  58. N. E. Day and S. A. Blngham, “Re: Nutrition intervention trials in linxian, China: Supplementation with specific vitamin/mineral combinations, cancer incidence, and disease-specific mortality in the general population,” Journal of the National Cancer Institute, vol. 86, no. 21, pp. 1645-1646, 1994. View at Publisher · View at Google Scholar · View at Scopus
  59. O. P. Heinonen, D. Albanes, J. Virtamo et al., “Prostate cancer and supplementation with α-tocopherol and β-carotene: incidence and mortality in a controlled trial,” Journal of the National Cancer Institute, vol. 90, no. 6, pp. 440–446, 1998. View at Publisher · View at Google Scholar · View at Scopus
  60. E. A. Klein, I. M. Thompson Jr., C. M. Tangen et al., “Vitamin E and the risk of prostate cancer: the selenium and vitamin E cancer prevention trial (SELECT),” Journal of the American Medical Association, vol. 306, no. 14, pp. 1549–1556, 2011. View at Publisher · View at Google Scholar · View at Scopus
  61. J. L. Hong, J. Ju, S. Paul et al., “Mixed tocopherols prevent mammary tumorigenesis by inhibiting estrogen action and activating PPAR-γ,” Clinical Cancer Research, vol. 15, no. 12, pp. 4242–4249, 2009. View at Publisher · View at Google Scholar · View at Scopus
  62. D. M. Hoffman, D. D. Grossano, L. Damin, and T. M. Woodcock, “Stability of refrigerated and frozen solutions of doxorubicin hydrochloride.,” American Journal of Health-System Pharmacy, vol. 36, no. 11, pp. 1536–1538, 1979. View at Google Scholar · View at Scopus
  63. E. Ulukaya, F. Ozdikicioglu, A. Y. Oral, and M. Demirci, “The MTT assay yields a relatively lower result of growth inhibition than the ATP assay depending on the chemotherapeutic drugs tested,” Toxicology in Vitro, vol. 22, no. 1, pp. 232–239, 2008. View at Publisher · View at Google Scholar · View at Scopus
  64. Y. Nishi, T. Yanase, Y.-M. Mu et al., “Establishment and characterization of a steroidogenic human granulosa-like tumor cell line, KGN, that expresses functional follicle-stimulating hormone receptor,” Endocrinology, vol. 142, no. 1, pp. 437–445, 2001. View at Publisher · View at Google Scholar · View at Scopus
  65. K. J. Reid, K. Lang, S. Froscio, A. J. Humpage, and F. M. Young, “Undifferentiated murine embryonic stem cells used to model the effects of the blue-green algal toxin cylindrospermopsin on preimplantation embryonic cell proliferation,” Toxicon, vol. 106, article no. 5192, pp. 79–88, 2015. View at Publisher · View at Google Scholar · View at Scopus
  66. T. Younis, D. Rayson, and C. Skedgel, “The cost-utility of adjuvant chemotherapy using docetaxel and cyclophosphamide compared with doxorubicin and cyclophosphamide in breast cancer,” Current Oncology, vol. 18, no. 6, pp. e288–e296, 2011. View at Google Scholar · View at Scopus
  67. R. L. Sutherland, R. E. Hall, and I. W. Taylor, “Cell Proliferation Kinetics of MCF-7 Human Mammary Carcinoma Cells in Culture and Effects of Tamoxifen on Exponentially Growing and Plateau-Phase Cells,” Cancer Research, vol. 43, no. 9, pp. 3998–4006, 1983. View at Google Scholar · View at Scopus
  68. A. T. McGown and B. W. Fox, “A proposed mechanism of resistance to cyclophosphamide and phosphoramide mustard in a Yoshida cell line in vitro,” Cancer Chemotherapy and Pharmacology, vol. 17, no. 3, pp. 223–226, 1986. View at Publisher · View at Google Scholar · View at Scopus
  69. L. B. Grochow and M. Colvin, “Clinical Pharmacokinetics of Cyclophosphamide,” Clinical Pharmacokinetics, vol. 4, no. 5, pp. 380–394, 1979. View at Publisher · View at Google Scholar · View at Scopus
  70. M. J. Moore, “Clinical Pharmacokinetics of Cyclophosphamide,” Clinical Pharmacokinetics, vol. 20, no. 3, pp. 194–208, 1991. View at Publisher · View at Google Scholar · View at Scopus
  71. M. E. De Jonge, A. D. R. Huitema, S. Rodenhuis, and J. H. Beijnen, “Clinical pharmacokinetics of cyclophosphamide,” Clinical Pharmacokinetics, vol. 44, no. 11, pp. 1135–1164, 2005. View at Publisher · View at Google Scholar · View at Scopus
  72. W. L. Miller and H. S. Bose, “Early steps in steroidogenesis: Intracellular cholesterol trafficking,” Journal of Lipid Research, vol. 52, no. 12, pp. 2111–2135, 2011. View at Publisher · View at Google Scholar · View at Scopus
  73. X. Wang, L. P. Walsh, A. J. Reinhart, and D. M. Stocco, “The role of arachidonic acid in steroidogenesis and steroidogenic acute regulatory (StAR) gene and protein expression,” The Journal of Biological Chemistry, vol. 275, no. 26, pp. 20204–20209, 2000. View at Publisher · View at Google Scholar · View at Scopus
  74. S. E. Campbell, W. L. Stone, S. Lee et al., “Comparative effects of RRR-alpha- and RRR-gamma-tocopherol on proliferation and apoptosis in human colon cancer cell lines,” BMC Cancer, vol. 6, no. 1, article no 13, 2006. View at Google Scholar · View at Scopus
  75. Q. Jiang, J. Wong, and B. N. Ames, “γ-Tocopherol Induces Apoptosis in Androgen-Responsive LNCaP Prostate Cancer Cells via Caspase-Dependent and Independent Mechanisms,” Annals of the New York Academy of Sciences, vol. 1031, no. 1, pp. 399-400, 2004. View at Publisher · View at Google Scholar
  76. G. Li, M. Lee, A. B. Liu et al., “δ-Tocopherol Is More Active than α- or γ-Tocopherol in Inhibiting Lung Tumorigenesis In Vivo,” Cancer Prevention Research, vol. 4, no. 3, pp. 404–413, 2011. View at Publisher · View at Google Scholar
  77. V. Edwards, E. Markovic, J. Matisons, and F. Young, “Development of an in vitro reproductive screening assay for novel pharmaceutical compounds,” Biotechnology and Applied Biochemistry, vol. 51, no. 2, pp. 63–71, 2008. View at Publisher · View at Google Scholar · View at Scopus
  78. S. A. Gross, J. M. Newton, and J. Hughes F.M., “Decreased intracellular potassium levels underlie increased progesterone synthesis during ovarian follicular atresia,” Biology of Reproduction, vol. 64, no. 6, pp. 1755–1760, 2001. View at Publisher · View at Google Scholar · View at Scopus
  79. M. Asaduzzaman, D. F. Gonzalez, and F. Young, “Ovarian Follicle Disaggregation to Assess Granulosa Cell Viability,” International Journal of Clinical Medicine, vol. 09, no. 05, pp. 377–399, 2018. View at Publisher · View at Google Scholar