Author:

Silvio Monfardini

Abstract

Adriamycin is an anti-tumor antibiotic discovered in Italy, which has been and is still being used in a wide variety of tumors. The laboratory and the initial clinical studies leading to the demonstration of its usefulness were carried out in Italy. Adriamycin is a drug over 50 years of old, but still useful and used in a wide variety of tumors such as breast, lung, ovarian, gastric carcinoma, Hodgkin’s disease, Non-Hodgkin‘s lymphomas, soft tissue sarcomas.

Introduction

The history of the discovery and development of adriamycin has been described in great detail by Giuseppe Cassinelli (2016). He was one of the members of the group led by Federico Arcamone who discovered adriamycin and with his daughter Giuliana was able to collect the story of all events leading to the discovery. They wrote: “In May 1960, the Farmitalia (FI) CEO Dr. Bertini and the Director of the Istituto Nazionale Tumori (INT) of Milan Prof. Pietro Bucalossi (at that time also the city's Mayor) signed a research agreement for the discovery and development up to clinical trials of new natural anti-tumor agents. With the terms of the agreement, a new unit of clinical chemotherapy was to be established within INT. Moreover, researchers, some paid by FI, were to become involved in INT laboratories equipped for pharmacologic and preclinical studies of new agents discovered in the FI Research Laboratories for Microbiology and Chemotherapydirected by Aurelio Di Marco. He supervised all the programs up to 1964, when he officially became the Director of the Division of Experimental Oncology B, a position in INT that he held until 1979, maintaining his collaboration with FI up to his death in 1984.”

The discovery of Daunomycin

Ten years earlier, in the 1950s, the FI Research Laboratories had begun an organized effort to isolate potential anti-tumor compounds from soil-based microbes.

In 1962 a soil sample was isolated from the area surrounding Castel del Monte, a 13th-century castle in Apulia and a strain of Streptomyces peucetius which produced a red pigment was isolated. An antibiotic produced from this bacterium was discovered by Aurelio Di Marco et al. and called daunomycin (Di Marco A, Gaetani M, Orezzi P et al., 1964) from the name Dauni, a pre-Roman tribe that occupied the area of Castel del Monte (Cassinelli 2016). It was shown that daunomycin can bind strongly to DNA, interfering with its functions also as a primer in RNA synthesis and in mitosis (Di Marco A et al., 1964).

In late 1963 the Italian FI researchers became aware that a similar compound had been isolated in the Rhône-Poulenc (RP) laboratories. This antibiotic had been originally extracted by RP researchers from a strain of Streptomyces coeruleorubidus and called rubidomycin deriving from the French word ‘rubis’, meaning ruby in color (Cassinelli 2016). In early 1964, standard reference samples of daunomycin and rubidomycin appeared indistinguishable and the two compounds were therefore considered as an identical antitumor antibiotic (Cassinelli 2016).

The availability of daunomycin allowed researchers working in FI and at the INT, coordinated by Di Marco, to demonstrate the broad spectrum of antitumor activity on experimental tumors, to implement pharmacological and toxicological studies and to make the intravenous formulation of pure daunomycin hydrochloride ready for human use. The data on outstanding antitumor activity quickened clinical application. Three years after the signature of the FI-INT agreement, in 1963 this new antitumor drug: daunomycin, obtained from a microbial culture, was ready to be used for clinical trials (Cassinelli 2016).

In the period from 1963 to 1967 the activity of daunomycin and rubidomycin in acute leukemia of adults and of children was demonstrated by several investigators in France, England and Italy, as well as in the United States. However, it was recognized that these drugs could produce fatal cardiac toxicity (Von Hoff, 1978; Massimo, 1967; Tan, 1967; Bernard, 1969; Bonadonna, 1969).

The efficacy demonstrated in these clinical trials allowed the approval of Cerubidine (rubidomycin RP) in France and Daunoblastina (daunomycin FI) in Italy. In 1969, the two companies RP and FI in joint communications announced that rubidomycin and daunomycin had been demonstrated to be the same product and the generic name daunorubicin was adopted (Cassinelli 2016).

Adriamycin, the discovery of daunomycin’s sister

The search for daunomycin's sister anthracyclines in 1967 led to the discovery and development of adriamycin by Arcamone, Cassinelli, Di Marco, and Gaetani in the FI Research Laboratories, from cultures of a mutant Streptomyces peucetius (Streptomyces peucetius caesius) (Arcamone, 1969). The chemical structure of this compound is very similar to that of daunomycin, its only difference being the substitution of a hydrogen atom with a hydroxyl group on the acetyl radical. The name of this new compound derived from the view of the Adriatic Sea from Castel del Monte, where the producing strain was isolated.

In acid media, adriamycin splits into two components, a red pigmented water-insoluble aglycone (adriamycinone) and a water-soluble basis-reducing amino-sugar (daunosamine). There are two proposed mechanisms by which adriamycin acts in the cancer cell: intercalation into DNA and disruption of topoisomerase-II-mediated DNA repair and generation of free radicals and their damage to cellular membranes, DNA and proteins (Cassinelli 2016). Adriamycin belongs to the anthracycline group, as do daunomycin and rubidomycin (daunorubicin). Thanks to the chemical knowledge acquired about the daunomycin structure, Arcamone set up an efficient laboratory procedure to obtain adriamycin from the easily available daunomycin. That allowed a higher availability of adriamycin.

The data obtained by Di Marco and coworkers on the outstanding activity of the drug against experimental tumors speeded up preclinical, pharmacologic, toxicologic, and formulation studies (Cassinelli 2016). In 1968 a few IV formulated adriamycin vials were sent to Gianni Bonadonna at INT to initiate Phase I-II clinical trials.

Four years previously, in early 1964, the Director of INT and newly elected Mayor of Milan, Prof. Pietro Bucalossi, met the young oncologist Gianni Bonadonna in New York who was working at the Memorial Hospital in David Karnofski’s group. At that time the Memorial Hospital was considered a Mecca for cancer research in the USA. Bucalossi convinced Bonadonna to come back to Milan at the INT (Minerva & Monfardini 2013). Bonadonna later confessed to the author of this story that he required an assistant position, otherwise he would never have come back to Italy. He arrived at the INT at the end of the same year 1964. At that time some anticancer chemotherapy at the INT was administered by Sergio Di Pietro, a former surgeon no longer active in the operating room. The INT was predominantly a surgical institute, with an atmosphere of diffuse skepticism on the efficacy of cancer chemotherapy.

Bonadonna managed a ward (the ‘Reparto C’) for patients with a neoplasia in an advanced stage, being however formally supervised by the ex-surgeon Di Pietro. He was nevertheless able to raise a dedicated team of young fellows (Silvio Monfardini, Mario De Lena, Franca Fossati-Bellani, Emilio Bajetta, Gabriele Tancini, Gianni Beretta) that were trained by him in clinical cancer management and research. Later on, in the book ‘Una Guerra da vincere’ (A war to be won) Bonadonna defined this group as the “Seven Samurai” (Bonadonna 2010). At the end of the sixties this team played a key role in the development of new anticancer drugs. The Clinical Chemotherapy Unit of the INT had been set up.

Bonadonna described the event of receiving the first adriamycin vials in the foreword of a volume when updating the epirubicin studies in 1984 which he dedicated to Prof. Di Marco, who died on January 4 of the same year (Bonadonna 1984):

“At the beginning of July 1968, a young laboratory technician stepped into my office carrying a carton box containing 30 vials of adriamycin (doxorubicin) as well as a brief report which summarized the chemical properties and the preclinical results of this daunorubicin analogue. ‘A gift from Doctor Di Marco — you may wish to test it in patients,’ she said. I asked for some additional details and spent the rest of the month discussing plans for a Phase I study with my coworkers. In September, after returning from vacation, we began to treat our first patient.”

At the INT the administration of adriamycin induced remissions in acute lymphoblastic and chronic (myeloid and lymphocytic) leukemias as well as in malignant lymphomas and solid tumors (Bonadonna et al., 1969). The main evidence of toxicity was stomatitis, bone marrow depression and loss of hair. Fever, gastroenteritis and phlebitis at the site of injection were toxic signs of minor importance.

The preliminary results, presented by Monfardini in New York at the Memorial Hospital in 1969 at the end of his fellowship year there, were received with some skepticism. A few months later his presentation to Emil Freireich and Emil Frei, the fathers of modern treatment of leukemia, at the MD Anderson in Houston, another temple of cancer medicine at the time, was on the contrary welcomed with interest. In the same year the publication of the definitive results published in the British Medical Journal (Bonadonna et al, 1969) and in the Italian journal Tumori (Monfardini et al., 1969) confirmed the drug’s broad activity spectrum.

Cardiac toxicity, the definition of the activity spectrum and the sister compounds

Bonadonna and Monfardini were aware of the cardiotoxicity of daunomycin, that they as well as others had been reporting previously (Bonadonna & Monfardini 1969), but in this first study the patients treated with Adriamycin did not present cardiac alteration attributable to the treatment. Later on, subsequent studies carried out in Europe and USA showed that this was a major concern during therapy as it may be dose-limiting. Such toxicity has been shown to correlate with the lifetime cumulative dose administered, cardiomyopathy rarely been observed after a well determined cumulative dosage, that should then not be overtaken.

Anthracycline was successfully used to produce regression in several neoplastic diseases such as acute lymphoblastic leukemia, acute myeloblastic leukemia, malignant non-Hogkin’s lymphomas, Hodgkin’s disease, breast carcinoma, ovarian carcinoma, small cell lung carcinoma, soft tissue and bone sarcomas, bladder carcinoma, thyroid carcinoma, gastric carcinoma, Wilms’ tumor, neuroblastoma and retinoblastoma. This information has been derived from some of the thousands of articles written on adriamycin (doxorubicin), here only one comprehensive reference summarizing the main feature of this drug is provided (Medscape 2024) http//reference.medscape.com, consulted on January 2024)

After the initial development of adriamycin, its activity spectrum was further defined. Following the demonstrated activity of adriamycin, the search for sister compounds, anthracycline analogs, continued, in order to try to decrease the cardiotoxic effect. The only analogs whose clinical usefulness has been demonstrated were epirubicin and idarubicin.

Epirubicin is a semisynthetic derivative of adriamycin, with a spectrum of activity and toxicity quite similar to that of adriamycin. This drug is a structural analogue of daunorubicin and has the same mechanism of action as daunorubicin and doxorubicin. Idarubicin is an effective agent for the management of acute non-lymphocytic leukemia and is reportedly more potent and less cardiotoxic than daunorubicin or doxorubicin.

Conclusions. The short- and long-term implications

The author recalls some implication of that discovery over 50 years ago: “Only a handful of antitumor drugs were available before adriamycin and there was diffused skepticism on the efficacy of chemotherapy among the other cancer specialists (surgeons, radiotherapists, radiologists). The toxic signs of adriamycin were visibly impressive, in a sense heavier than those of the few agents that were used in the sixties (mainly cyclophosphamide, vinblastine, procarbazine). During the adriamycin trial, Bucalossi, who was a surgeon, said with a tone of ironyafter paying a visit to the Reparto C, “Dr Bonadonna, are all your patients bold?”. We were conscious of having very little to offer our patients with advanced cancer, but we were driven by the desire of achieving something more and the initial rapid responses observed with Adriamycin seemed soon to counter balance the toxic effects. This was some source of support for ourselves and consequently for the patients on treatment. At that time there were no Ethical Committees. All the responsibility lay with us and on the basis of very simple study protocols. On the other hand, the measurement of the toxicity signs was rigorous as well as the methodology of response evaluation such as the centimetric measurement of lesions, while in Italian Academia in the case of malignant lymphoma the effect of therapy, usually alkylating agents, were evaluated quoting the dimension of eggs of a hen rather than that of a pigeon. The American way of conducting the research and the ability of managing all patient clinical problems with an internistic approach acquired by Bonadonna from Karnofsky allowed to achieve internationally recognized results. The number of studies of other investigators on adriamycin over the next few years was impressive, the use of this drug was widespread and implemented rapidly worldwide.

One consequence at the INT was that the Group could be defined initially as the Clinical Chemotherapy Unit with Bonadonna as the formal head. But the success of the Adriamycin trials was also followed by a change of paradigm on how those should be considered who were treating cancer patients with advanced cancer. No more cancer chemotherapists according to the surgeons of the Institute, but Medical Oncologists. The short-term implication in Italy was the spreading out of the new approach to the medical treatment of tumors. The definition of the aim, training, activity of this discipline was in fact defined with the Foundation of the Associazione Italiana Oncologia Medica in 1973 at the INT (Minerva Monfardini, 2013).

A few years after the initial trial, the efficacy of adriamycin in combination with other anticancer drugs was demonstrated by the same group in breast cancer. This was also possible because a wide population of patients with breast cancer was followed at the INT because of the nation-wide recognized tradition of excellent surgical management of breast cancer. The Group was also in the position of leading seminal studies for malignant lymphomas using adriamycin in combination with other antitumor drugs, since a big number of such cases was referred to the INT because of the presence of a radiotherapy department with experience in the treatment of malignant lymphomas.

It was then clear that a new treatment modality, the medical one, besides surgery and radiotherapy, had to be considered in the treatment of malignant lymphomas and breast cancer. This had a further positive effect on the interdisciplinary practice within the institute but also in other Cancer Centers in Italy.

Over 50 years on Adriamycin remains a fundamental component of the therapy of Hodgkin’s disease and non-Hodgkin’s lymphomas, breast cancer and other solid tumors.

Images

IMAGE 1

Adriamycin structural formula

IMAGE 2

Researchers of the Farmitalia Laboratories participating in the discovery of the anthracyclines: daunomycin and adriamycin (doxorubicina).

From left to right: Spalla, Arcamone, Canevazzi, Gaetani, Orezzi, Cassinelli, Grein.

IMAGE 3

5 of the” 7 Samurai”. From left to right: De Lena, Tancini, Monfardini , Bajetta and [Bonadonna*(@giovanni-bonadonna).

Acknowledgements

The author would like to thank Dr Giuliana Cassinelli for the iconographic material provided.

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