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抗癌药(Antineoplasticagents)
抗癌药(Antineoplasticagents)1Overview
IntroductionMalignantdiseaseaccountsforahighproportionofdeathsinindustrialisedcountries.Thetreatmentofanticancerdrugistogivepalliation,induceremissionand,ifpossible,cure.OverviewIntroduction2OverviewIntroductionCanceroccursafternormalcellshavebeentransformedintoneoplasticcellsthroughalterationoftheirgeneticmaterialandtheabnormalexpressionofcertaingenes.Neoplasticcellsusuallyexhibitchromosomalabnormalitiesandthelossoftheirdifferentiatedproperties.Thesechangesleadtouncontrolledcelldivisionandmanyresultintheinvasionofpreviouslyunaffectedorgans,aprocesscalledmetastasis.OverviewIntroduction3
AdvancesinCancerChemotherapy
Treatmentoptionsofcancer:Surgery:before1955Radiotherapy:1955~1965Chemotherapy:after1965ImmunotherapyandGenetherapy
AdvancesinCancerChemothera4AdvancesinCancerChemotherapyThetreatmentofapatientwithcancermayaimto:givepalliation,forexamplepromptreliefofunpleasantsymptomssuchassuperiorvenacavaobstructionfromamediastinaltumorinduce‘remission’sothatallmacroscopicandmicroscopicfeaturesofthecancerdisappear,thoughdiseaseisknowntopersistcure,forwhichallthecellsoftheclonemustbedestroyed.AdvancesinCancerChemotherap5CancerChemotherapy
DiseaseName5YearsSurvivalRateChildhoodAcuteLymphoblasticLeukemia50~80%AdultAcuteLymphoblasticLeukemia20~60%ChildhoodAcuteMyeloblasticLeukemia20~60%AdultAcuteMyeloblasticLeukemia 10~20%BreastCancer(Premenopausal) 10~20%BreastCancer(Postmenopausal) 0~15%Hodgkin’slymphoma* 40~80%CancerChemotherapyDisea6CancerChemotherapyDiseaseName5YearsSurvivalRateSmallCellLungCancer(LimitedStage) 10~20% (ExtensiveStage)0~5%Non-Hodgkin’slymphoma* 40~65%OvarianCancer 40~60%ChildrenSolidTumor(Nephroblastoma,Rhabdomyosarcoma,Lymphoma,Osteosarcoma)* 60~90%Trophoblastoma(ChorionEpithelioma)**80~90%SeminomaofTestis** 60~90%EmbryonicCarcinomaofTestis 60~80%Note:*Combinationwithothertherapeutics **ChemotherapyLevelofourcountryishighCancerChemotherapyDiseaseNam7TheClassificationofAnticancerDrugsAccordingtochemicalstructureandresourceofthedrug;Accordingtobiochemistrymechanismsofanticanceraction;Accordingtothecycleorphasespecificityofthedrug
TheClassificationofAnticanc8TheClassificationofAnticancerDrugsAccordingtochemicalstructureandresourceofthedrug:
AlkylatingAgents,Antimetabolite,Antibiotics,PlantExtracts,Hormones,Others.TheClassificationofAnticanc9TheClassificationofAnticancerDrugsAccordingtobiochemistrymechanismsofanticanceraction:BlocknucleicacidbiosynthesisDirectinfluencethestructureandfunctionofDNAInterferetranscriptionandblockRNAsynthesis
InterfereproteinsynthesisandfunctionInfluencehormonehomeostasisOthersTheClassificationofAnticanc10TheClassificationofAnticancerDrugsAccordingtothecycleorphasespecificityofthedrug:
Cellcyclenonspecificagents(CCNSA)Cellcyclespecificagents(CCSA)TheClassificationofAnticanc11TheBasicConceptof
CellGenerationCycleThecycleofcellreplicationincludes:M(Mitosis)phaseG1(Gap1,periodbeforeS)phaseS(DNAsynthesis)phaseG2(Gap2,periodafterS)phase
GrowthFraction(GF)TheBasicConceptof
CellGen12抗癌药英文课件13GrowthFraction(GF)GF=ProliferatingcellgroupTotaltumorcellgroupCCNSA:drugsthatareactivethroughoutthecellcycle.CCSA:
drugsthatactduringaspecificphaseofthecellcycle.GrowthFraction(GF)GF=Prolife14CCSAandCCNSACellCycleNonspecificAgents(CCNSA)
drugsthatareactivethroughoutthecellcycle
AlkylatingAgentsPlatinumCompoundsAntibiotics
CCSAandCCNSACellCycleNonsp15CellCycleSpecificAgents(CCSA)
drugsthatactduringaspecificphaseofthecellcycle
SPhaseSpecificDrug:
Aantimetabolites,TopoisomeraseInhabitors
MPhaseSpecificDrug:
VincaAlkaloids,Taxanes
G2PhaseSpecificDrug:
BbleomycinCCSAandCCNSACellCycleSpecificAgents(CC16MechanismofAnticancerDrugsBlocknucleicacid(DNA,RNA)biosynthesisDirectlydestroyDNAandinhibitDNAreproductionInterferetranscriptionandblockRNAsynthesisInterfereproteinsynthesisandfunctionInfluencehormonehomeostasisMechanismofAnticancerDrugsB17BlockNucleicAcid(DNA,RNA)BiosynthesisAntimetabolites:FolicAcidAntagonist:
inhibitdihydrofolatereductase(methotrexate)PyrimidineAntagonist:
inhibitthymidylatesynthetase(fluorouracil);inhibitDNApolymerase(cytarabine)PurineAntagonist:
inhibitinterconversionofpurinenucleotide(mercaptopurine)RibonucleosideDiphosphateReductaseAntagonist:
(hydroxyurea)
BlockNucleicAcid(DNA,RNA)18InterfereProteinSynthesis
Antitubulin:
vincaalkaloids
and
taxanes;Interferethefunctionofribosome:
harringtonines;Influenceaminoacidsupply:
L-asparaginase
Bindtubulin,destroyspindletoproducemitoticarrest.InterfereProteinSynthesisAn19InterfereTranscriptionandBlockRNASynthesisBindwithDNAtoblockRNAproduction.
doxorubicinInterfereTranscriptionandBl20InfluencetheStructureandFunctionofDNAAlkylatingAgent:
mechlorethamine,cyclophosphamideandthiotepaPlatinum:
cis-platiniumAntibiotic:
bleomycinandmitomycinCTopoismeraseinhibitor:
camptothecineand
podophyllotoxin
InfluencetheStructureandFu21InfluenceHormoneHomeostasis
Thesedrugsbindtohormonereceptorstoblocktheactionsofthesexhormoneswhichresultsininhibitionoftumorgrowth.EstrogensandestrogenantagonisticdrugAndrogensandandrogenantagonisticdrugProgestogendrugGlucocorticoiddruggonadotropin-releasinghormoneinhibitor:
leuprolide,goserelinaromataseinhibitor:
aminoglutethimide,anastrazoleInfluenceHormoneHomeostasis22TheLongRoadofaNewMedicineTheLongRoadofaNewMedicin23TheMainStepofAnticancerDrugResearch
Non-clinicalResearch:1.AnticancerDrugScreen:
invitro:tumorcellculture,tumorinhibitor/killtest
invivo:animalxenograftmodele.g.Ehrlichascitestumor,S180lymphosarcoma2.Pharmacodynamics,pharmacokineticsandtoxicologytestTheMainStepofAnticancerDr24TheMainStepofAnticancerDrugResearchClinicalResearch:
Phase1clinicaltrialPhase2clinicaltrialPhase3clinicaltrialPhase4clinicaltrialTheMainStepofAnticancerDr25TheMainStepofAnticancerDrugResearchPhase1clinicaltrial
InPhase1clinicaltrials,researcherstestanewdrugortreatmentinasmallgroupofpeople(20-80)forthefirsttimetoevaluateitssafety,determineasafedosagerange,andidentifysideeffects.TOLERANCEPHARMACOKINETICSTheMainStepofAnticancerDr26TheMainStepofAnticancerDrugResearchPhase2clinicaltrial
InPhase2clinicaltrials,thestudydrugortreatmentisgiventoalargergroupofpeople(40-100)toseeifitiseffectiveandtofurtherevaluateitssafety.
TheMainStepofAnticancerDr27TheMainStepofAnticancerDrugResearchPhase3clinicaltrial
InPhase3studies,thestudydrugortreatmentisgiventolargegroupsofpeople(morethan200)tofurtherdetermineitseffectiveness,monitorsideeffects,compareittocommonlyusedtreatments,andcollectinformationthatwillallowthedrugortreatmenttobeusedsafely.TheMainStepofAnticancerDr28TheMainStepofAnticancerDrugResearchPhase4clinicaltrial
Phase4studiesaredoneafterthedrugortreatmenthasbeenmarketed.Thesestudiescontinuetestingthestudydrugortreatmenttocollectinformationabouttheireffectinvariouspopulationsandanysideeffectsassociatedwithlong-termuse.
TheMainStepofAnticancerDr29AnticancerDrugsAlkylatingAgentAntimetaboliteAntibioticsAlkaloid
HormonesOthers(cis-platinum,carboplatin,lobaplatin)AnticancerDrugsAlkylatingAge30AlkylatingAgentsOneofthefrighteningdevelopmentsofWorldWarIwastheintroductionofchemicalwarfare.Thesecompoundswereknownasthenitrogenmustardgases.Thenitrogenmustardswereobservedtoinhibitcellgrowth,especiallyofbonemarrow.Shortlyafterthewar,thesecompoundswereinvestigatedandshowntoinhibitthegrowthofcancercells.AlkylatingAgentsOneofthefr31AlkylatingAgentsMechanismofActionNitrogenmustardsinhibitcellreproductionbybindingirreversiblywiththenucleicacids(DNA).Thespecifictypeofchemicalbondinginvolvedis
alkylation.Afteralkylation,DNAisunabletoreplicateandthereforecannolongersynthesizeproteinsandotheressentialcellmetabolites.Consequently,cellreproductionisinhibitedandthecelleventuallydiesfromtheinabilitytomaintainitsmetabolicfunctions.AlkylatingAgentsMechanismof32ClassificationofAlkylatingAgentsBisChloroethylAmines:Cyclophosphamide,Chlormethine,Chlorambucil,SarcolysineNithrosoureas:Carmustine,LomustineEthyeneammoniumorAziridines:Thiotepa,triethylenemelamineAlkysulfonates:BusulfanClassificationofAlkylatingA33ResistanceofAlkylatingAgents
Resistancetoalkylatingagentshasseveralcauses:
Membranetransportmaybedecreased.Thedrugmaybeboundbyglutathione(GSH)viaGSH-S-transferaseormetallothioneinsinthecytoplasmandinactivated.Thedrugmaybemetabolizedtoinactivespecies.ResistanceofAlkylatingAgent34AdverseEffectsofAlkylatingAgentsMyelosuppressionisthedose-limitingadverseeffectforalkylatingagents.Nauseaandvomitingarecommonasareteratogenesisandgonadalatrophy,althoughinthelattercasesthesearevariable,accordingtothedrug,itsschedule,androuteofadministration.Treatmentalsocarriesamajorriskofleukemogenesisandcarcinogenesis.AdverseEffectsofAlkylating35AlkylatingAgents——MustineMustinemustbeinjectedintravenouslybecauseitishighlyreactive.Itdisappearsveryrapidlyfromtheblood,theactivityofMustinelastsonlyafewminutes.ThemainindicationforMustineisintreatmentofHodgkinsdiseaseandlymphomas,butitmayalsobeusefulinothermalignancies.AlkylatingAgents——MustineMust36AlkylatingAgents——CyclophosphamideCyclophosphamidecanalsobegivenorally.Indications:Itisusedinthetreatmentofchroniclymphocycticleukemia,non-Hodgkin’slymphomas,breastandovariancancer,andavarietyofothercancers.Itisalsoapotentimmunosuppressant,itisusedinthemanagementofrheumatoiddisordersandautoimmunenephritis.AdverseEffects:Alopecia,nausea,vomiting,myelosuppression,andhemorrhagiccystitis.AlkylatingAgents——Cycloph37AlkylatingAgents——NitrosoureasCarmustine,Lomustine,SemustinePharmacokinetics:Nitrosoureasarehighlylipophilicandreachcerebrospinalfluidconcentrationsthatareabout30%ofplasmaconcentrations.Indications:BecauseoftheirexcellentCNSpenetration,carmustineandlomustinehavebeenusedtotreatbraintumors.AlkylatingAgents——Nitrosourea38AlkylatingAgents——
PhenylalanineNitrogenMustardMelphalanisanitrogenmustardthatisprimarilyusedtotreatmultiplemyeloma(plasmacellmyeloma),breastcancer,andovariancancer.AlkylatingAgents——
Phenylala39AlkylatingAgents——
AlkysulfonatesBusulfan[Myleran]Indications:Busulfanisadministeredorallytotreatchroicgranulocyticleukemiaandothermyeloproliferativedisorders.AdverseEffects:Busulfanproducesadverseffectsrelatedtomyelosuppression.Itonlyoccasionallyproducesnauseaandvomitting.Inhighdoses,itproducesararebutsometimesfatalpulmonaryfibrosis,”busulfanlung”.AlkylatingAgents——
Alkysulfo40AlkylatingAgents——Thiotepa
Thiotepaisconvertedrapidlybylivermixed-functionoxidasestoitsactivemetabolitetriethylenephosphoramide(TEPA);itisactiveinbladdercancer.AlkylatingAgents——Thiotepa41AntimetabolitesGeneralCharacteristics:AntimetabolitesareSphase-specificdrugsthatarestructuralanaloguesofessentialmetabolitesandthatinterferewithDNAsynthesis.Myelosuppressionisthedose-limitingtoxicityforalldrugsinthisclass.AntimetabolitesGeneralCharact42ClassificationofAntimetabolitesFolicacid
Antagonists:MTX
PurineAntagonists:6MP6TG
PyrimidineAntagonists:5FUaraCHUClassificationofAntimetaboli43Antimetabolites——
FolicAcidAntagonistMethotrexate(MTX)MechanismofAction:
ThestructuresofMTXandfolicacidaresimilar.MTXisactivelytransportedintomammaliancellsandinhibitsdihydrofolatereductase,theenzymethatnormallyconvertsdietaryfolatetothetetrahydrofolateformrequiredforthymidineandpurinesynthesis.Antimetabolites——
FolicAcidA44Antimetabolites——
FolicAcidAntagonistMethotrexate(MTX)Indications:TheuseofMTXinthetreatmentofchoriocarinoma,atrophoblastictumor,wasthefirstdemonstrationofcurativechemotherapy.Itisespeciallyeffectivefortreatingacutelymphocyticleukemiaandfortreatingthemeningealmetastasesofawiderangeoftumors.Antimetabolites——
FolicAcidA45Antimetabolites——
FolicAcidAntagonist
Methotrexate(MTX)AdverseEffects:MTXismyelosuppressive,producingsevereleukopenia,bonemarrowaplasia,andthrombocytopenia.Thisagentmayproduceseveregastrointestinaldisturbances.Renaltoxicitymayoccurbecauseofprecipitation(crystalluria)ofthe7-OHmetaboliteofMTX.Antimetabolites——
FolicAcidA46Antimetabolites——
PurineAntagonists6-Mercapapurine(6-MP)
Thedrugsarebelievedtoactsimilarlytoinhibitpurinebasesynthesis,althoughtheirexactmechanismsofactionarestilluncertain.Indications:MercaptopurineisusedprimarilyforthemaintenanceofremissioninpatientswithacutelymphocyticleukemiaandisgivenincombinationwithMTXforthispurpose.AdverseEffects:Welltolerate.Myelosuppressionisgenerallymildwiththioguanine.Long-termmercaptopurineusemaycausehepatotoxicity.Antimetabolites——
PurineAntag47Antimetabolites——
PyrimidineAntagonists5-Fluorouracil(5-FU)MechanismofAction:Fluorouracilisananalogueofthymineinwhichthemethylgroupisreplacedbyafluorineatom.Ithastwoactivemetabolites:5-FdUMPand5-FdUTP.5-FdUMPinhibitsthymidylatesynthetasesandpreventsthesynthesisofthymidine,amajorbuildingblockofDNA.5-FdUTPisincorporatedintoRNAbyRNApolymeraseandinterfereswithRNAfunction.Antimetabolites——
PyrimidineA48Antimetabolites——
PyrimidineAntagonists5-Fluorouracil(5-FU)Indications:Fluorouracilisexclusivelyusedtotreatsolidtumors,especiallybreast,colorectal,andgastrictumorsandsquamouscelltumorsoftheheadandneck.Antimetabolites——
PyrimidineA49Antimetabolites——
PyrimidineAntagonists5-Fluorouracil(5-FU)AdverseEffects:Fluorouracilmaycausenauseaandvomiting,myelosuppression,andoralandgastrointestinalulceration.Nauseaandvomittingareusuallymild.Withfluorouracil,myelosuppressionismoreproblematicafterbolusinjections,whereasmucosaldamageisdose-limitingwithcontinuousinfusions.Antimetabolites——
PyrimidineA50Antimetabolites——
PyrimidineAntagonistsCytarabineIndications:Cytarabinehasanarrowclinicalspectrumandisprimarilyusedincombinationwithdaunorubicinorthioguanineforthetreatmentofacutenonlymphocyticleukemia.AdverseEffects:Highdosesofcytarabinecandamagetheliver,heart,andotherorgans.
Antimetabolites——
PyrimidineA51AntibioticsClassificationofAntibiotics:Adriamycin(AnthracyalineAntibiotics)MitomycinCBleomycinActinomycinDAntibioticsClassificationofA52AntibioticsAdriamycinandDaunorubicin:Properties:AdriamycinandDaunorubicinaretetracyclineringswiththesugardaunosamine.TheyareDNAintercalatingagentsthatblockthesynthesisofDNAandRNA.TheseagentsareprimarilytoxicduringtheSphaseofcellcycle.Theseagentsimpartsaredtingetotheurine.Adramycinisusedtotreatacuteleukemias,lymphoma,andanumberofsolidtumors.AntibioticsAdriamycinandDaun53AntibioticsMitomycinC:Mechanism:MitomycinCisanantineoplasticantibioticthatalkylatesDNAandtherebycausesstrandbreakageandinhibitionofDNAsynthesis.Indications:Itisprimarilyusedincombinationwithvinvristineassalvagetherapyforbreastcancer.AdverseEffects:Mitomycinproducesdelaysandprolongedmyelosuppressionthatpreferentiallyaffectsplateletsandleukocytes.AntibioticsMitomycinC:54AntibioticsActinomycinD:ActinomycinDintercalatesDNAandtherebypreventsDNAtranscriptionandmessengerRNAsynthesis.Thedrugisgivenintravenously,anditsclinicaluseislimitedtothetreatmentoftrophoblastic(gestational)tumorsandthetreatmentofpediatrictumors,suchasWilms’tumorandEwing’ssarcoma.AntibioticsActinomycinD:55AntibioticsBleomycin:Mechanism:ThedrughasitsgreatesteffectonneoplasticcellintheG2phaseofthecellreplicationcycle.AlthoughbleomycinintercalatesDNA,themajorcytotoxicityisbelievedtoresultfromironcatalyzedfreeradicalformationandDNAstrandbreakage.Indications:ItisusefulinHodgkin’sandnon-Hodgkin’slymphomas,testicularcancer,andseveralothersolidtumors.AdverseEffects:Bleomycinproducesverylittlemyelosuppression.ThemostserioustoxicitiesofBleomycinarepulmonaryandmucocutaneousreactions.AntibioticsBleomycin:56Anti-CancerPlantAllaloidsTubulin-BindingAgents
VincaAlkaloids:Thecellularmechanismofactionofvincaalkaloidsisthepreventionofmicrotubuleassembly,causingcellstoarrestinthelateG2phasebypreventingformationofmitoticfilamentsfornuclearandcelldivision.Anti-CancerPlantAllaloidsTub57Anti-CancerPlantAllaloidsTubulin-BindingAgentsVincaalkaloids:
Vinblastine,vincristin,vindesineandvinorelbineareallalkaloidsderivedfromtheperiwinkleplant(Vincarosea).Indications:VinblastineisusedincombinationwithBleomycinandCisplatinformetastatictesticulartumors.Vincristineisusedincombinationwithprednisonetoinduceremissioninchildhoodleukemia.Vinorelbineisusedtotreatnon-small-celllungcancerandbreastcancer.Anti-CancerPlantAllaloidsTub58Anti-CancerPlantAllaloidsTubulin-BindingAgentsPaclitaxel:
Taxanesenhanceallaspectsoftubulinpolymerization,anactionthatistheoppositetothatofvincaalkaloids,buttheyarealsocytotoxic,emphasizingthedynamicimportanceoftubulinpolymerizationasatargetforcytotoxicdrugs.
Paclitaxel,TaxotereAnti-CancerPlantAllaloidsTub59InterferetheFunctionofRibosome:CephalotaxusAlkaloids:
HarringtonineHomoharringtonineAnti-CancerPlantAllaloidsInterferetheFunctionofRibo60PlatinumCompoundCisplatin:MechanismofAction:CisplatinbindstoguanineinDNAandRNA,andtheinteractionisstabilizedbyhydrogenbonding.ThemolecularmechanismofactionisunwindingandshorteningoftheDNAhelix.PlatinumCompoundCisplatin:61PlatinumCompoundCisplatin:Indications:Cisplatinhasefficacyagainstawiderangeofneoplasms.Itisgivenintravenouslyasafirst-linedrugfortesticular,ovarian,andbladdercancer,anditisalsousefulinthetreatmentofmelanomaandanumberofothersoildtumors.AdverseEffect:Cisplatinproducesrelativelylittlemyelosuppressionbutcancauseseverenausea,vomiting,andnephrotoxicity.PlatinumCompoundCisplatin:62PlatinumCompoundCarboplatin:Indication:Carboplatinhasasimilarspectrumofactivity,butitisapprovedonlyasasecond-linedrugforovariancancer.PlatinumCompoundCarboplatin:63HormonesSeveraltypesofhormone-dependentcancer(especiallybreast,prostate,andendometrialcancer)respondtotreatmentwiththeircorrespondinghormoneantagonists.Estrogenantagonistsareprimarilyusedinthetreatmentofbreastcancer,whereasandrogenantagonistsareusedinthetreatmentofprostatecancer.Corticosteroidsareparticularlyusefulintreatinglymphocyticleukemiasandlymphomas.HormonesSeveraltypesofhormo64HormonesEstrogens:Estrogensinhibittheeffectsofendogenousandrogensandandrogen-dependentmetastaticprostaticcarcinoma.Diethylstilbestrolisusuallytheagentofchoice.Cardiacandcerebrovascularcomplicationsandcarcinomaofthemalebreastarepotentialadverseeffects.HormonesEstrogens:65HormonesProgenstins:Progestinsareusefulinthemanagementofendometrialcarcinomaandback-uptherapyformetastatichormone-dependentbreastcancer.
HormonesProgenstins:66HormonesAntiestrogen:
TamoxifenTamoxifenisthedrugofchoiceinpostmenopausalwomenwithorrecoveringfrommetastaticbreastcancer.Itismosteffectiveinpatientswhohaveestrogenreceptor-positivetumors.Tamoxifenisalsousedasadjunvctivetherapytooophorectomytoleuprolideorgoserelininpremenopausalwomenwithestrogenreceptor-positivetumors.HormonesAntiestrogen:Tamoxife67HormonesAndrogens:Androgenactivityinbreastcancerissimilartothatofestrogens,perhapsforthesamemechanisticreasons.Virilizingeffectsandhepatictoxicitymakethemunacceptabletomostpatients.Fluoxymesteroneisthemostwidelyusedagent.Danazolhasuseinhematologyinaplasticanemiaandcongenitalanemias.HormonesAndrogens:68HormonesGlucocorticoids:Theyareintegralcomponentsofcurativetherapyforacutelymphoblasticleukemia,non-Hodgkin’slymphoma,andHodgkin’sdisease.Glucocorticoidshaveessentialrolesinthepreventionofallergicreaction,emesiscontrol,reliefofintracranialhypertensionorspinalcordcompressioninneurologiccomplications,andpainrelief.HormonesGlucocorticoids:69ProblemsWithCancerChemotherapy
DrugResistance
DrugToxicityProblemsWithCancerChemother70DrugResistance
DenovoResistanceAcquiredResistanceMultidrugResistance(MDR)DrugResistanceDenovoResist71DrugResistance
Denovoresistance:Denovoresistancecanbedenovogenetic(i.e.thecellsareinitiallyinherentlyresistant),orcanarisebecausedrugsareunabletoreachthetargetcellsbecauseofpermeabilitybarrierssuchastheblood-brainbarrier.DrugResistanceDenovoresist72DrugResistance
AcquiredResistance:Acquireddrugresistancemayresultfromgenomicmutations,suchastheinductionordeletionofenzymesinvolvedindrugina
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