Journal of Controlled Release 148 (2010) 135146

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Journal of Controlled Release

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j c o n r e l

Review

To exploit the tumor microenvironment: Passive and active tumor targeting of

nanocarriers for anti-cancer drug delivery
Fabienne Danhier a, Olivier Feron b, Vronique Prat a,
a
b

Universit Catholique de Louvain, Louvain Drug Research Institute, Unit of Pharmaceutics, UCL-FARG 7320, Avenue E. Mounier, B-1200, Brussels, Belgium
Universit Catholique de Louvain, Pole of Pharmacology and Therapeutics, Institute of Experimental and Clinical Research, UCL-FATH 5349, Avenue E. Mounier, B-1200, Brussels, Belgium

a r t i c l e

i n f o

Article history:
Received 31 May 2010
Accepted 10 August 2010
Available online 24 August 2010
Keywords:
Active targeting
Passive targeting
Enhanced Permeability and Retention effect
Nanocarriers

a b s t r a c t
Because of the particular characteristics of the tumor microenvironment and tumor angiogenesis, it is
possible to design drug delivery systems that specically target anti-cancer drugs to tumors. Most of the
conventional chemotherapeutic agents have poor pharmacokinetics proles and are distributed nonspecically in the body leading to systemic toxicity associated with serious side effects. Therefore, the
development of drug delivery systems able to target the tumor site is becoming a real challenge that is
currently addressed. Nanomedicine can reach tumor passively through the leaky vasculature surrounding
the tumors by the Enhanced Permeability and Retention effect whereas ligands grafted at the surface of
nanocarriers allow active targeting by binding to the receptors overexpressed by cancer cells or angiogenic
endothelial cells.
This review is divided into two parts: the rst one describes the tumor microenvironment and the second one
focuses on the exploitation and the understanding of these characteristics to design new drug delivery systems
targeting the tumor. Delivery of conventional chemotherapeutic anti-cancer drugs is mainly discussed.
2010 Elsevier B.V. All rights reserved.

Contents
1.
2.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tumor microenvironment . . . . . . . . . . . . . . . . . . . . .
2.1.
Angiogenesis in cancer. . . . . . . . . . . . . . . . . . . .
2.2.
Enhanced Permeability and Retention (EPR) effect . . . . . .
2.3.
pH . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
Drug targeting . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.
Passive targeting . . . . . . . . . . . . . . . . . . . . . .
3.2.
Active targeting . . . . . . . . . . . . . . . . . . . . . . .
3.2.1.
The targeting of cancer cell . . . . . . . . . . . . .
3.2.2.
The targeting of tumoral endothelium . . . . . . . .
3.3.
Preclinically and clinically used tumor-targeted nanomedicines
3.4.
Stimuli-sensitive nanocarriers . . . . . . . . . . . . . . . .
3.4.1.
Internal stimuli . . . . . . . . . . . . . . . . . . .
3.4.2.
External stimuli. . . . . . . . . . . . . . . . . . .
3.5.
Multifunctional nanocarriers . . . . . . . . . . . . . . . . .
4.
Conclusions and perspectives . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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135
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144

1. Introduction

Corresponding author. Universit Catholique de Louvain, Louvain Drug Research

Institute, Unit de pharmacie galnique, Avenue Mounier UCL 7320, B-1200 Brussels,
Belgium. Tel.: + 32 2 7647320; fax: + 32 2 7647398.
E-mail address: veronique.preat@uclouvain.be (V. Prat).
0168-3659/$ see front matter 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.jconrel.2010.08.027

Cancer is a leading cause of death around the world. The World

Health Organization estimates that 84 million people will die of
cancer between 2005 and 2015. For effective cancer therapy, it is
necessary to improve our knowledge of cancer physiopathology,
discover new anti-cancer drugs and develop novel biomedical

136

F. Danhier et al. / Journal of Controlled Release 148 (2010) 135146

technologies. Currently, the cancer therapy has become a multidisciplinary challenge requiring close collaboration among clinicians,
biological and materials scientists, and biomedical engineers. Conventional chemotherapeutic agents are distributed non-specically in the
body affecting both normal and tumoral cells. Given the potency of
modern pharmacological agents, tissue selectivity is a major issue.
Hence, the dose achievable within the solid tumor is limited resulting
in suboptimal treatment due to excessive toxicities. The ultimate goal
of cancer therapeutics is to increase the survival time and the quality of
life of the patient by reducing the systemic toxicity of chemotherapy
[1].The idea of exploiting vascular abnormalities of tumors, avoiding
penetration into normal tissue interstitium while allowing access to
tumors, becomes particularly attractive. In this context, the tumor
targeting of nanomedicine-based therapeutics has emerged as one
approach to overcome the lack of specicity of conventional
chemotherapeutic agents [2,3].
This concept dates back to 1906 when Ehrlich rst imagined the
magic bullet [4]. The challenge of the targeting is triple: (i) to nd
the proper target for a particular disease; (ii) to nd the drug that
effectively treats this disease and (iii) to nd how to carry the drug.
The specic tumor targeting of nanocarriers leads to better proles of
pharmacokinetics and pharmacodynamics, controlled and sustained
release of drugs, an improved specicity, an increased internalization
and intracellular delivery and, more importantly, a lower systemic
toxicity. The tumor targeting consists in passive targeting and
active targeting; however, the active targeting process cannot be
separated from the passive because it occurs only after passive
accumulation in tumors [5].
New moleculary targeted anti-cancer agents currently used in
clinical trials illustrate the success of the targeting concept (imatinib
mesylate (Gleevec), getinib (Iressa), trastuzumab (Herceptin),
and cetuximab (C225, Erbitux). Alternatively, existing anti-cancer
agents can be more effective by using nanomedicines (the medical
application of nanotechnology). The European Science Foundation's
Forward Look on Nanomedicine dened nanomedicines as nanometer size scale complex systems, consisting of at least two components,
one of which being the active ingredient. Protecting drug from the
degradation, nanocarriers have to be able to target a drug to the tumor
site, reducing damage to normal tissue (Table 1). The development of
nanocarriers for poorly soluble drugs is very interesting because a
large proportion of new drug candidate emerging from high
throughput screening are poorly-water soluble drugs which are also
poorly absorbed and which present a low bioavailability. The
representations of the most currently used in preclinical and clinical
tumor-targeted nanomedicines are illustrated in Fig. 1.
Nanoparticles (Fig. 1A) are solid and spherical structures, ranging
around 100 nm in size, in which drugs are encapsulated within the
polymeric matrix. We distinguish nanospheres in which the drug is
dispersed throughout the particles and nanocapsules in which the
drug is entrapped in a cavity surrounded by a polymer membrane [6].
They can be PEGylated and grafted with targeting ligands (Fig. 1B).
Polymeric micelles (Fig. 1A) are arranged in a spheroidal structure

Table 1
Goals and specications of targeted nanoscale drug delivery system.
1. Increase drug concentration in the tumor through:
(a) passive targeting
(b) active targeting
2. Decrease drug concentration in normal tissue
3. Improve phamacokinetics and pharmacodynamics proles
4. Improve the solubility of drug to allow intravenous administration
5. Release a minimum of drug during transit
6. Release a maximum of drug at the targeted site
7. Increase drug stability to reduce drug degradation
8. Improve internalization and intracellular delivery
9. Biocompatible and biodegradable

Fig. 1. Nanomedicine in drug delivery. A. Types of nanocarriers currently described in

preclinical and clinical studies. B. Schematic representation of PEGylation and ligand
grafting.

with hydrophobic core which increases the solubility of poorly-water

soluble drugs, and the hydrophilic corona which allows a long
circulation time of the drug by preventing the interactions between
the core and the blood components. These systems are dynamic and
have a size usually below 50 nm [2]. Liposomes (Fig. 1A) are closed
spherical vesicles formed by one or several phospholipid bilayers
surrounding an aqueous core in which drugs can be entrapped. They
can be also PEGylated and grafted with targeting ligands [7].
Dendrimers (Fig. 1A) are highly branched macromolecules with
controlled three-dimensional architecture. Polymers grow from a
central core by a series of polymerisation reactions. Drugs are
attached to surface groups by chemical modications [8]. Polymer
drug conjugates (Fig. 1A) are polymeric macromolecules constituted
by a polymer backbone on which drugs are conjugated via linker
regions. They can be grafted with targeting ligands [9].
The common method to protect nanocarriers from the reticulo
endothelial system consists of coating the surface of the particles with
polyethylene glycol (PEG), a procedure called PEGylation (Fig. 1B). To
contribute to the stealth characteristics of PEGylated nanoparticles,
there are three important factors, (i) the molecular weight of the PEG
chain, (ii) the surface chain density and (iii) the conformation. The
coating of PEG chains to the surface of nanoparticles results in an
increase in the blood circulation half-life by several orders of
magnitude. By creating a hydrophilic protective layer around the
nanoparticles, steric repulsion forces repel the absorption of opsonin
proteins, thereby blocking and delaying the opsonization process [10].
2. Tumor microenvironment
In cancer therapy, the tumor microenvironment is one of many
areas which are studied to design new therapies. More precisely, the
knowledge and the understanding of the tumor microenvironment
allow researchers to elaborate different therapeutic strategies, based
on numerous differences compared with normal tissue including
vascular abnormalities, oxygenation, perfusion, pH and metabolic
states. Here, the differences in terms of morphology of tumor
vasculature and the pH will be particularly described as they are the
more relevant characteristics for the design of nanocarriers as tumortargeted drug delivery systems.

F. Danhier et al. / Journal of Controlled Release 148 (2010) 135146

2.1. Angiogenesis in cancer

Angiogenesis is dened as the formation of new blood vessels from
existing ones. For solid tumors (12 mm3), oxygen and nutrients can
reach the center of the tumor by simple diffusion. Because of their
non-functional or non-existent vasculature, non-angiogenic tumors
are highly dependent on their microenvironment for oxygen and the
supply of nutrients. When tumors reach 2 mm3, a state of cellular
hypoxia begins, initiating angiogenesis. Angiogenesis is regulated by a
ne balance of activators and inhibitors [11]. In the angiogenesis
process, ve phases can be distinguished: 1. endothelial cell
activation, 2. basement membrane degradation, 3. endothelial cell
migration, 4. vessel formation, and 5. angiogenic remodeling. Hypoxia
increases cellular hypoxia inducible factor (HIF) transcription, leading
to upregulation of pro-angiogenic proteins such as vascular endothelial growth factor (VEGF), platelet derived growth factor (PDGF) or
tumor necrosis factor- (TNF-) [12]. Activated endothelial cells
express the dimeric transmembrane integrin v3, which interacts
with extracellular matrix proteins (vibronectin, bronectin, a.o.) and
regulates the migration of the endothelial cell through the extracellular matrix during vessel formation [13]. The activated endothelial
cells synthesize proteolytic enzymes, such as matrix metalloproteinases, used to degrade the basement membrane and the extracellular
matrix. The inner layer of endothelial cells undergoes apoptosis
leading to formation of the vessel lumen. Immature vasculature
undergoes extensive remodeling during which the vessels are
stabilized by pericytes and smooth-muscle cells. This step is often
incomplete resulting in irregular shaped, dilated and tortuous tumor
blood vessels [14]. This ability of tumors to progress from a nonangiogenic to angiogenic phenotype (called the angiogenic switch)
is central to progression of cancer and allows the dissemination of
cancer cells throughout the body, leading to metastasis [11,15].

2.2. Enhanced Permeability and Retention (EPR) effect

Structural changes in vascular pathophysiology could provide
opportunities for the use of long-circulating particulate carrier
systems. The ability of vascular endothelium to present open
fenestrations was described for the sinus endothelium of the liver
[16], when the endothelium is perturbed by inammatory process,
hypoxic areas of infracted myocardium [17] or in tumors [18]. More
particularly, tumor blood vessels are generally characterized by
abnormalities such as high proportion of proliferating endothelial
cells, pericyte deciency and aberrant basement membrane formation
leading to an enhanced vascular permeability. Particles, such as
nanocarriers (in the size range of 20200 nm), can extravasate and
accumulate inside the interstitial space. Endothelial pores have sizes
varying from 10 to 1000 nm [19]. Moreover, lymphatic vessels are
absent or non-functional in tumor which contributes to inefcient
drainage from the tumor tissue. Nanocarriers entered into the tumor
are not removed efciently and are thus retained in the tumor. This
passive phenomenon has been called the Enhanced Permeability and
Retention (EPR) effect, discovered by Matsumura and Maeda [2022].
The abnormal vascular architecture plays a major role for the EPR
effect in tumor for selective macromolecular drug targeting at tissue
level that can be summarized as follows and illustrated in Fig. 2:
(1)
(2)
(3)
(4)
(5)

Extensive angiogenesis and hypervasculature

Lack of smooth-muscle layer, pericytes
Defective vascular architecture: fenestrations
No constant blood ow and direction
Inefcient lymphatic drainage that leads to enhanced retention
in the interstitium of tumors
(6) Slow venous return that leads to accumulation from the
interstitium of tumor

137

Physiological changes in blood ow within the tumors and in

transport properties of tumor vessels are consequences of these
vascular abnormalities. In 1987, Jain hypothesized that the osmotic
pressure in tumors must be high. This high tumor interstitial uid
pressure (IFP) could be a barrier for efcient anti-cancer drug delivery
[23]. It is now well known that the IFP of most solid tumors is
increased. Many anti-cancer drugs high molecular weight compounds in particular are transported from the circulatory system
through the interstitial space by convection rather than by diffusion.
Increased IFP contributes to a decreased transcapillary transport in
tumors, leading to a decreased uptake of drugs into tumor. In addition,
IFP tends to be higher at the center of solid tumors, diminishing
toward the periphery, creating a mass ow movement of uid away
from the central region of tumor. To ensure that all the tumor get an
adequate drug supply, drug molecules or drug-loaded nanocarriers
should migrate through the tumor interstitial space from a site of
entry to remote cells. This process is hindered by high IFP. Due to their
greater size, the transport of drug-loading nanocarriers is less affected
by this enhanced IFP in tumors. Moreover, the microvasculature
pressure in tumors is also one to two orders of magnitude higher than
in normal tissues. This facilitates extravasation of nanocarriers that
could otherwise have been precluded by high IFP. Many types of
nanocarriers successfully overcome these barriers and selectively
accumulate in the tumors [2325].
2.3. pH
While the intracellular pH of cells within healthy tissues and
tumors is similar, tumors exhibit a lower extracellular pH than normal
tissues. Accordingly, although tumor pH may vary according to the
tumor area, average extracellular tumor pH is between 6.0 and 7.0
whereas in normal tissues and blood, the extracellular pH of is around
7.4 [26,27]. Low pH and low pO2 are intimately linked and a variety of
insights now support their roles in the progression of tumor from in
situ to invasive cancer [28]. The low extracellular tumor pH mostly
arises from the high glycolysis rate in hypoxic cancer cells. Amazingly,
this ATP-generating pathway is also exploited by tumor cells when
oxygen is available [29]. This phenomenon named the Warburg effect
emphasizes that proliferating tumor cells do not exploit the full
capacity of glucose oxidation to produce energy. Both defects in the
mitochondrial respiratory chain and the need of glycolysis-derived
biosynthetic intermediates account for this metabolic preference
(reviewed in [29]). To maintain a high glycolytic rate however requires
that pyruvate is converted into lactate to generate nicotinamide
adenine NAD+, a factor required by different glycolytic enzymes.
Lactate itself needs to be eliminated from the cell to favor the
metabolic ux and avoid cytotoxicity development. Monocarboxylate
transporter will export one proton together with one lactate molecule,
leading to a progressive acidication of the tumor extracellular space
(and a slight alkalinisation of the cytosol). Hypoxia-induced expression of carbonic anhydrase IX (CA IX) will also contribute to exacerbate
the pH gradient between the intra- and extracellular compartments
through the conversion of CO2 to bicarbonate and subsequent uptake
of this weak base through the anion exchanger Cl-/bicarbonate [30].
The resulting pH gradients between intra- and extracellular tumor
cells but also between the tumor mass and the host tissue are
therefore potential sources of differential drug partitioning and
distribution. In a low pH extracellular environment, the uncharged
fraction of a weak acid increases and such a drug can thus more easily
diffuse through the cell membrane. The relatively basic intracellular
compartment may in turn favor the ionization of the molecule,
thereby promoting the cytosolic accumulation of the drug. Alteration
in this process is proposed to contribute to the multidrug resistance
(MDR) phenomenon [31]. The exposure to chemotherapy may indeed
favor the selection of tumor-cell clones with very acidic organelles
which will trap drugs and thereby reduce their activity; if this

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F. Danhier et al. / Journal of Controlled Release 148 (2010) 135146

Fig. 2. Differences between normal and tumor tissues that explain the passive targeting of nanocarriers by the Enhanced Permeability and Retention effect. A. Normal tissues contain
linear blood vessels maintained by pericytes. Collagen bres, broblasts and macrophages are in the extracellular matrix. Lymph vessels are present. B. Tumor tissues contain
defective blood vessels with many sac-like formations and fenestrations. The extracellular matrix contains more collagen bres, broblasts and macrophages than in normal tissue.
Lymph vessels are lacking.
Adapted from [24].

organelle is part of the secretory pathway then the drug will be

transported out of the cell by exocytosis.
3. Drug targeting
3.1. Passive targeting
Passive targeting consists in the transport of nanocarriers through
leaky tumor capillary fenestrations into the tumor interstitium and cells
by convection or passive diffusion (Figs. 3 and 4A) [32]. The convection
refers to the movement of molecules within uids. Convection must be
the predominating transport mode for most large molecules across
large pores when the net ltration rate is zero. In the contrary, lowmolecular weight compounds, such as oxygen, are mainly transported
by diffusion, dened as a process of transport of molecules across the
cell membrane, according to a gradient of concentration, and without
contribution of cellular energy. Nevertheless, convection through the
tumor interstitium is poor due to interstitial hypertension, leaving
diffusion as the major mode of drug transport.
Selective accumulation of nanocarriers and drug then occurs by
the EPR effect [32].The EPR effect is now becoming the gold standard
in cancer-targeting drug designing. All nanocarriers use the EPR effect
as a guiding principle. Moreover, for almost all rapidly growing solid

tumors the EPR effect is applicable [22]. Indeed, EPR effect can be
observed in almost all human cancers with the exception of
hypovascular tumors such as prostate cancer or pancreatic cancer
[21,33].
The EPR effect will be optimal if nanocarriers can evade immune
surveillance and circulate for a long period. Very high local
concentrations of drug-loaded nanocarriers can be achieved at the
tumor site, for instance 1050-fold higher than in normal tissue
within 12 days [34]. To this end, at least three properties of
nanocarriers are particularly important. (i) The ideal nanocarrier
size should be somewhere between 10 and 100 nm. Indeed, for
efcient extravasation from the fenestrations in leaky vasculature,
nanocarriers should be much less than 400 nm. On the other hand, to
avoid the ltration by the kidneys, nanocarriers need to be larger than
10 nm; and to avoid the a specic capture by the liver, nanocarriers
need to be smaller than 100 nm. (ii) The charge of the particles should
be neutral or anionic for efcient evasion of the renal elimination. (iii)
The nanocarriers must be hidden from the reticuloendothelial
system, which destroys any foreign material through opsonization
followed by phagocytosis [7,35].
Nevertheless, to reach passively the tumor, some limitations exist.
(i) The passive targeting depends on the degree of tumor vascularization and angiogenesis. [5]. Thus extravasation of nanocarriers will

Fig. 3. Visualization of extravasation of PEG-liposomes. A. Extravasation of PEG-liposomes with 126 nm in mean diameter from tumor microvasculature was observed. Liposome
localization in the tumor was perivascular. B. In normal tissue, extravasation of PEG-liposomes with 128 nm in mean diameter was not detected. Only uorescent spots within the
vessel wall were observed [33].

F. Danhier et al. / Journal of Controlled Release 148 (2010) 135146

139

Fig. 4. A. Passive targeting of nanocarriers. (1) Nanocarriers reach tumors selectively through the leaky vasculature surrounding the tumors. (2) Schematic representation of the
inuence of the size for retention in the tumor tissue. Drugs alone diffuse freely in and out the tumor blood vessels because of their small size and thus their effective concentrations
in the tumor decrease rapidly. By contrast, drug-loaded nanocarriers cannot diffuse back into the blood stream because of their large size, resulting in progressive accumulation: the
EPR effect. B. Active targeting strategies. Ligands grafted at the surface of nanocarriers bind to receptors (over)expressed by (1) cancer cells or (2) angiogenic endothelial cells.

vary with tumor types and anatomical sites. (ii) As previously

mentioned, the high interstitial uid pressure of solid tumors avoids
successful uptake and homogenous distribution of drugs in the tumor
[24]. The high interstitial uid pressure of tumors associated with the
poor lymphatic drainage explain the size relationship with the EPR
effect: larger and long-circulating nanocarriers (100 nm) are more
retained in the tumor, whereas smaller molecules easily diffuse [36]
(Fig. 4A.2).

3.2. Active targeting

In active targeting, targeting ligands are attached at the surface of
the nanocarrier (Fig. 1B) for binding to appropriate receptors
expressed at the target site (Fig. 4B). The ligand is chosen to bind to
a receptor overexpressed by tumor cells or tumor vasculature and not
expressed by normal cells. Moreover, targeted receptors should be
expressed homogeneously on all targeted cells. Targeting ligands are
either monoclonal antibodies (mAbs) and antibody fragments or nonantibody ligands (peptidic or not). The binding afnity of the ligands
inuences the tumor penetration because of the binding-site
barrier. For targets in which cells are readily accessible, typically
the tumor vasculature, because of the dynamic ow environment of
the bloodstream, high afnity binding appears to be preferable
[37,38].
Various anti-cancer therapeutics, grouped under the name ligandtargeted therapeutics, are divided into different classes based on the
approach of drug delivery [39]. The common basic principle of all these
therapeutics is the specic delivery of drugs to cancer cells. Main

classes of ligand-targeted therapeutics are illustrated in Fig. 5.

Antibodies (monoclonal antibody or fragments) (Fig. 5.A) target a
specic receptor, interfering with signal-transduction pathways,
regulating proto-oncogenes involved in cancer cells proliferation
such as trastuzumab (anti-ERBB2, Herceptin), bevacizumab (antiVEGF, Avastin) or etaracizumab, a humanized anti-v3 antibody
(Abegrin). In this case, the active molecule plays the role of both
targeting ligand and drug. Antibodies (or fragments) may only play the
role of targeting ligand when they are coupled with therapeutic
molecules (Fig. 5B). 90yttriumibritumomab tiuxetan (Zevalin),
directed against anti-CD-20, was the rst radioimmunotherapeutic
received for clinical approval [40]. The rst immunotoxin approved in
clinical was denileukin diftitox (Ontak), an interleukin (IL)-2diphteria toxin fusion protein [41]. The only immunoconjugate to
receive clinical approval is gemtuzumab ozogamicin (Mylotarg) [42].
Immuno-nanocarriers (Fig. 5C) use a different approach: cytotoxic
drug is encapsulated into a nanocarrier and antibodies (or fragments),
the targeting ligands, are coupled to the particle surface. Finally, for
targeted nanocarriers (Fig. 5D), antibodies are replaced by molecule
(peptidic or not) binding to specic receptors. In this review, we focus
on active targeting of immuno- and targeted nanocarriers.
In the active targeting strategy, two cellular targets can be
distinguished: (i) the targeting of cancer cell (Fig. 4B.1) and (ii) the
targeting of tumoral endothelium (Fig. 4B.2).

3.2.1. The targeting of cancer cell

The aim of active targeting of internalization-prone cell-surface
receptors, overexpressed by cancer cells, is to improve the cellular

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F. Danhier et al. / Journal of Controlled Release 148 (2010) 135146

Fig. 5. Main classes of ligand-targeted therapeutics. A. Targeting antibodies are

generally monoclonal immunoglobulin g (IgG) (a) or Fab fragments (b) or F(ab)2
fragments (c). B. Immunoconstructions are formed by the linking of antibodies or
fragments to therapeutic molecules. C. Targeted nanocarriers are nanocarriers
presenting targeted ligands at the surface of the nanocarrier. The ligands are either
monoclonal antibodies and antibody fragments (immuno-nanocarriers) or nonantibody ligands (peptidic or not). Targeted nanocarriers contain therapeutic drugs.

uptake of the nanocarriers. Thus, the active targeting is particularly

attractive for the intracellular delivery of macromolecular drugs, such
as DNA, siRNA and proteins. The enhanced cellular internalization
rather than an increased tumor accumulation is responsible of the
anti-tumoral efcacy of actively targeted nanocarriers. This is the base
of the design of delivery systems targeted to endocytosis-prone
surface receptors [43]. The ability of the nanocarrier to be internalized
after binding to target cell is thus an important criterion in the
selection of proper targeting ligands [44]. In this strategy, ligandtargeted nanocarriers will result in direct cell kill, including
cytotoxicity against cells that are at the tumor periphery and are
independent on the tumor vasculature [45]. The more studied
internalization-prone receptors are:
(i) The transferrin receptor. Transferrin, a serum glycoprotein,
transports iron through the blood and into cells by binding to
the transferring receptor and subsequently being internalized
via receptor-mediated endocytosis. The transferrin receptor is a
vital protein involved in iron homeostasis and the regulation of
cell growth. The high levels of expression of transferrin
receptor in cancer cells, which may be up to 100-fold higher
than the average expression of normal cells, its extracellular
accessibility, its ability to internalize and its central role in the
cellular pathology of human cancer, make this receptor an
attractive target for cancer therapy [44,46].
(ii) The folate receptor is a well-known tumor marker that binds to
the vitamin folic acid and folatedrug conjugates or folategrafted nanocarriers with a high afnity and carries these
bound molecules into the cells via receptor-mediated endocytosis. Folic acid is required in one carbon metabolic reactions
and consequently, is essential for the synthesis of nucleotide
bases. The alpha isoform, folate receptor- is overexpressed on
40% of human cancers. In contrast, folate receptor- is
expressed on activated macrophages and also on the surfaces
of malignant cells of hematopoietic origin [47].
(iii) Glycoproteins expressed on cell surfaces. Lectins are proteins of
non-immunological origin which are able to recognize and

bind to carbohydrate moieties attached to glycoproteins

expressed on cell surface. Cancer cells often express different
glycoproteins compared to normal cells. Lectins interaction
with certain carbohydrate is very specic. Lectins can be
incorporated into nanoparticles as targeting moieties that are
directed to cell-surface carbohydrates (direct lectin targeting)
and carbohydrates moieties can be coupled to nanoparticles to
target lectins (reverse lectin targeting). The use of lectins and
neoglycoconjugates for direct or reverse targeting strategies is
a traditional approach of colon drug targeting [48].
(iv) The Epidermal growth factor receptor (EGFR). The EGFR is a
member of the ErbB family, a family of tyrosine kinase
receptors. Its activation stimulates key processes involved in
tumor growth and progression, including proliferation, angiogenesis, invasion and metastasis. EGFR is frequently overexpressed in a lot of cancer, especially in breast cancer, has also
been found to play a signicant role in the progression of
several human malignancies. Human epidermal receptor-2
(HER-2) is reported to be expressed in 1491% of patients with
breast cancer [49,50]. EGFR is expressed or overexpressed in a
variety of solid tumors, including colorectal cancer, non-smallcell lung cancer and squamous cell carcinoma of the head and
neck, as well as ovarian, kidney, pancreatic, and prostate cancer
[51].
3.2.2. The targeting of tumoral endothelium
Destruction of the endothelium in solid tumors can result in the
death of tumor cells induced by the lack of oxygen and nutrients. In
1971, Judah Folkman suggested that the tumor growth might be
inhibited by preventing tumors from recruiting new blood vessels
[52]. This observation is the base of the design of nanomedicines
actively targeted to tumor endothelial cells [53]. By attacking the
growth of the blood supply, the size and metastatic capabilities of
tumors can be regulated. Thus, in this strategy, ligand-targeted
nanocarriers bind to and kill angiogenic blood vessels and indirectly,
the tumor cells that these vessels support, mainly in the tumor core.
The advantages of the tumoral endothelium targeting are: (i) there is
no need of extravasation of nanocarriers to arrive to their targeted
site, (ii) the binding to their receptors is directly possible after
intravenous injection, (iii) the potential risk of emerging resistance is
decreased because of the genetically stability of endothelial cells as
compared to tumor cells, and (iv) most of endothelial cells markers
are expressed whatever the tumor type, involving an ubiquitous
approach and an eventual broad application spectrum [38]. The main
targets of the tumoral endothelium include:
(i) The vascular endothelial growth factors (VEGF) and their
receptors, VEGFR-1 and VEGFR-2, mediate vital functions in
tumor angiogenesis and neovascularization [54]. Tumor hypoxia
and oncogenes upregulate VEGF levels in the tumor cells,
resulting in an upregulation of VEGF receptors on tumor
endothelial cells. Two major approaches to target angiogenesis
via the VEGF way have been studied: (i) targeting VEGFR-2 to
decrease VEGF binding and induce an endocytotic pathway and
(ii) targeting VEGF to inhibit ligand binding to VEGFR-2 [1,55].
(ii) The v3 integrin is an endothelial cell receptor for extracellular matrix proteins which includes brinogen (brin),
vibronectin, thrombospondin, osteopontin and bronectin
[56]. The v3 integrin is highly expressed on neovascular
endothelial cells but poorly expressed in resting endothelial
cells and most normal organs, and is important in the calciumdependent signaling pathway leading to endothelial cell
migration [1]. Cyclic or linear derivatives of RGD (ArgGly
Asp) oligopeptides are the most studied peptides which bind to
endothelial v3 integrins. The v3 integrin is upregulated in
both tumor cells and angiogenic endothelial cells [56].

F. Danhier et al. / Journal of Controlled Release 148 (2010) 135146

(iii) Vascular cell adhesion molecule-1 (VCAM-1) is an immunoglobulin-like transmembrane glycoprotein that is expressed on
the surface of endothelial tumor cells. VCAM-1 induces the cellto-cell adhesion, a key step in the angiogenesis process. Overexpression of VCAM-1 is found in various cancers, including
leukemia, lung and breast cancer, melanoma, renal cell
carcinoma, gastric cancer and nephroblastoma [57].
(iv) The matrix metalloproteinases (MMPs) are a family of zincdependent endopeptideases. MMPs degrade the extracellular
matrix, playing an essential role in angiogenesis and metastasis
more particularly in endothelial cell invasion and migration, in
the formation of capillary tubes and in the recruitment of
accessory cells. Membrane type 1 matrix metalloproteinase
(MT1-MMP) is expressed on endothelial tumor cells, including
malignancies of lung; gastric, colon and cervical carcinomas;
gliomas and melanomas [58]. Aminopeptidase N/CD13, a
metalloproteinase that removes amino-acids from unblocked
N-terminal segments of peptides or proteins, is an endothelial
cell-surface receptor involved in tumor-cell invasion, extracellular matrix degradation by tumor cells and tumor metastasis
in vitro and in vivo [59]. NGR (AsnGlyArg) peptide is reported
to bind to the aminopeptidase [60].
Although the tumor vasculature is recognized as a major target for
cancer therapies, an additional type of vascular cells, the pericytes,
have been described as an alternative target that is also potentially
important. It has been demonstrated that the aminopeptidase A, the
membrane-associated protease, is upregulated and active in these
cells [45,61].
3.3. Preclinically and clinically used tumor-targeted nanomedicines
Clinical trials of nanomedicine without targeting ligands are
summarized in Table 2. The rst liposomes to be approved by the
regulatory authorities were Doxil and Myocet. Both products
contain the cytotoxic drug doxorubicin. Myocet is a doxorubicin
formulation of uncoated liposomes whereas Doxil is a PEG-liposome
formulation designed to prolong blood circulation time. Free
doxorubicin presents an elimination half-life time of 0.2 h. This
value is enhanced to 2.5 h and 55 h for Myocet and Doxil,
respectively [62]. Doxil has been shown to induce a lower
cardiotoxicity than free doxorubicin. Myocet is currently used in
clinical to treat breast cancer in combination with other chemotherapeutic agent (cyclophosphamide). Doxil is used to treat
women with metastatic breast cancer who have an increased risk of
heart damage, advanced ovarian cancer and AIDS related Kaposi's
sarcoma. Other liposomal systems have been approved such as
DaunoXome and Onco-TCS, non-PEGylated liposomal formulations of daunorubicin and vincristine. Because of the well-known
toxicity of Cremophor EL, a surfactant included in the paclitaxel
formulation (Taxol), novel formulations of paclitaxel have been
and are always intensively studied.
Abraxane, a solvent free, albumin-bound nanoparticles of
paclitaxel, also known as nab-paclitaxel, is currently used in
metastatic breast cancer after failure of combination chemotherapy
for metastatic disease or relapse within 6 months of adjuvant
chemotherapy. In a Phase III study, Abraxane demonstrated higher
response rates, a better safety prole compared with conventional
paclitaxel, and improved survival in patients receiving it as secondline therapy [63]. Albumin is a plasma protein with a molecular
weight of 66 kDa. Because albumin is found in the plasma of the
human body, it is non-toxic and well tolerated by immune system.
Albumin has attractive phamacokinetics owing to its long half-life
which is particularly interesting to design a drug carrier for passive
targeting. Albumin seems to help endothelial transcytosis of proteinbound and unbound plasma constituents via the binding to a cell-

141

Table 2
Examples of passively tumor-targeted nanocarriers in cancer therapy.
Clinical data are extracted from http://www.clinicaltrials.gov (May 2010).
Nanocarriers

Drug

Name

Indications

Status

Polymeric
micelles

Paclitaxel

Genexol-PM

Breast, lung,
pancreatic cancer
Recurrent breast
cancer
Various
Metastatic breast
cancer
Hepatocarcinoma
Advanced breast
cancer
Breast, ovarian cancer
Advanced lung cancer
Breast, lung, colon
Various
Ovarian, metastatic
breast cancer, Kaposi
sarcoma
Breast cancer
Kaposi Sarcoma
Non-Hodgkin
lymphoma Various
Leukemia, melanoma

IIIII

Nanoparticles

Doxorubicin
Albuminpaclitaxel
Doxorubicin
Paclitaxel

Polymerdrug Paclitaxel
conjugates
Doxorubicin
Paclitaxel
Liposomes
Doxorubicin

NK911
Abraxane
Transdrug
Nanoxel
Xyotax
(CT-2103)
PK1
Taxoprexin
Doxil

Doxorubicin
Myocet
Daunorubicin DaunoXome
Vincristine
Onco-TCS
Marqibo

IV
III
Approved
Approved
I
II
III
II
IIIII
Approved

Approved
Approved
Approved
II
II

surface receptor (gp60) [7]. gp60 binds to caveolin-1 with subsequent

formation of transcytotic vesicles (caveolae). It has been proposed
that Abraxane targets cancer tissues because of the high metabolic
demand and active transport of plasma proteins for anabolic
processes. Abraxane could be transported into tumor by secreted
protein acidic rich in cysteine (SPARC) or osteonectin, which binds
albumin because of a sequence homology with gp60. SPARC as
caveolin-1 is often expressed in some cancers (e.g. breast, lung and
prostate), which could explain why albumin is known to accumulate
in some tumors and thus facilitates intratumor accumulation of
albumin-bound drugs [64,65].
In active targeting, the strategy consists in grafting a targeting
ligand at the surface of nanocarriers to provide an enhanced
selectivity and thus efcacy, as compared to the passive targeting.
Although many authors report the evidence of this strategy in
preclinical models, until now only three clinical trials have been
conducted (Table 3): the galactosamine-targeted PHPMA doxorubicin
(PK2) [66], the GAH-targeted doxorubicin-containing immunoliposomes (MCC-465) [67] and the transferrin-targeted oxaliplatin
containing liposomes [68]. On the other hand, a much larger number
of preclinical studies are published, using various nanomedicines and
targeting ligands (Table 3).
It is important to note that for each active targeted nanocarriers
described in the literature, only one strategy is exploited: the cancer
cell targeting or the tumoral endothelium targeting. However, v3
integrins targeted nanocarriers could be considered as doubletargeting systems because v3 integrins are upregulated in both
tumor cells and angiogenic endothelial cells [56]. This double
targeting is described for integrin antagonists as etaracizumab. In
addition to its anti-angiogenic effects, etaracizumab inhibited tumor
growth by directly affecting tumor cells [69]. This double targeting is
not yet exploited by systems delivering chemotherapeutics. Indeed,
v3 integrin targeted nanocarriers were only described as systems
able to target the tumor vasculature, resulting in tumor regression and
inhibition of the growth of metastases [70,71].

3.4. Stimuli-sensitive nanocarriers

A new targeting strategy consists in developing activable or
activated nanocarriers. Nanocarriers maintain the stealth function

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Table 3
Examples of nanocarriers using the active tumoral targeting strategy.
Clinical data are extracted from http://www.clinicaltrials.gov.
Targeting ligands/targets

Nanocarriers

Indications/tumor cells

Status

Ref

Transferrin
Transferrin receptor

Liposomes
Liposomes
Liposomes (MBP-426)

A2780 ovarian cancer cell

C6 glioma
Metastatic solid tumor

In vitro
Preclinical
Phase I

[72]
[73]
[68]

Folate
Folate receptor

Liposomes
Nanoparticles
Micelles

Human KB
SKOV3
Human KB

Preclinical
In vitro
Preclinical

[74]
[75]
[76]

Micelles
Polymerdrug conjugate (PK2)
Liposomes

HepG2
Liver
B16 melanoma

In vitro
Phase I/II
In vitro

[77]
[66]
[78]

Liposomes

MCF-7

Preclinical

[79]

Liposomes

BT-474/MCF-7 breast cancer

Preclinical

[43]

Liposomes

MDA-MB-468, U87 glioma

Preclinical

[80]

Nanoparticles

K1735-M2 and CT-26 tumors

Preclinical

[81]

Magnetic nanoparticles

Human liver cancer

Preclinical

[82]

Liposomes
Nanoparticles
Nanoparticles
Micelles

B16 melanoma
Pancreatic/renal orthopic tumors
TLT
MDA-MB-435 breast cancer

Preclinical
Preclinical
Preclinical
Preclinical

[83]
[70]
[71]
[84]

Liposomes

Human Colo 677 tumor

Preclinical

[38]

Liposomes

Colon 26 NL-17 carcinoma

Preclinical

[85]

Liposomes

HT1080

Preclinical

[86]

Liposomes

Neuroblastoma

Preclinical

[87]

Liposomes (MCC-465)

Metastatic stomach cancer

Phase I

[67]

Lectins
Galactosamine
Asialoglyco-protein receptor
Hyaluronan
CD44 receptor
EGF
Anti-HER-2
HER-2 receptor
Anti-HER-2 MAb
HER-2 receptor
Anti-EGRF Mab
EGRF receptor
VEGF
Anti-Flk1 Mab
VEGFR-2 (Flk-1)
Anti-VEGF Mab
VEGF
RGD peptide
RGD peptide
Integrins (v3)

VCAM-1
Anti-VCAM-1
VCAM-1
MMP
GPLPLR
MT1-MMP
Anti-MT1-MMP Fab
MT1-MMP
NGR
Aminopeptidase N
GAH
GAH Fab

during circulation, upon arrival at the tumor site, transformation of

the nanocarriers is triggered by the unique tumoral extracellular
environment, allowing the drug release or the interaction with a
specic target. The drug retention in nanocarriers can also be solved
by application of external stimuli allowing a controlled and selective
targeting of cells.
3.4.1. Internal stimuli
The issue of very acidic endosomes may be considered as a
potential advantage. The use of drug-loaded micelles that destabilizes
at an early endosomal pH of 6.0 should in theory maximize
intracellular drug delivery and minimize drug release at the
extracellular pH and at the lysosomal pH (around 5.0). An elegant
study by Kim and colleagues has validated this concept [88]. These
authors used a pH-sensitive doxorubicin-loaded mixed-micelles
system conjugated with folic acid and documented cytotoxic effects
not only in wild-type sensitive but also doxorubicin-resistant ovarian
MDR cancer-cell lines. To optimize the doxorubicin release from early
endosomal compartment, the pH sensitivity of the micelles was
controlled by a mixture of polymers, namely polyhistidine-cophenylalanine and poly-L-lactic acid. The concept of targeting the

endosomal pH is however still in its infancy and nowadays most of the

conclusive efforts to exploit differences in pH as a guide to deliver
more drugs arise from the basic difference of extracellular pH in
tumor versus healthy tissues. Ligands such as poly(l-histidine) or
polysulfonamide actually offer systems particularly well suited to act
as pH-sensitive polymeric carriers. The unsaturated nitrogen in the
imidazole ring of histidine has lone pairs of electrons that endow it
with pH-dependent amphoteric properties. In other words, poly
(histidine) acts as a weak base that has the ability to acquire a cationic
charge when the pH of the environment drops below 6.5. Incorporation of poly(histidine) ligand to polymeric micelles may thus lead to
physical destabilization in the extracellular, acidic tumor medium.
Lee and colleagues documented for instance that the blending of poly
(L-lactic acid)/PEG block copolymer with polyHis/PEG allows to tailor
the triggering pH of the polymeric micelles to acidic pH as
encountered in tumors [89]. Of note, the accumulation of histidine
residues inside acidic endosomal vesicles can also induce a proton
sponge effect, which increases their osmolarity/swelling and favors
payload delivery.
Similarly, exposure to the acidic extracellular tumor pH leads to
the neutralization of polysulfonamides (which are negatively charged

F. Danhier et al. / Journal of Controlled Release 148 (2010) 135146

at pH 7.4). Consecutive disruption of ionic interactions may then

facilitate the delivery of the nanoparticle content or even expose so far
hidden motifs to further facilitate delivery. This may be particularly
suited to allow the exposure of cell-penetrating peptides endowed
with the capacity to translocate their conjugated moieties into the cell
[90]. Such a shielding/deshielding mechanism was recently reported
to expose cationic TAT (HIV transactivator of transcription) peptide in
the tumor microenvironment [91]. Tumor extracellular/endosomal
pH-sensitive nanocarriers have therefore the potential to overcome
the lack of selectivity of conventional anti-cancer modalities and
together with EPR to increase the efcacy of therapeutic entities
including siRNA, drugs or radioisotopes.
Others targeted therapies able to specically kill tumor cells are
based on tumor site-specic enzymatically activation of prodrugs.
Either a selected enzyme is accumulated in the tumor by guiding the
enzyme to the neoplasic cells or a harmless prodrug is applied and
specically converted by this enzyme into a cytotoxic drug only at the
tumor site [92]. This targeted enzyme prodrug strategy has no
application, to our knowledge, to nanocarriers. Nevertheless, nanocarriers may also be activated by enzyme overexpressed in the tumor.
Indeed, specic enzymes of tumor may control the release of a drug
from a nanocarrier by the cleavage of a linker of the polymers [93]. For
example, a drugpolymer conjugate was created by conjugating
methotrexate to dextran via a peptide linker that could be cleaved by
MMP-2and MMP-9, 2 important tumor-associated enzymes [35].
Redox/thiol sensitive polymers are another class of responsive
polymers. The conversion of disuldes and thiols is a key step in many
biological processes. Disulde bonds can be converted reversibly to
thiols by various reducing agents and undergo disulde exchange in
the presence of other thiols. For this reason, polymers containing
disulde linkages can be considered both redox and thiol-responsive
[93]. For example, it was demonstrated that supromolecular polymer
surfactant complexes can form micelles susceptible to thiol-induced
dissociation [94].
3.4.2. External stimuli
Many pathological areas show distinct hyperthermia (e.g. 42 C in
human ovarian carcinoma). Temperature-sensitive nanocarriers
contain a polymer with a low critical solution temperature (LCST).
Because of the precipitation of the polymer when the temperature is
above the LCST (in the tumor), the nanocarrier structure is damaged
and the drug is released. The poly(N-isopropylacrylamide) (NIPAM) is
the most widely used polymers for thermoresponsive nanocarriers
[95]. Local heating of the tumor may be achieved by various physical
means, among which the least invasive, easiest and cheapest is
ultrasound.
Magnetic nanoparticles were rstly designed for magnetic resonance imaging via passive targeting. Currently, some superparamagnetic iron oxide nanoparticles (SPION) are in early clinical trials and
several formulations have been approved for medical imaging, such as
Feridex, Combidex or Ferumoxytol [96,97]. Magnetic nanoparticles are also studied for drug targeting applications. A number of
SPION systems have been coated with targeting ligands (active
targeting). Under the inuence of external magnets, it is possible to
guide nanoparticles to a particular targeted site [98,99]. The
increasing local temperature obtained by using SPION in an
alternating magnetic eld allowed the elimination of the tumor.
This principle is called the magnetic thermal ablation [100].
Photo-responsive polymers are molecules that change their
properties when they are irradiated with light of the appropriate
wavelength. Typically, the light induces structural transformations of
specic functions of this kind of polymers. For example, when
exposed to UV irradiation, cleavage of the pyrenyl-methyl esters
caused the pyrene-containing hydrophobic methacrylate units to be
transformed to hydrophilic methacrylic acid units, resulting in micelle
dissociation [94]. Because light of UV and visible wavelengths is

143

readily absorbed by the skin, these systems may present some

limitations. For this reason, other polymers sensitive to infra-red or
near infra-red lights are studied [101,102].
The drug delivery and the release from nanocarriers may also be
triggered by external ultrasound. Ultrasonic waves can be used to
induce either thermal or mechanical effects. Local heating can be
induced using high-intensity focused ultrasound (HIFU), inducing
phase transition of the polymers, which involves the drug release
from nanocarriers. The drug release may also be induced by
mechanical effects associated with ultrasound, such as transient
cavitation [103].
3.5. Multifunctional nanocarriers
Different drug delivery systems are currently studied. These
systems are typically based on only one useful function(s): (i) the
longevity (PEGylation), (ii) the targetability (passive or active
targeting) and (iii) the stimuli sensitivity (pH, temperature, ultrasound, etc.). An increasing number of publications deal with the
combination of these functions for the designing of drug delivery
systems [104]. Multifunctional nanocarriers may combine therapeutic
and diagnostic strategies but also different therapeutic approaches.
Therefore, multifunctional drug carriers may combine the targetability and the stimuli sensitivity. Cyclic NGR peptide targeted
thermally sensitive liposome was designed for binding preferentially
to CD13/aminopeptidase N overexpressed in tumor vasculature; these
liposomes released doxorubicin at 41 C (in the tumor) while the
release was minimal at 37 C. This system allows the improvement of
the drug release and the total accumulation in the tumor [105]. Biotin
targeted thermoresponsive micelles were also described [106].
Another example is the double-targeted pH-responsive nanocarriers.
Liposomes and micelles were protected by low pH-cleavable PEG
chains. Monoclonal antibodies were attached at the surface of noncleavable longer PEG chains and additional functions (TAT peptide)
were attached at the surface of non-cleavable anchor shorter than the
cleavable PEG chain. In addition to prolonged circulation (PEGylation), this system combined the target recognition (antibody) and the
activation of the system under local stimuli (lowered pH) (Fig. 6)
[107]. Magnetic nanoparticles were conjugated with anti-VEGF
monoclonal antibody as double-targeting vector for the radioimmunotherapy of liver cancer with an external magnetic eld [106].
It is also possible to design drug delivery systems by combining
two forms of targetability: the cancer cell targeting and the tumoral
endothelium targeting. Doxorubicin was formulated in liposomes
targeted against tumor cells via anti-G2 monoclonal antibodies and
against the tumor vasculature via the NGR peptide which targets the
aminopeptidase N (CD13). It was demonstrated that these two
therapies are complementary. Circulating tumor cells, very early
metastases and the dividing rim of mature tumors will be most
sensitive to tumor-targeted therapies, whereas angiogenic metastases
and more mature tumors will be most sensitive to antivascular
therapies [45]. The combination of different strategies results in
multifunctional nanocarriers of new generation. They represent a
growing area of drug delivery system research (Fig. 6).
4. Conclusions and perspectives
In conclusion, we have described the tumor microenvironment to
better understand the possibilities and the opportunities to design
new passive or active targeted drug delivery systems. Nanocarriers
can escape from tumor vasculature through the leaky endothelial
tissue that surrounds the tumor and then accumulate in certain solid
tumors by the EPR effect. This phenomenon is called the passive
targeting. The basis for increased tumor specicity is the differential
accumulation of drug-loaded nanocarriers in tumor tissue versus
normal tissue [108,109]. Target ligands attached to the surface of

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F. Danhier et al. / Journal of Controlled Release 148 (2010) 135146

Fig. 6. Double-targeted smart nanocarrier with temporarily hidden function. A. Schematic representation. Polymeric chains are attached to the carrier via low pH-degradable
bonds. After accumulation in the tumor due to PEG (longevity) and ligand (specic targeting), local pH-dependent removal of protecting PEG chains allows the direct interaction of
the cell-penetrating functions of the carrier with the tumor cells. B. Fluorescence microscopy showing interaction of smart TAT peptide-modied liposomes. Rhodamine-labeled
TAT-liposomes are effectively taken by cells. The attachment of PEG chains to the liposomes surface (18%) leads to the almost completely blocked uptake of TAT-mediated liposomes.
However, if PEG is attached via pH-sensitive bonds, PEG chains are eliminated from the liposome surface and thus the TAT-mediated uptake of the liposomes by cells is good
[104,107].

nanocarriers may act as homing devices, improving the selective

delivery of drug to specic tissue and cells. Among various ligands
currently developed allowing the active targeting of tumors some
target tumor endothelial cells while others targets cancer cells
themselves [110].
The US National Science Foundation estimates that the nanotechnology market will be worth $ 1 trillion by 2015. The National Cancer
Institute is engaged in efforts to harness the power of nanotechnology
to radically change the way we diagnose, image and treat cancer. This
includes the design of targeted contrast agents that improve the
resolution of tumor imaging and nanomedicines able to act on specic
cells. Nanomedicines as drug delivery systems are expected to change
the pharmaceutical landscape in the future, offering new opportunities to market drugs that until now could not be administered
(poorly-water soluble drugs, bioactive macromolecules). Fewer
clinical examples illustrate that nanotechnology has enabled the
existence of new therapeutics that would otherwise not exist. The
benet of a targeted drug delivery system over the equivalent nontargeted system is expected to be substantial. The attractive
properties of nanomedicines include their ability of controlled release
of drugs, the targeting of specic tissues and the biocompatibility.
Nanomedicines offer the possibility to modify the pharmacokinetics
parameters and to decrease the systemic toxicity of drugs. In the
current context where it is required to nd not only more effective
but also less toxic treatments, nanomedicines nd their place.
Indeed, in a global approach of treatments, today, the efciency
but also the patient's quality of life are taken into account. Regarding
the growing number of clinical trials of nanomedicines combined
with radiotherapy or with conventional chemotherapy, there is an
evidence of the success of these therapies in the future [111].
According to the current clinical trials, combinations of treatments
seem to be the future. Indeed, before a new drug delivery system is
approved, it is already being tested in combination with other
treatments. Drug delivery systems may thus be associated with
vasoactive agents to increase the EPR-mediated targeting [109], with
radiation or with conventional chemotherapy. It is also possible to

associate drug delivery systems with different targeting strategies.

Therefore, there is no doubt that nanocarriers, particularly multifunctional systems or associations, will exist as main therapeutic arsenal in
the future. Nevertheless until now, some limitations exist: (i) the
major limitation impeding the entry of targeted nanomedicines onto
the market is that innovative research ideas within academia are not
exploited in collaboration with the pharmaceutical industry [53]. (ii)
A new subdiscipline of nanotechnology called nanotoxicology has
emerged. Indeed, in vivo systems are extremely complex and the
interactions of nanocarriers with biological components are vast. As
expected, the size and surface properties of nanocarriers modify the
behavior of these components in the body. More data are needed to
understand their structureproperty relationship. Some nanomedicines received regulatory approvals showing their biocompatibility
while others were not tested. Studies and regulations are necessary in
order to fully dene the biocompatibility of nanocarriers in humans.
(iii) Clinical trials of combined treatments are difcult to conduct
particularly because the proof of principle and complete toxicology
data are difcult to establish.
In the future, we can expect the emergence of many nanotechnology platforms for drug delivery applications. Nanotechnology will
change the very foundations of cancer diagnosis, treatment and
prevention.

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