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Clinical significance of angiogenesis Clinical significance of angiogenesis inhibitors in the treatment of cancerinhibitors in the treatment of cancer

Łukasz ŁapińskiAnna Wiela-Hojeńska

Krystyna Orzechowska-Juzwenko

Department of Clinical Pharmacology

Wrocław Medical University

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AngiogenesisAngiogenesis

(gr. angeion- blood vessel, genesis- formation)

a process of new blood vessels formation

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Angiogenesis plays important role in many physiological conditions,

e.g. fetal development, female reproductive cycle or

wound healing

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The angiogenic process is regulated by balance between

endogenous proangiogenicand angiogenic factors

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Stimulatory and inhibitory factors of angiogenesis

Lim S.T., Levine A.M.: Angiogenesis and hematological malignancies. Hematology, 2005, 10, 11-24.

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Others stimulators and inhibitors of angiogenesis1. Stimulators:• angiogenin• cyclooxygenase-2• erythropoietin• β- estradiol• G-CSF• interleukin (IL) 8• matrix metalloproteases (MMP)• nitric oxide• tumor necrosis factor α• vascular endothelial growth

factor (VEGF)

2. Inhibitors:• heparinases• heparin hexasaccharide

fragment• interferon- α, β, γ• IL 4, IL 12, IL 18• 2- methoxyestradiol• plasminogen activator

inibitors• prolactin 16kDa fragment• retinoids• tetrahydrocortisol-S

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Role Role inin thethe formationformation ofofnewnew vesselsvessels

Erythropietin Nitric oxide

• ↑ endothelial cellsproliferation

• ↑ angiogenesis in vivo

• ↑ permeability

• ↑ endothelial cellsproliferation

• ↑ fibroblast growth factorliberation

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Angiogenesis also plays Angiogenesis also plays important role in pathogenesis important role in pathogenesis

of many diseasesof many diseases

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In pathological conditions balance between angiogenesis stimulators and inhibitors is

disturbed

Nyberg P., Xie L., Kalluri R.: Endogenous inhibitors of angiogenesis. Cancer Res., 2005, 65, 3967-3979

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Role of angiogenesis in diseasesRole of angiogenesis in diseases

Angiogenesis

1. Cancer

2. Rheumatoid arthritis

3. Ophtalmia

4. Psoriasis

5. AIDS complications

Angiogenesis

1. Ictus

2. Infertility

3. Scleroderma

4. Ulcer

5. Cardiomyopathy

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Growth of cancer depends on an adequate supply of oxygen, nutrients and the removal of

waste products

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Angiogenic process may be initiated by

• hypoxia in cancerous cells

• mutation in suppressor genes

• mutation in oncogenes

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The process of angiogenesis

Pandya N.M., Dhalla N.S., Santani D.D.: Angiogenesis- a new target for futuretherapy. Vascular Pharmacol., 2006, 44, 265-274.

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Angiogenesis also plays an important role in spread of

solid tumors

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Role of angiogenesis in cancer development, its growth and formation of metastasis

Hoeben A., Landuyt B., Highley M.S., Wildiers H., van Oosterom A.T., de Bruijn E.A.: Vascular endothelial growth factor and angiogenesis. Pharmacol. Rev., 2004, 56, 549-580.

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AAngiogenesisngiogenesis inhibitorsinhibitors

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Inhibition levels of tumoral angiogenesis

Shinkaruk S., Bayle M., Lain G., Deleris G.: Vascular endothelial cell growthfactor , an emerging target for cancer chemotherapy. Curr. Med. Chem.- Anti-cancer agents, 2003, 3, 95-117.

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Angiogenesis can be stopped or altered by:

• blocking initial signals from the tumor• making initial signals from the tumor

less effective• stopping the enzyme pathway• normalizing mangled blood vessels• preventing the switch from turning on

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Vascular endothelial growth factor VEGF

One of the most specific and critical regulators of angiogenesis

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VEGF functions VEGF functions on eon enndothelialdothelial cellscells

Function MechanismProliferation Activation of mitogen-activated

protein kinasesPermeability Vesicovascular organelles;

endothelial fenestrations; opening of junctions between adjacent endothelial cells

Invasion Induction of metalloproteinases uPA, uPAR, TTPA

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VEGF functions VEGF functions on eon enndothelialdothelial cellscells

Function MechanismMigration Activation of FAK, p38, nitric oxideSurvival Induction of PI3K/Akt, Bcl2, A1,

survivin, XIAP or FAK; inhibition of capases

Activation Up-regulation of integrin expression; alteration is cell cytoskeleton

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Binding specificity of various VEGF family members and their receptors (VEGFR)

Hicklin D.J., Ellis L.M.: Role of the Vascular Endothelial Growth Factor pathwayin the tumor growth and angiogenesis. J. Clin. Oncol., 2005, 23, 1011-1027.

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Tumor expression of VEGF correlates with tumor

invasiveness and prognosisin patients with cancer

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Excessive expression of VEGFExcessive expression of VEGF in in human malignancieshuman malignancies

Cancer type Tumours (%) Correlations

Non-small-cell lung

45 - 55

Colorectal 40 - 60Recurrence, survival

Breast 30 - 60 Vascular density, relapse-free survival, overall survival

Prostate 30 Vascular density, relapse-free survival

Renal 30 - 100 Vascular density

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Over expression of VEGF mRNA in human malignancies

• intracranial tumour• thyroid tumour• lung cancer• breast cancer• gastrointestinal tract tumour• urinary tract tumour• female reproductive tract tumour• angiosarcoma

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Relationship between VEGF expression and metastasis in colon cancer patients

Ellis L.M., Takahashi Y., Liu W., Shaheen R.M.: Vascular endothelial growthfactor in human colon cancer: biology and therapeutic implication. Oncologist, 2000, 5, 11-15.

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Relationship between vessel count and metastasis in colon cancer patients

Ellis L.M., Takahashi Y., Liu W., Shaheen R.M.: Vascular endothelial growthfactor in human colon cancer: biology and therapeutic implication. Oncologist, 2000, 5, 11-15.

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Kaplan-Meier curves for vessel count expression in colon cancer patients

Ellis L.M., Takahashi Y., Liu W., Shaheen R.M.: Vascular endothelial growthfactor in human colon cancer: biology and therapeutic implication. Oncologist, 2000, 5, 11-15.

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Kaplan-Meier curves for VEGF expression in colon cancer patients

Ellis L.M., Takahashi Y., Liu W., Shaheen R.M.: Vascular endothelial growthfactor in human colon cancer: biology and therapeutic implication. Oncologist, 2000, 5, 11-15.

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BevacizumabAvastin

• monoclonal antibody • signal-blocking angiogenesis inhibitor• intercepts a tumor’s VEGF signals and

stops them from connecting with the endothelial cells

• is used in colon cancer therapy

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Bevacizumab pharmacokinetics

• linear pharmacokinetics• therapeutic plasma concentration

10-30 µg/ml• terminal elimination half-life time1-2 weeks

Optimal dose and schedule depend on tumour type

• dose 5-15 mg/kg• schedule every 2-3 weeks

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Yang J.C., Haworth L., Sherry R.M. Hwu P.: A randomized trial ofbevacizumab, an anti-vascular endothelial growth factor antibody, for metastatic renal cancer. N. Engl. J. Med.., 2003, 349, 427-434.

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Bevacizumab clinical trials in solid tumors

• breast cancer• non-small cell lung

cancer• colorectal cancer• rectal cancer• renal cell carcinoma • hepatocellular

cancer• pancreatic cancer

• soft- tissue sarcoma• Kaposi’s sarcoma• mesothelioma• head and neck• melanoma• carcinoid carcinoma• prostate• ovarian cancer• cervical cancer

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Bevacizumab clinical trials in hematologic malignancies

• myelodysplastic syndrome• non-Hodgkin lymphoma • acute myeloid leukemia• chronic myeloid leukemia• multiple myeloma

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Bevacizumab phase II clinical trials efficacy results in patients with metastatic breast

cancerOutcome 3 mg/kg 10 mg/kg 20 mg/kg TotalTotal

n 18 41 16 7575

Response rate (%) 1 (5.6) 3 (7.3) 1 (6.3) 5 (6.5 (6.77))

Median response duration (month) 3.1 5.6 8.0 5.65.6

Stable disease or better at day 154 (%)

2 (11) 7 (17) 3 (19) 12 (16)12 (16)

Median survival (month) 14.0 12.8 7.6 10.210.2

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Combination of the antibody with standard chemotherapy and

radiotherapy regimen significantly prolonged time of

progression and increasesurvival than chemotherapy alone

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Angiogenesis inhibitors

1. Mechanism of action is cytostatic (causing arrest of cell division, not cell death).

2. Objective response is not a decision-making surrogate end point.

3. Chronic administration is required to demonstrate activity.

4. Cytotoxic chemotherapy is not viewed as competition but as a potential partner in therapeutic effect.

5. Importance of tumor cell burden and resistance may be less than with cytotoxics.

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Angiogenesis inhibitors

1. Target: endothelial cell receptors.

2. Resistance may not be important, as the target is a normal host cell.

3. Hypoxia and cell kinetics may not be important; role of tumor cell burden to be determined.

Cytotoxic therapy

1. Target: tumor cells.

2. Resistance is a major factor.

3. Hypoxia, cell kinetics, and tumor cell burden are critical factors.

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Combining cytotoxic agents and angiogenesis inhibitors

1. Cellular targets are different, with both pathways likely to result in decreased tumor burden.

2. Resistance patterns should not overlap.3. Lack of myelosupression with

angiogenesis inhibitors enables full doses of both agents to be administered.

4. Assumption of additive effects is reasonable.

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Efficacy of bevacizumab (BEV) when added to carboplatin/paclitaxel (CP) in patients with locally

advanced or metastatic NSCLC

OutcomeCP alone

(n=32)CP + BEV 7.5 mg/kg

(n=32)

CP + BEV 15 mg/kg

(n=34)Response rate (%)

18.8 28.1 31.5

TTP (months [range])

4.2 (0-12.6)

4.3 (0.2-12.9)

7.4 (0.7-12.5)*

Mean survival (month)

14.9 11.6 17.7

p = 0.02

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Results of phase II controlled study of bevacizumabin patients with metastatic colorectal cancer

Fluorouracil, leucovorin, and bevacizumab

Outcome

Fluorouracil plus

leucovorin(n=36) 5 mg/kg

(n=35)10 mg/kg

(n=35)

Response rate (%) 6 (17) 14 (40)* 8 (24)

Median time to disease progression (month)

5.2 9.0** 7.2

Median survival (month)

13.8 21.5 16.1

* p = 0.029 ** p = 0.005

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Results of phase III trial of first-line Irinotecan, fluorouracil and leucovorin with or without bevacizumab

in patients with metastatic colorectal cancer

OutcomeIFL + placebo

(n=412)IFL + bevacizumab

(n=403)

Response rate (%) 35 45*

Median time to disease progression (month)

7.1 10.4**

Median progression-free survival (month)

6.2 10.6***

Median survival (month)

15.6 20.3****

* p=0.0029, **p=0.0014, ***p<0.00001, ****p=0.00003

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Main adverse events associated with bevacizumab plus carboplatin/paclitaxel in

patients with advanced or metastatic NSCLC

CP alone CP + BEV 7.5 mg/kg

CP + BEV 15 mg/kg

All G 3/4 All G 3/4 All G 3/4Fever 4 0 11 2 11 2Hypertension 1 1 5 0 6 2Bleeding 0 0 4 2 0 0Diarrhea 6 0 9 3 14 1Leucopenia 10 7 15 10 19 13Epistaxis 2 0 10 0 15 0Hemoptysis 2 0 9 3 4 1

Adverse event

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Frequency of adverse effects in a phase II controlled study of bevacizumab in patients with

metastatic colorectal cancer

5-FU/LV + bevacizumab5-FU/LV

5 mg/kg 10 mg/kgAll G 3/4 All G 3/4 All G 3/4

Any event 35 19 35 26 32 25Diarrhea 29 13 32 10 24 10Leucopenia 1 1 4 2 1 1Stomatitis 6 0 8 0 6 0Fever 4 0 13 0 11 1Headache 5 0 11 0 12 1Rash 7 0 16 1 11 0Chills 1 0 5 0 5

Adverse event

0

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Frequency of adverse effects in a phase II controlled study of bevacizumab in patients with

metastatic colorectal cancer

5-FU/LV + bevacizumab5-FU/LV

5 mg/kg 10 mg/kgAll G 3/4 All G 3/4 All G 3/4

Abdominal pain 19 1 16 3 15 4Weight loss 8 0 5 1 3 0GI hemorrhage 0 0 2 0 5 3Epistaxis 4 0 16 0 17 0Hypertension 1 0 4 3 9 8Infection 7 0 14 0 8 1Trombotic events 3 1 9 5 4

Adverse event

2

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Frequency of adverse effects in a phase III trials of first-line irinotecan, fluorouracil, and leucovorin with or without bevacizumab in patients with metastatic colorectal cancer

%Adverse effect IFN + placebo

(n=412)IFN + bevacizumab

(n=403)Grade 3 or 4 bleeding 2.5 3.1

Any tromboembolism 16.1 19.3

Grade 3 hypertension 2.3 10.9

Grade 3 proteinuria 0.8 0.8

Gastrointestinal perforation 0.0 1.5

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VEGF/VEGFR inhibitors under investigation

Hicklin D.J., Ellis L.M.: Role of the Vascular Endothelial Growth Factor pathwayin the tumor growth and angiogenesis. J. Clin. Oncol., 2005, 23, 1011-1027.

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AZD2171 Recentin

• significantly reduce the size of glioblastomas

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Sorafenib, sunitinib

• inhibition of receptor tyrosine kinaseactivity

• are used in renal cell carcinoma

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Thalidomide

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Normalization of tumor vasculature following anti-VEGFR-2 therapy

Hicklin D.J., Ellis L.M.: Role of the Vascular Endothelial Growth Factor pathway in the tumor growth and angiogenesis. J. Clin. Oncol., 2005, 23, 1011-1027.

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Other possibility is the therapy withendogenous inhibitors of

angiogenesis, such endostatin and angiostatin

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Other angiogenesis inhibitorsOther angiogenesis inhibitorsin phase II/III in phase II/III clinical trialsclinical trials

Agent MechanismAngiozyme Ribozyme

Endostatin Induction of endothelial cell apoptosis

Neovastat Matrix metalloproteasesinhibitor

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AngiopoietinAngiopoietin role in the role in the formation of new vesselsformation of new vessels

Angiopoietin 2Angiopoietin 1• endothelial cell (EC)

sprouting• vessel stabilization

• EC migration• EC proliferation• EC spouting only in the

presence of VEGF• vessel destabilization by

antagonizing angiopoietin 1 signaling

• ↑ EC apoptosis

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The interaction relation between VEGF and angiopoietins in the development of tumor angiogenesis

Huang Z., Bao S.D.: Roles of main pro- and anti-angiogenic factors in tumorangiogenesis. World J. Gastroenterol., 2004, 10, 463-470.

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Some anticancer drugs e.g. paclitaxeland cyclophosphamide have been

found to interfere with angiogenesis, though they were not originally

developed for that reason

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Plants with Plants with antiangiogenicantiangiogenic activityactivity

Plants Antiangiogenic effects

Green tee extract Inhibits in vitro and in vivotumor angiogenesis

Soy phytochemicalconcentrate

Inhibits angiogenesis in prostate and bladder carcinoma xenograf

Viscum album coloratum(aquous extract)

Inhibits lung tumorangiogenesis and metastatis

Polypodium leucotomos(extract)

Inhibits number of blood vessels in UVB- irradiated mouse skin

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PhytochemicalsPhytochemicalswith with antiantiangiogenicangiogenic activityactivity

Phytochemicals Antiangiogenic effectsSilymarin / silibin Inhibits VEGF and MMP-2 secretion,

growth and tube formationEpicatechin / Epigallocatechin

Inhibits VEGF transcription and production, increases apoptotic death of endothelial cells

Curcumin Inhibits microvessels densityResveratol Inhibits angiogenesis, metastatis and

tube formationQuercetin Inhibits endothelial cells proliferation,

migration and tube formationHydroxyflavone Inhibits in vitro angiogenesis

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