CAI: effects on cytotoxic therapies in vitro and in vivo

EFFECTIVE TRANSSCLERAL DELIVERY OF TWO RETINAL ANTI-ANGIOGENIC MOLECULES

PURPOSE

To evaluate the human transscleral diffusion and intravitreal delivery of carboxyamido-triazole (CAI) and 2-Methoxyestradiol (2ME2).

METHODS

The transscleral diffusion of two retinal antiangiogenic molecules, CAI and 2ME2, was measured in vitro to assess their potential transscleral delivery. Varying concentrations and different solvents of CAI and 2ME2 were placed in the upper compartment of a two-chamber acrylic perfusion apparatus, on the episcleral side of the sclera obtained from human donor eyes. Samples were taken from the lower compartment (uveal side) for up to 24 hours and measured by high performance liquid chromatography.

RESULTS

All three solutions that contained CAI efficiently diffused through the sclera with permeability constants that ranged from 2.8 to 5.5 x 10 cm/s. The scleral permeability constant derived for 2ME2 was 9.96 x 10 cm/s. The permeability constants obtained for both CAI and 2ME2 are similar to each other as well as to permeability constants measured for other small molecules such as fluorescein and dexamethasone fluorescein.

CONCLUSION

Both CAI and 2ME2 traverse the sclera efficiently. These data combined with the reported inhibition of posterior segment neovascularization observed with these two molecules demonstrates that CAI and 2ME2 are good candidate molecules to treat posterior segment neovascularization by local delivery.

Successful Implementation of the Randomized Discontinuation Trial Design: An Application to the Study of the Putative Antiangiogenic Agent Carboxyaminoimidazole in Renal Cell Carcinoma—CALGB 69901

Purpose

To assess the disease-stabilizing activity of carboxyaminoimidazole (CAI) in patients with metastatic renal cell cancer (RCC) using a randomized discontinuation trial (RDT) design.

Patients and Methods

Recruited patients had a performance status of 0 to 2, minimal neuropathy or cerebellar dysfunction, measurable disease, and normal organ function. Treatment with 250 mg/d CAI was initiated in all patients and continued until disease progression in those with an objective response. Protocol treatment was discontinued for unacceptable toxicity or progressive disease; patients with stable disease at the 16-week evaluation point were randomly assigned in a double-blind manner to continued CAI or placebo. The primary end point was the stable disease rate in the randomized groups.

Results

A total of 368 patients were accrued and received therapy. Ninety percent had a performance status of 0 or 1, 80% underwent a prior nephrectomy, and 41% had received no prior systemic therapy. Serious or life-threatening toxicity was experienced by 34%, with asthenia (15%) and neuropsychiatric difficulties (7%) being most common. At the randomization point, 51% of patients had progressed, 30% withdrew, 1% experienced a partial response, and 17% had stable disease and were randomly assigned. A Bayesian futility analysis utilizing the first 49 randomly assigned patients suggested that the probability of demonstrating a higher stable disease rate in the experimental group was less than 9% even under the most optimistic a priori assumptions, and further trial accrual was halted.

Conclusion

CAI is inactive in RCC. The RDT design should be further explored for evaluating activity of putative disease stabilizing agents.

Randomized discontinuation design: application to cytostatic antineoplastic agents

PURPOSE

Propose a phase II study design to evaluate the activity of a putative cytostatic agent, acknowledging heterogeneity of tumor growth rates in the population of patients.

METHODS

In the setting of renal cell carcinoma, some patients' tumors will grow slowly naturally. An appropriate design has to distinguish antiproliferative activity attributable to the novel agent from indolent disease. We propose a randomized discontinuation design that initially treats all patients with the study agent (stage 1) and then randomizes in a double-blind fashion to continuing therapy or placebo only those patients whose disease is stable (stage 2). This design allows the investigators to determine if apparent slow tumor growth is attributable to the drug or to selection of patients with naturally slow-growing tumors.

RESULTS

By selecting a more homogeneous population, the randomized portion of the study requires fewer patients than would a study randomizing all patients at entry. The design also avoids potential confounding because of heterogeneous tumor growth. Because the two randomly assigned treatment groups each comprise patients with apparently slow growing tumors, any difference between the groups in disease progression after randomization is more likely a result of the study drug and less likely a result of imbalance with respect to tumor growth rates. Stopping rules during the initial open-label stage and the subsequent randomized trial stage allow one to reduce the overall sample size. Expected average tumor growth rate is an important consideration when deciding the duration of follow-up for the two stages.

CONCLUSION

The randomized discontinuation design is a feasible alternative phase II study design for determining activity of possibly cytostatic anticancer agents.

Essential role of calcium in vascular endothelial growth factor A-induced signaling: mechanism of the antiangiogenic effect of carboxyamidotriazole

Vascular endothelial growth factor-A (VEGF-A) plays a major role in tumor angiogenesis and raises the concentration of intracellular free calcium ([Ca2+]i). Carboxyamidotriazole (CAI), an inhibitor of calcium influx and of angiogenesis, is under investigation as a tumoristatic agent. We studied the effect of CAI and the role of [Ca2+]i in VEGF-A signaling in human endothelial cells. VEGF-A induced a biphasic [Ca2+]i signal. VEGF-A increased the level of intracellular inositol 1,4,5-trisphosphate (IP3), which suggests that VEGF-A releases Ca2+ from IP3-sensitive stores and induces store-operated calcium influx. Reduction of either extracellular or intracellular free Ca2+ inhibited VEGF-A-induced proliferation. CAI inhibited IP3 formation, both phases of the calcium signal, nitric oxide (NO) release, and proliferation induced by VEGF-A. CAI prevented neither activation of VEGF receptor-2 (VEGFR-2) (KDR/Flk-1), phospholipase C-g, or mitogen-activated protein kinase (MAP kinase) nor translocation of nuclear factor of activated T cells (NFAT). We conclude that calcium signaling is necessary for VEGF-A-induced proliferation. MAP kinase activation occurs independently of [Ca2+]i but is not sufficient to induce proliferation in the absence of calcium signaling. Inhibition of the VEGF-A-induced [Ca2+]i signal and proliferation by CAI can be explained by inhibition of IP3 formation and may contribute to the antiangiogenic action of CAI. Calcium-dependent NO formation may represent a link between calcium signaling and proliferation.

New agents for the treatment of renal cell carcinoma

One-third of patients with renal cell carcinoma present with unresectable or metastatic disease. Immunotherapy, the current standard treatment, induces response in only 10-20% of patients. Chemotherapy with current agents is minimally effective. Other approaches including allogeneic stem cell transplant, vaccine and gene therapy and signal transduction inhibitors, offer promise in early Phase studies. This paper reviews the current treatment options and promising new agents in development.

Pharmacological and functional properties of voltage-independent Ca2+ channels

During the last few years, considerable progress has taken place in our knowledge of the molecular and functional properties of the various voltage-independent Ca2+ channels. In addition to the ionotropic receptor-channels (ROCs), that are not discussed in the present review, these channels include the SMOCs, activated via second messengers or other transducing processes directly triggered by receptor activation; and the SOCCs, activated as a consequence of depletion of the rapidly exchanging Ca2+ stores in the cytoplasm. In parallel, a pharmacological approach to the study of these channels has been developed, based primarily on heterogeneous drugs already known for different biological effects, and subsequently recognized as voltage-independent Ca(2+)-channel blockers. From the systematic analysis of the effects of these drugs new information has emerged about SMOCs and SOCCs function. In addition, pharmacological blockade of these channels appears to have beneficial therapeutic effects in pathological conditions such as tumoral cell growth, inflammation and immunity. At the moment the field is rapidly evolving, with major developments expected in the years ahead.