Angiogenesis inhibitors in clinical development for lung cancer

Proanthocyanidins, Isolated from Choerospondias axillaris Fruit Peels, Exhibit Potent Antioxidant Activities in Vitro and a Novel Anti-angiogenic Property in Vitro and in Vivo

The production of new blood vessels (angiogenesis) is an important stage in the growth and spread of cancerous tumors. Anti-angiogenesis is one strategy for controlling tumor progression. This study evaluated the antioxidant and anti-angiogenic activities of a proanthocyanidins (PAs) extract from Choerospondias axillaris peels. HPLC-MS analysis revealed that numerous oligomeric forms of the PAs were detected in the PAs extract, including dimers, trimers, tetramers, and flavan-3-ol monomers. The PAs extract possessed appreciable free radical scavenging activity (IC50/DPPH = 164 ± 7 μg/mL, IC50/ABTS = 154 ± 6 μg/mL), potent reducing power (0.930 ± 0.030 g AAE/g), and strong cellular antioxidant activity (EC50 = 10.2 ± 1.4 and 38.9 ± 2.1 μg/mL without or with PBS-wash, respectively). It could also retard various stages of angiogenesis, such as the migration of endothelial cells and the creation of tubes, without causing toxicity to the cells. With regard to intracellular signal transduction, the PAs extract attenuated the phosphorylation of Akt, ERK, and p38MAPK dose-dependently in endothelial cells from human umbilical veins. In transgenic zebrafish embryo, new blood vessel formation was suppressed by PAs extract in a concentration-dependent manner at 72 h post fertilization. Thus, these results suggest that PAs from C. axillaris peels could be a good source of natural inhibitors to target angiogenesis.

Psychoneuroimmunology and the pediatric surgeon

The mind-body connection is receiving increasing scrutiny in a large number of clinical settings, although research has lagged in the pediatric specialties. Psychoneuroimmunology (PNI) is a novel interdisciplinary scientific field that examines the relationship of the mind to the patient's neurologic, endocrine, and immune systems by examining critical parameters such as the effects of mental stress on wound healing and infection rates. Techniques that modify a patient's emotional and mental responses to illness and surgery have positive effects on their physiology resulting in improved recoveries and higher patient satisfaction rates. In the appropriate clinical settings, an awareness of PNI can enhance outcomes for pediatric surgical patients.

Histo-proteomic profiling of formalin-fixed, paraffin-embedded tissue

In the functional proteome era, the proteomic profiling of clinicopathologic-annotated tissues is an essential step for mining and evaluating candidate biomarkers for disease. For many diseases, but especially cancer, the development of predictive biomarkers requires performing assays directly on the diseased tissue. The last decade has seen the explosion of both prognostic and predictive biomarkers in the research setting but few of these biomarkers have entered widespread clinical use. Previously, application of routine proteomic methodologies to clinical formalin-fixed and paraffin-embedded tissue specimens has provided unsatisfactory results. In this paper, we will discuss recent advancements in proteomic profiling technology for clinical applications. These approaches focus on the retention of histomorphologic information as an element of the proteomic analysis.

Angiotensin-converting enzyme inhibitors and risk of esophageal and gastric cancer: a nested case-control study

BACKGROUND & AIMS

There are contradictory results regarding the association between angiotensin-converting enzyme (ACE) inhibitors and cancer. We aimed to investigate whether ACE inhibitors protect against esophageal and gastric cancer.

METHODS

We conducted a population-based case-control study nested within the General Practitioners' Research Database in the United Kingdom. All individuals in the General Practitioners' Research Database aged 40-84 years between 1994 and 2001 were followed up until detection of an esophageal or gastric cancer (cases), other cancer, age of 85 years, death, or end of study period.

RESULTS

Among 4.34 million person-years, 909 cases of esophageal and 1023 cases of gastric cancer were identified, and 10,000 matched controls were selected at random. Adjustments included smoking, body mass index, concurrent medication, and gastrointestinal disorders. Current use of ACE inhibitors decreased the risk of esophageal adenocarcinoma by 29% (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.43-1.17), but not of squamous-cell carcinoma (OR, 1.27; 95% CI, 0.71-2.28) compared with nonusers. A high daily dose of ACE inhibitors decreased the risk of both adenocarcinoma and squamous-cell cancer of the esophagus and rendered a 45% decrease of total esophageal cancer (OR, 0.55; 95% CI, 0.33-0.93). Our data showed no clear association between the use of ACE inhibitors and risk of gastric cancer (OR, 1.07; 95% CI, 0.84-1.36).

CONCLUSIONS

The use of ACE inhibitors may decrease the risk of developing esophageal cancer, particularly among users with a high daily dose. No association was found between gastric cancer and ACE inhibitors.

New anti angiogenesis developments through electro-immunization: Optimization by in vivo optical imaging of intradermal electrogenetransfer

Direct application of high voltage electric pulses of milliseconds duration to the skin of a mouse enhances in vivo intradermal delivery of injected therapeutic molecules such as DNA. The efficacy of gene transfer and expression is dependent on electrical parameters. DNA electrotransfer in tissues increases the associated DNA expression vaccine potency. This protocol is called "electro-immunization". In the present study, we report a new strategy for optimizing electro-immunization. In vivo fluorescence imaging was used to detect the expression of a fluorescent protein (DsRed) and therefore allowed rapid optimization of the protocol. In vivo electrogenetransfer in the skin was well tolerated and DsRed expression was followed for over 2 weeks. Expression was voltage dependent under our conditions. Parameters were selected giving the highest level of expression. Under these optimized conditions, electrotransfer of a plasmid encoding VEGF was evaluated for its immune response as a gene therapy of interest involved in anti-angiogenic strategies. Anti VEGF 165 antibodies in sera of mice were evaluated by ELISA and compared to those obtained after conventional immunization. Comparable titres of antibodies were obtained in both groups. An IgG2a predominance was found in mice immunized with the plasmid whereas a IgG1 predominance was observed in mice immunized classically. Skin electro-immunization is therefore shown as a good route for DNA immunization for anti-angiogenesis concern.

Clinical implications of EGFR expression in the development and progression of solid tumors: focus on non-small cell lung cancer

Dysregulation of the epidermal growth factor receptor (EGFR) signaling pathway is associated with the development and progression of malignancy, and EGFR-targeted therapies offer the promise of better treatment for many types of solid tumors, including non-small cell lung cancer. Anti-EGFR agents include monoclonal antibodies (mAbs) targeting the EGFR extracellular receptor domain and small-molecule tyrosine kinase inhibitors (TKIs) targeting the EGFR intracellular kinase domain. Both mAbs and TKIs have demonstrated encouraging results as monotherapies and in combination with chemotherapy and radiotherapy. This review provides a critical update on the status of these novel therapeutics.

Cellular signaling molecules as therapeutic targets in glioblastoma multiforme

Despite recent advances in operative techniques, chemotherapy, and radiotherapy, the prognosis in patients with glioblastoma multiforme (GBM) remains poor; the majority die within a year of diagnosis. Although often effective at reducing mass effect and tumor burden, surgical debulking and cytotoxic therapies have never demonstrated an unequivocally significant benefit in treating patients with GBM. This shortcoming has led to the development of molecules that target specific steps in the transduction pathways of high-grade glioma cells. In this article the authors review various cellular and extracellular signaling pathways that may prove promising in the treatment of patients with malignant glioma.

Angiogenesis in non-small cell lung cancer: The prognostic impact of neoangiogenesis and the cytokines VEGF and bFGF in tumours and blood

BACKGROUND

Due to a dismal prognosis of advanced lung cancer, novel screening tools and more effective treatments are clearly needed. Lately, an increasing number of tumour-released angiogenic cytokines which affect vessel formation, tumour growth, invasion, and metastasis have been identified. Vascular endothelial growth factors (VEGFs) and basic fibroblast growth factor (bFGF) are among the most important angiogenic factors. Based on available literature, we have explored the mechanisms of angiogenesis and its prognostic significance in non-small cell lung cancer, estimated by microvessel density (MVD) and the presence of VEGF and bFGF in the tumour and blood from NSCLC patients.

METHODS

Several comprehensive Pubmed searches for the period January 1993 to May 2005 were performed using strategic combinations of the terms non-small cell lung cancer, angiogenesis, vascular endothelial growth factor, basic fibroblast growth factor, tumour expression, microvessel density, circulating, and serum.

RESULTS

NSCLC neoangiogenesis, as measured by MVD, and tumour expression of VEGF are poor prognostic factors for survival (MVD, HR 1.8-2.0; VEGF, HR 1.5). bFGF tumour expression is also associated with poor survival and more aggressive disease. When evaluating the prognostic impact of elevated VEGF levels in blood, 10 of 16 studies (63%) indicated a negative prognostic impact. Of five studies on the prognostic value of circulating bFGF, three studies reported a negative prognostic impact, while one indicated bFGF as a good prognostic factor and one was inconclusive.

CONCLUSION

Angiogenic factors are poor prognostic indicators for tumour aggressiveness and survival in NSCLC. Assessments of circulating levels of VEGF and possibly bFGF may be valuable future tools for treatment planning and monitoring of treatment effect and relapse. First, however, these blood tests need to be standardised and validated in large-scale prospective clinical trials.

New Agents in the Management of Advanced Mesothelioma

Malignant pleural mesothelioma (MPM) is a seemingly uncommon tumor whose incidence has in fact increased steadily and progressively over the last 30 years. Indeed, an actual "epidemic" is expected in Europe over the next 20 years. Despite unquestionable improvement in the diagnostic methods at our disposal and the availability of new treatment strategies, the prognosis of MPM patients remains dramatically poor (12 to 18 months' median survival from diagnosis), although exceptional cases of long-survivors are reported in all literature series. The current review will cover the dramatic improvements in the treatment of this rare disease that have been recently achieved, as well as the promise that new, molecular-targeted therapies, such as bortezomid, mTOR ( m ammalian t arget o f r apamycin) inhibitors, and Met inhibitors, seem to offer for the next few years. With pemetrexed we now have a drug that is able to impact patient survival. Together with the newer drugs, rapidly emerging from the laboratory to be applied in the clinic, we have the hope of making further advances in the struggle against this disease.

Current Management of Advanced Non-Small Cell Lung Cancer: Targeted Therapy

Lung cancer is one of the most frequent causes of cancer-related death in the United States. For patients with advanced non-small cell lung cancer (NSCLC), chemotherapy, alone or in combination with radiation therapy, is considered the standard treatment. Although this treatment may result in a modest improvement in patient survival, overall prognosis of these patients remains dismal, and the treatment is nonspecific, nonselective, and toxic. Therefore, new therapeutic strategies are needed. During the past decade, several molecules that contribute to lung cancer progression and metastasis have been identified. Growth factors and proangiogenic factors have been the focus of intense research in cancer since therapeutic approaches for their inhibition do exist. The role of these factors was studied in different organs and tumors and was found to be phenotypically distinct. Several molecular targeted therapies have shown efficacy and had been approved for treatment of specific cancers. Most advanced in clinical research for lung cancer are targeted therapies that inhibit the epidermal growth factor receptor (EGFR) and the vascular endothelial growth factor (VEGF) signaling pathways. Others are signaling pathway inhibitors. The first targeted therapy for lung cancer is gefitinib, an EGFR inhibitor, which was approved in several countries in 2003. Goals of molecular targeted therapy studies include the following: better understanding of the exact role of particular growth factors in specific tumors; establishment of new clinical study designs for biological agents; and tailoring appropriate combinations of conventional chemotherapy and/or radiotherapy with biological therapy for specific patients. Achievement of these goals will hopefully lead to incorporation of biological therapy into the current anticancer arsenal, for the benefit of lung cancer patients.

Kinetics of Marked Development of Lung Metastasis of Rat Prostatic Carcinomas Transplanted in Syngeneic Rats

In order to investigate how and when metastases develop under experimental conditions, kinetics of the size and the number of lung metastasis lesions in F344 rats were examined after syngeneic transplantation of rat prostate carcinomas induced by 3,2'-dimethyl-4-aminobiphenyl (DMAB). Cell proliferation of the subcutaneous tumor and lung metastatic lesions was evaluated along with the expression of VEGF-A splicing variants and endostatin, serum VEGF levels and vascular density in the tumor. Several pieces of tumor tissue were introduced subcutaneously into two different sites on the dorsal side of F344 rats through a 14G needle. Average body weight of recipient rats markedly decreased despite only a gradual increase in tumor volume. The absolute total number of metastatic lesions in rats (n=5) were 2, 10, 19 and 194 at weeks 7.5, 9, 11 and 13, respectively, and a notable increase was observed at week 13. Similarly, the mitotic index of lung metastatic lesions increased remarkably at week 9 while the mitotic index and apoptotic index of transplanted tumors did not change throughout the experimental period. Expression of VEGF-A121, A164, A188 and endostatin, serum VEGF levels and vascular density did not correlate with the spread of lung lesions. In conclusion, both the number and the size of metastatic lesions increased at the same time after a notable increase in cell proliferation. Factors other than VEGF or endostatin may be involved in the mechanism of explosive lung metastasis spread.

VEGF treatment induces signaling pathways that regulate both actin polymerization and depolymerization

The angiogenic growth factor vascular endothelial growth factor (VEGF) enhances endothelial cell migration through the activation of multiple signaling transduction pathways. Actin reorganization is an important component in VEGF-induced migration, yet the signaling pathways mediating this process remain unclear. Actin reorganization involves both actin polymerization and depolymerization, and in this study we demonstrate that VEGF-treatment regulates both of these activities. With respect to actin polymerization, our results indicate that the actin nucleation promoting factors (NPF) neural Wiskott-Aldrich syndrome protein (N-WASP) binds the SH2- plus SH3-domain containing adaptor protein Nck in both control and VEGF-treated cells. We had previously showed that VEGF treatment leads to the recruitment of Nck to activated receptor, and our current results indicate a VEGF-dependent redistribution of N-WASP to the cell surface. A Nck dominant-negative blocked Nck recruitment to receptor, blocked N-WASP cellular redistribution and attenuated actin stress fiber formation. With respect to actin depolymerization, VEGF-treatment led to the rapid phosphorylation of the actin depolymerization factor cofilin, and its upstream regulator, LIM-kinase (LIMK). Unlike what is observed in certain other cell types, the p21-activated kinase (PAK), a Nck binding protein, does not mediate VEGF-induced LIMK phosphorylation, as a PAK dominant-negative had no effect on this activity. The PAK dominant-negative also did not affect VEGF-induced actin reorganization. Pharmacological inhibitors of phosphoinositide-3 kinase (PI3-K) and the rho-activated kinase (ROCK) attenuated VEGF-induced LIMK phosphorylation, indicating a role for (PI3-K) and ROCK in the signaling pathways leading to regulation of LIMK activity.

Arterial spin labeling blood flow magnetic resonance imaging for the characterization of metastatic renal cell carcinoma(1)

RATIONALE AND OBJECTIVE

This study sought to assess the feasibility of arterial spin labeling (ASL) blood flow (BF) magnetic resonance imaging (MRI) for the study of metastatic renal cell carcinoma (RCC) in the body, where the respiratory, cardiac, and peristaltic motions present challenges when applying ASL.

MATERIALS AND METHODS

ASL was performed using a background-suppressed single-section flow-alternating inversion recovery (FAIR) preparation and a single-shot fast spin-echo imaging sequence on a 3.0-T whole body imager. Tumor BF was evaluated for 26 patients with RCC metastatic to the liver, bone, lung, or lymph nodes before VEGF receptor inhibitor therapy. Two cases with tumor size change after treatment were also scanned 1 month after therapy. For validation, kidney cortex BF in five normal volunteers was measured with the same technique and compared with literature values.

RESULTS

ASL was successfully performed in all normal volunteers and in 20 of 26 patients. The six failures resulted from a systematic error, which can be avoided in future studies. For normal volunteers, measured kidney cortex BF was 275 +/- 14 mL/min/100 g, a value consistent with the literature. ASL determined tumor BF averaged across tumor volume and subjects was 194 mL/min/100 g (intersubject SD = 100), resulting in high perfusion signal and conspicuity of lesions. Bright signal was also seen in large vessels and occasionally in bowel. In the two cases studied 1 month after therapy, ASL perfusion changes were consistent with tumor size changes.

CONCLUSION

With background suppression, ASL MRI is a feasible method for quantifying BF in patients with renal cell carcinoma. This technique may be useful for evaluating tumor response to antiangiogenic agents.

Angiogenesis inhibitors in the treatment of small cell and non-small cell lung cancer

Angiogenesis is believed to play a critical role in cancer; however, antiangiogenic therapy has not been demonstrated to improve the survival of patients who have lung cancer. In this article, the evidence that supports a role for angiogenesis in the pathogenesis of lung cancer, trials of antiangiogenic agents in lung cancer performed to date, and the lessons learned from these studies are discussed.

Molecular targeting in radiotherapy of lung cancer

Molecular targeting is a promising option to increase the radiation response of tumours and to decrease normal tissue reactions, i.e. to achieve therapeutic gain. Molecular targeting substances in themselves are not curative while radiation is a highly efficient cytotoxic agent, with local recurrences often occurring from only few surviving clonogenic cells. High-dose radiotherapy therefore offers optimal conditions to evaluate the potential of specific biology-driven drugs for oncology. This review summarises the current status of preclinical and clinical research on combined radiation with examples of molecular targeting substances relevant for the treatment of NSCLC (EGFR, COX-2, VEGFR, KGF, TGF-beta, BBI).

Bmx is a downstream Rap1 effector in VEGF-induced endothelial cell activation

We had previously shown that Rap1 mediates certain of the signaling pathways involved in VEGF-induced endothelial cell migration, although the downstream Rap1 effectors are not known. Towards the goal of identifying those effectors, we utilized a commercially available antibody array filter to identify proteins that either directly interact with Rap1 or interact indirectly through a multi-protein complex. The protocol identified 10 possible Rap1-interacting proteins, including the Bmx non-receptor tyrosine kinase. The conclusion that VEGF treatment leads to a Rap1/Bmx complex was confirmed by an experiment in which cell lysates from VEGF and control cells were immunoprecipitated with Bmx antibodies and Western blotting was done using anti-Rap1 antibodies. VEGF treatment led to the recruitment of Bmx to the CAS scaffolding protein, and inhibition of the Bmx kinase blocked VEGF-induced cell migration. Formation of a Rap1/Bmx complex was not observed in cells transfected with an expression vector for a dominant-negative Rap1, indicating that Bmx is a downstream Rap1 effector in VEGF-induced endothelial cell activation.

Targeting angiogenesis: a review of angiogenesis inhibitors in the treatment of lung cancer

It has now been almost 30 years since Dr J. Folkman first proposed that inhibition of angiogenesis could play a key role in treating cancer; however, it is only recently that anti-angiogenesis agents have entered the clinical setting. The search for novel therapies is particularly important in lung cancer, where the majority of patients succumb to their disease despite aggressive treatments. Several classes of agents now exist that target the different steps involved in angiogenesis. These include drugs inhibiting matrix breakdown, the matrix metalloproteinase inhibitors (MMPIs), such as marimastat, prinomastat, BMS275291, BAY12-9566, and neovastat drugs that block endothelial cell signaling via vascular endothelial growth factor (VEGF) and its receptor (VEGFR) including rhuMAb VEGF, SU5416, SU6668, ZD6474, CP-547,632 and ZD4190. Drugs that are similar to endogenous inhibitors of angiogenesis including endostatin, angiostatin and interferons. There has also been renewed interest in thalidomide. Drugs such as squalamine, celecoxib, ZD6126, TNP-470 and those targeting the integrins are also being evaluated in lung cancer. Despite early enthusiasm for many of these agents, Phase III trials have not yet demonstrated significant increases in overall survival and toxicity remains an issue. It is hoped that as our understanding of the complex process of angiogenesis increases, so will our ability to design more effective targeted therapies.

Antiangiogenic drugs and current strategies for the treatment of lung cancer

Significant advances in the treatment of lung cancers, especially advanced-stage non-small cell lung cancer, have been marginal despite decades of intensive basic research and clinical trial testing. Among the newest class of promising drugs being tested is the angiogenesis inhibitor. The recent success of a randomized phase III trial testing an antivascular endothelial growth factor (VEGF) antibody with chemotherapy for the treatment of metastatic colon cancer has raised hopes that antiangiogenic drugs will have similar benefits for the treatment of lung cancer. Ironically, the sheer number and diversity of such drugs makes selecting the most promising candidates difficult. More detailed and definitive information on the specific factors that induce angiogenesis in types of lung cancer, such as the relative importance of VEGF or other proangiogenic growth factors in non-small cell lung cancer, small cell lung cancer, and mesothelioma angiogenesis, is therefore clearly needed. The nonangiogenic phenotype of some non-small cell lung cancers may render this subset particularly difficult to treat with angiogenesis inhibitors; such tumors, however, may be promising candidates for acute-acting vascular-targeting agents. As with other types of cancer, success with angiogenesis inhibitors will no doubt depend on a number of factors including screening patients' tumors for presence or absence of a particular drug target (eg, bioactive VEGF receptor-2 bound VEGF) when targeting VEGF, selecting the optimal biologic/therapeutic doses of antiangiogenic drugs, monitoring antiangiogenic drug activity in tumors, and determining optimal combinations to use with chemotherapy regimens.

Novel treatments in non–small cell lung cancer

Although it has been exciting for lung cancer doctors to observe objective remissions with gefitinib and erlotinib in heavily pretreated NSCLC patients, all of the reported phase III trials testing noncytotoxic, targeted therapies in NSCLC have been negative. Two basic strategies have been employed in developing and conducting these randomized studies. In the case of gefitinib and the matrix metalloproteinase inhibitors, phase III trials were launched based on preclinical data. The second strategy was based on survival results from phase II trials involving regimens consisting of the targeted agent and chemotherapy. Unfortunately, negative results have been observed with the first phase III study (chemotherapy +/- ISIS 3521), which was based on the results of a phase II trial. The initial negative results with targeted agents suggest that a paradigm shift in cancer drug development is needed. Typically, the development of a cytotoxic agent involves determination of the maximum tolerated dose, followed by an assessment of activity as defined by the objective response rate in specific tumor types. "Active" drugs are then moved into phase III testing to determine the effect on survival. Other than targeting the specific tumor type and defining the usual eligibility parameters, no attempt is made to select patients for treatment with new agents. It seems unlikely that there will be significant progress with the targeted therapies unless there is a paradigm shift from this classic model of cancer drug development to a model in which much greater effort is directed toward identifying the target or targets in preclinical models. Intensive effort should be devoted to the development of reliable, clinically applicable assays for the targets that could identify patients who are most likely to benefit from a specific treatment. Rothenberg et al recently made similar recommendations with respect to improving the drug discovery process for cancer. These investigators have emphasized testing new agents in the most appropriate setting, increasing efforts to understand the role of the target, and collection of tissue in an effort to select appropriate patients. Although results from initial randomized trials of targeted therapies in NSCLC have been relatively disappointing, this is not a time to be discouraged. Rather, it is a time to increase the collaborative efforts between basic scientists and clinical investigators.

Emerging drugs for non-small cell lung cancer

Lung cancer is the leading cause of cancer death in the world. Therapeutic improvements caused by recent cytotoxic agents seem to have reached a plateau. New therapeutic strategies are, therefore, necessary to improve the cure rate. These include receptor-targeted therapy, signal transduction or cell-cycle inhibition, angiogenesis inhibitors, cyclooxygenase-2 (COX-2) inhibitors, gene therapy and vaccines. The antiepidermal growth factor receptor (EGFR) group includes compounds acting on the extracellular domain of EGFR, such as IMC-C225 and trastuzumab; small molecules inhibiting EGFR phosphorylation, such as ZD 1839 and OSI-774; or compounds that interfere with one of the downstream steps, such as mitogen-activated protein kinase kinase (MEK) inhibitors. Farnesyl transferase inhibitors, such as SCH66336, and protein kinase C inhibitors, such as ISIS 3521, have also shown antitumour activity. Antiangiogenesis inhibitors include matrix metalloprotease inhibitors (MMPIs), suchs as marimastat, AG3340, BAY 12-9566, BMS-275291 and Col-3. Antiangiogenic agents offer great potential for the treatment of lung cancer, as shown in preclinical models, whereas emerging data suggest that there are limits to their use as monotherapy in advanced disease. Molecules targeting vascular endothelial growth factor (VEGF) or its receptor (VEGFR) also seem to control tumour progression and may prolong survival. COX-2 inhibitors are another class of agents currently under evaluation in clinical trials for their chemoprevention role in subjects at high lung cancer risk, and also in patients with non-small cell lung cancer (NSCLC) in combination with standard chemotherapeutics. Genetic and immunologic therapies represent two additional promising modalities. All of these therapies are in different phases of clinical testing and have shown encouraging activity alone or in combination with chemotherapy drugs.

Anti-angiogenesis in cancer therapy

OBJECTIVE

To review tumor angiogenesis, identify potential targets for anti-angiogenic cancer therapy, and highlight certain anti-angiogenic agents in clinical trials.

DATA SOURCE

Research articles, abstracts, review articles, and book chapters.

CONCLUSION

Tumor angiogenesis is a complex, multistep process that provides a target for antineoplastic therapy whereby tumor neovasculature is interrupted at various steps in the angiogenic process. Clinical trials are investigating the application and efficacy of anti-angiogenic agents.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses must continually increase their knowledge with the onset of newer, targeted agents. This will provide a background for educating and caring for the patient who is receiving anti-angiogenic therapy.

Angiogenesis inhibitors under study for the treatment of lung cancer

Several classes of agents now exist that target the different steps involved in angiogenesis. These include drugs inhibiting matrix breakdown, the matrix metalloproteinase inhibitors (MMPIs), such as marimastat, prinomastat, BMS275291, BAY12-9566, and neovastat. Trials of this class of agents have all been negative to date. Drugs that block endothelial cell signaling via vascular endothelial growth factor (VEGF) and its receptor (VEGFR) including rhuMAb VEGF, SU5416, SU6668, ZD6474, CP-547,632 and ZD4190 are all in earlier stages of clinical trial. Drugs that are similar to endogenous inhibitors of angiogenesis including interferons have also been evaluated without success. Endostatin has been shown to have an acceptable toxicity profile, but clinical evidence of activity has not yet been demonstrated. There has also been renewed interest in thalidomide. Drugs such as squalamine, celecoxib, ZD6126, TNP-470 and those targeting the integrins are also being evaluated in lung cancer. Despite early enthusiasm for many of these agents, Phase III trials have not yet demonstrated significant increases in overall survival and toxicity remains an issue. It is hoped that as our understanding of the complex process of angiogenesis increases, so will our ability to design more effective targeted therapies.

Advances in molecular therapies in patients with brain tumors

BACKGROUND

We are witnessing the development of new treatment modalities for primary brain tumors. An area under intense investigation is the use of small molecules targeting intracellular signaling pathways that interfere with growth, invasion, and metastasis of high-grade gliomas.

METHODS

We review clinical trials of small molecules in adults with brain tumors. This search included electronic databases, specialty journals, textbooks, proceedings, and Web sites of the National Cancer Institute and other cooperative brain tumor groups in Europe and the United States.

RESULTS

Several drugs with the ability to down-regulate the growth and invasion of malignant gliomas are at various stages of testing. Most of these focus on interfering with oncogenic and tumor survival pathways. Examples include inhibitors of tyrosine kinases, farnesyltransferases, and matrix metalloproteinases. These molecules are at different stages of testing, and a conclusive picture of which drug is most effective, either alone or in combination, needs better definition. The metalloproteinase inhibitor marimastat with temozolomide has given the best results to date in phase II trials, increasing the rate of 6-month progression-free survival for recurrent glioblastoma multiforme and anaplastic gliomas.

CONCLUSIONS

As our understanding of the biology of gliomas increases and new drugs targeting specific molecular pathways enter well-designed cooperative trials, the control and prognosis of these tumors should improve.