1. Novel Antiangiogenic Agents: Current Clinical Development George W. Sledge, Jr. MD Indiana University Cancer Center

2. Antiangiogenic Therapies: Potential Targets Block pro-angiogenic molecules (e.g., VEGF) Add anti-angiogenic regulators (e.g. angiostatin, endostatin, TSP-1) Inhibit stroma-degrading enzymes (e.g., MMPIs) Target vascular antigens (e.g., avb3 integrin) Attack pericytes

3. VEGF Is a Key Mediator of Angiogenesis Upstream activators of VEGF synthesis Downstream signaling pathways

4. Ligand sequestration: MAbs, soluble receptors Receptor blocking Mabs, soluble receptors Tyrosine kinase inhibition: TKIs Inhibition of tyrosine phosphorylation and downstream signalinginhibition p85 PLC  GRB2SOS ras Transcription factor inhibition Inhibit receptor production; ribozymes Methods of VEGF Signal Inhibition Indirect - inhibition of growth factors, HER-2

5. rhuMAb VEGF (Recombinant Humanized Monoclonal Antibody to VEGF) vascular endothelial growth  Humanized to avoid immunogenicity (93% human, 7% murine).  Recognizes all isoforms of factor, K d = 8 x 10 -10 M  Terminal half life 17-21 days

6. Efficacy of rhuMAb VEGF Dose (mg/kg)3 1020 (n=18) (n=41) (n=16) CR0 1 0 PR1 3 1 Stable at 22 weeks2 4 2 CR/PR/SD at 22 wks.3 8 3 Rx > 1 year0 3 -

7. Eligibility: - One or two prior therapies OR - Relapse within 12 months of adjuvant anthracycline and taxane - No CNS mets RANDOMIZERANDOMIZE Capecitabine + rhuMAb VEGF Capecitabine Refractory Metastatic Disease Accrual goal: 400 patients

8. Toxicities of Anti-VEGF Therapy Hemorrhage (lung cancers) Hypertension (anti-VPF) Headaches/migraines Clots (maybe) Proteinura/nephrotic syndrome

9. Intracellular Signaling Pathways Activated by VEGF Binding to VEGFR2

10. ZD6474

11. SU11248 Potently Inhibits VEGFR, PDGFR and Kit in Biochemical and Cellular Assays

12. Anti-Flt-1 Ribozyme Uppercase = ribonucleotides; lowercase = 2’-O-methyl ribonucleotide; B = inverted 2’-deoxyribose abasics; s = phosphorothiolate linkage; u4 = 2’-C-allyl nucleotide. Sandberg JA et al. J Clin Pharmacol. 2000;40:1462-1469.

13. The Problem With Anti- Angiogenic Therapy: Resistance

14. Mechanisms of Resistance Endothelial cell heterogeneity Tumor heterogeneity Impact of tumor microenvironment Compensatory response to hypoxic insults Re-growth independence from angiogenesis Vascular mimicry Vasculogenesis

15. Thwarting Resistance Use chemotherapy with anti-angiogenic intent - ‘metronomic therapy’ Combine with chemotherapy Combine multiple anti-angiogenics Combine with other biologics Use anti-angiogenics as targeted therapy Use anti-angiogenics in adjuvant setting

16. Use Standard Therapies With Anti-Angiogenic Intent Concept: –Standard chemotherapeutic agents have potent anti-angiogenic activity –We use them poorly from an anti- angiogenic standpoint –Metronomic therapy (chronic low-dose chemotherapy) overcomes resistance

17. Metronomic Therapy in the Clinic: Colleoni Study design: Phase II trial of CTX 50 mg p.o. qd + MTX 2.5 mg p.o. D 1,2 qwk. Patient Characteristics: 64 MBC pts, 32 with 1 prior regimen, 20 with 2+ prior regimens, 41 with adjuvant regimen Results: CR + PR = 19%; CR + PR + SD >24 wk = 31.7

18. Combine anti-angiogenic agents with standard chemotherapy Concept: –Chemotherapeutics are anti-angiogenics –Pro-angiogenic factors protect tumor endothelium –Preclinical support for combinations of anti-angiogenics’s with CT

19. Eligibility: - No prior Rx for mets - Adjuvant taxane if >12 mos. Exclusion: - Her-2 + - CNS mets - Proteinuria - Uncontrolled HTN RANDOMIZERANDOMIZE Arm A: Paclitaxel + rhuMAb VEGF Arm B: Paclitaxel E2100 Accrual goal: ~690

20. Combine anti-angiogenic agents with each other Concept: –Angiogenesis is a redundant process –Tumor progression is associated with angiogenic growth factor progression--> resistance to individual agents –Preclinical evidence of combinatorial benefit with anti-angiogenics

21. Combine anti-angiogenic agents with other biologics Concept: –Angiogenesis is under control of numerous polypeptide growth factors –Targeting growth factor receptors decreases angiogenesis –Potential for additivity/synergy

22. *P < 0.001 relative to Control, **P < 0.001 rel. to DC101. ** * * Effect of Anti-angiogenic Therapy on Mice With Colon Cancer Carcinomatosis

23. Use anti-angiogenic therapy as targeted therapy Concept: –Antiangiogenic therapy is viewed as general therapy –Resistance to specific agents implies specific resistance phenotypes/genotypes –Target therapy to specific tumors

24. Use anti-angiogenic therapy as adjuvant therapy Concept: –Anti-angiogenic therapy has not eliminated drug resistance –Pro-angiogenic factors increase as tumors progress –Resistance is a function of tumor size/mutation rate –Treat tumors before they become resistant

25. Adjuvant Angiogenesis: Requirements Chronic safety Combinatorial safety Chronic dose maintenance Large Proof-of-Concept trials Disease-specific rationale Proof of efficacy in advanced disease (???)

26. BMS-275291 Potent, peptidomimetic inhibitor of MMPs –rationally designed to spare sheddases metalloproteinases which process TNF-a, TNF-aRII Daily, oral, outpatient regimen Expectations –No dose-limiting arthritis –Complementary efficacy to chemotherapy

27. BMS-275291 Adjuvant Pilot Patients with Stage I-IIIa breast cancer receiving standard therapies randomized (2:1) to: BMS-275291 1200 mg/day x 12 months Placebo daily x 12 months All patients may continue open-label for one additional year; Accrual goal = 120