The rationale and future potential of angiogenesis inhibitors in neoplasia.

Malignant tumours are angiogenesis-dependent diseases. Several experimental studies suggest that primary tumour growth, invasiveness and metastasis require neovascularisation. Tumour-associated angiogenesis is a complex multistep process under the control of positive and negative soluble factors. A mutual stimulation occurs between tumour and endothelial cells by paracrine mechanisms. Angiogenesis is necessary, but not sufficient, as the single event for tumour growth. There is, however, compelling evidence that acquisition of the angiogenic phenotype is a common pathway for tumour progression, and that active angiogenesis is associated with other molecular mechanisms leading to tumour progression. Experimental research suggests that it is possible to block angiogenesis by specific inhibitory agents, and that modulation of angiogenic activity is associated with tumour regression in animals with different types of neoplasia. The more promising angiosuppressive agents for clinical testing are: naturally occurring inhibitors of angiogenesis (angiostatin, endostatin, platelet factor-4 and others), specific inhibitors of endothelial cell growth (TNP-470, thalidomide, interleukin-12 and others), agents neutralising angiogenic peptides (antibodies to fibroblast growth factor or vascular endothelial growth factor, suramin and analogues, tecogalan and others) or their receptors, agents that interfere with vascular basement membrane and extracellular matrix [metalloprotease (MMP) inhibitors, angiostatic steroids and others], antiadhesion molecules antibodies such as antiintegrin alpha v beta 3, and miscellaneous drugs that modulate angiogenesis by diverse mechanisms of action. Antiangiogenic therapy is to be distinguished from vascular targeting. Gene therapy aimed to block neovascularisation is also a feasible anticancer strategy in animals bearing experimental tumours. Antiangiogenic therapy represents one of the more promising new approaches to anticancer therapy and it is already in early clinical trials. Because angiosuppressive therapy is aimed at blocking tumour growth indirectly, through modulation of neovascularisation, antiangiogenic agents need to be developed and evaluated as biological response modifiers. Therefore, adequate and well designed clinical trials should be performed for a proper evaluation of antiangiogenic agents, by determination and monitoring of surrogate markers of angiogenic activity.     

Antiangiogenesis and radiotherapy: what is the role of combined modality treatment?

The formation of new blood vessels is a prerequisite for the growth of primary and metastatic tumour. Thus, strategies that aim at the inhibition of tumour angiogenesis have gained considerable interest in recent years. Furthermore, there is a need to identify the role of antiangiogenic agents in conjunction with conventional anticancer modalities like chemotherapy or radiotherapy. It is the objective of this review to summarise experimental data for different antiangiogenic agents used for combined modality experiments with radiotherapy. Promising data have been reported for a series of antiangiogenic agents for combined modality treatment with radiotherapy using tumour growth delay as the primary end-point. Yet, the results from different agents with various tumour lines are contradictory in part. Furthermore, enhancement of local tumour control, the main objective of curative radiotherapy, has so far been demonstrated for only two agents (DC101 and CA4DP), while experiments using TNP-470 even revealed a reduction of local tumour control when combined with irradiation. Finally, detailed studies investigating the modulation of normal tissue reactions for the combination of radiotherapy and inhibitors of angiogenesis are pending so far. Thus, experimental data currently available do not consistently support the beneficial effects of combined modality treatment with inhibitors of angiogenesis and radiotherapy. We therefore conclude that there is still a long way to go until we know which antiangiogenic agent will clinically be suitable for what tumour entity for combined treatment of radiotherapy and inhibitors of angiogenesis.     

The pursuit of optimal outcomes in cancer therapy in a new age of rationally designed target-based anticancer agents

There have been extraordinary advances in anticancer therapy over the last few decades, particularly for patients with relatively uncommon malignancies, largely because of the advent of nonspecific cytotoxic chemotherapeutics. Although these agents have also brought improved outcomes for patients with many of the more common solid cancers, it is clear that the point of 'diminishing return' has been reached. The recent development of a plethora of rationally designed target-based anticancer agents has opened up new opportunities and extraordinary therapeutic challenges. Since these agents appear primarily to target malignant cells, they can be expected to be less toxic at clinically effective doses than the cytotoxic agents. Among the various types of rationally designed target-based agents are those that target strategic facets of cell growth signal transduction, angiogenesis, metastasis and cell cycle regulation. While the primary therapeutic benefit of these agents is expected to be decreased tumour growth, evidence suggests that objective tumour responses may also be achieved. However, because of their potentially cytostatic properties, the clinical efficacy of such biologically based agents may not be readily demonstrable with traditional phase I and II study methodologies. Additionally, their dose-toxicity relationships are likely to be less steep than those of the nonspecific cytotoxic agents, thereby rendering such concepts as the maximum tolerated dose less meaningful than alternatives such as the optimal biological dose or the biologically effective dose. Those end-points generally considered, both from a regulatory and clinical viewpoint, to be of secondary importance in trials of cytotoxic agents, such as time to disease progression, disease-related symptoms and quality of life, may evolve into primary end-points. Present findings from preclinical studies suggest that the development, evaluation and general clinical use of rationally designed target-based anticancer agents will require a radical departure from the traditional paradigms if the full potential of these new therapies is to be exploited.     

Antineovascular therapy, a novel antiangiogenic approach

Angiogenesis is a crucial event in tumour growth, since the growth of tumour cells depends on the supply of essentials such as oxygen and nutrients. Therefore, suppression of angiogenesis is expected to show potent therapeutic effects on various cancers. Additionally, this 'antiangiogenic therapy' is thought not only to eradicate primary tumour cells, but also suppress tumour metastases through disruption of haematogenous metastatic pathways. Tumour dormancy therapy does not aim to disrupt newly formed angiogenic vessels but aims to inhibit further formation of neovessels through inhibiting certain processes of angiogenesis. This raises a question of whether or not these antiangiogenic agents bring complete cure of tumours as complete cut-off of oxygen and nutrients is not expected by the treatment with these agents. This paper will review a novel antiangiogenic therapy, antineovascular therapy (ANET). ANET is categorised in antiangiogenic therapy but is different from tumour dormancy therapy using conventional angiogenic inhibitors: ANET aims to disrupt neovessels rather than to inhibit neovessel formation. ANET is based on the fact that angiogenic endothelial cells are growing cells and would be effectively damaged by cytotoxic agents when the agents are effectively delivered to the neovessels. The complete eradication of angiogenic endothelial cells may cause complete cut-off of essential supplies to the tumour cells and lead to indirect but strong cytotoxicity instead of cytostasis caused by the inhibition of angiogenesis. For the purpose of ANET, an angiogenic vasculature-targeting probe has been developed, by which cytotoxic anticancer agents are actively delivered to the angiogenic endothelial cells by using drug delivery system (DDS) technology. Another way to damage newly formed vessels by cytotoxic agents is achieved by metronomic-dosing chemotherapy. This chemotherapy shifts the target of chemotherapeutic agents from tumour cells to angiogenic endothelial cells by selective dosing schedule. Similarly, the shift of target from tumour cells to angiogenic endothelial cells enhanced therapeutic efficacy of cancer photo-dynamic therapy (PDT): in this antiangiogenic PDT, photosensitizers are delivered more to neovessel endothelial cells than to tumour cells. These therapeutic strategies would be clinically applied in the future.     

Angiogenesis inhibitors. New agents in cancer therapy

Tumours that do not develop a blood supply cannot grow larger than 1 to 2mm3. The growth of a tumour blood supply, called angiogenesis, is a complex process that greatly increases the likelihood of metastatic spread and aggressive tumour behaviour. Molecular processes involved in angiogenesis include stimulation of endothelial growth by tumour cytokine production (vascular endothelial growth factor), degradation of extracellular matrix proteins by metalloproteinases, and migration of endothelial cells mediated by cell membrane adhesion molecules called integrins. These processes are being targeted by several new types of agents broadly classified as angiogenesis inhibitors. Additionally, endogenous angiogenesis inhibitors have been discovered and one of them, endostatin, is currently undergoing clinical trials. The unique targets of these drugs make them distinct from traditional cytotoxic chemotherapeutic agents. Unlike cytotoxic chemotherapy, in which the biological effect of the drug produces the antitumour effect as well as the toxic effect, angiogenesis inhibitors may produce their biological effect independently of the toxic effect. This fact raises important questions among clinical investigators as to what is the most effective way to administer these drugs and monitor their effects. This paper details some of the scientific evidence making angiogenesis an important therapeutic target as well as issues regarding the structure of clinical trials with these new anticancer agents.     

Tumour endoproteases: the cutting edge of cancer drug delivery?

Despite progression in anticancer drug development and improvements in the clinical utilization of therapies, current treatment regimes are still dependent upon the use of systemic antiproliferative cytotoxic agents. Although these agents are unquestionably potent, their efficacy is limited by toxicity towards 'normal' cells and a lack of tumour selective targeting, resulting in a therapeutic index which is modest at best. Consequently, the development of more tumour selective cancer treatments, with better discrimination between tumour and normal cells is unequivocally an important goal for cancer drug discovery. One such strategy is to exploit the tumour phenotype as a mechanism for tumour-selective delivery of potent therapeutics. An exciting approach in this area is to develop anticancer therapeutics as prodrugs, which are non-toxic until activated by enzymes localized specifically in the tumour. Enzymes suitable for tumour-activated prodrug development must have increased activity in the tumour relative to non-diseased tissue and an ability to activate the prodrug to its active form. One class of enzyme satisfying these criteria are the tumour endoproteases, particularly the serine- and metallo-proteases. These proteolytic enzymes are essential for tumour angiogenesis, invasion and metastasis, the major defining features of malignancy. This review describes the concept behind development of tumour-endoprotease activated prodrugs and discusses the various studies to date that have demonstrated the huge potential of this approach for improvement of cancer therapy.     

Molecular targets in the inhibition of angiogenesis

Angiogenesis, the process of blood vessel formation, is crucial for malignant tumour growth and metastases; therefore, it has become an attractive target for anticancer therapy. Theoretically applicable to most solid tumours, this therapy may be advantageous over existing cytotoxic therapy, since it is directed at genetically stable endothelium growing within tumours rather than at malignant cells, which acquire resistance to treatment. Many promising angiogenesis inhibitors have been developed, although their activity has yet to be demonstrated in human clinical trials. To improve therapeutic benefit, this may require further insight into tumour angiogenesis, development of appropriate surrogate markers of activity, treatment of early stage neoplastic disease and probably a combination of different classes of antiangiogenesis agents to overcome redundant mechanisms of angiogenesis control.     

Tumour angiogenesis: a novel therapeutic target in patients with malignant disease

Angiogenesis refers to the formation of new blood vessels from an existing vasculature and is recognised as a necessary requirement for most tumours to grow beyond 1-2 mm in diameter. Factors established as playing a role in angiogenesis may be divided into two principal groups: (a) those that stimulate endothelial cell proliferation and/or elongation, migration and vascular morphogenesis including vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), platelet derived endothelial cell growth factor (PD-ECGF) and the tie and tek receptors, and (b) proteases and their receptors involved in the breakdown of basement membranes and the extracellular matrix (ECM) including the matrix metalloproteinases (MMPs), cathepsins and those involved in the plasmin cascade. Angiogenesis has been identified as a potential target for development of anticancer agents. The discovery of a range of naturally-occurring factors which negatively regulate angiogenesis, including the thrombospondins, angiostatin and endostatin, and the tissue inhibitors of MMPs (TIMPs), has given added impetus to this approach. Synthetic anti-angiogenic compounds have been developed, including TNP-470, carboxyamidotriazole, VEGF-tyrosine kinase inhibitors and MMP inhibitors (MMPI) which, like the naturally-occurring anti-angiogenic factors, inhibit angiogenesis in vitro and in vivo, and tumour development, growth and metastasis in vivo. Anti-angiogenic agents also enhance the antitumour activity of many conventional cytotoxic chemotherapeutic agents. Such combinations may have a particular role as adjuvant therapies following surgical resection of primary tumours. Unlike tumour cells, tumour associated endothelial cells do not develop resistance to anti-angiogenic agents. Furthermore, anti-angiogenic agents are generally cytostatic rather than cytotoxic. As such, these agents are, in general, likely to be administered over long periods of time. Therefore, as well as having proven antitumour efficacy, an anti-angiogenic compound will need to be well-tolerated if it is to become established in the clinical management of patients with malignant disease.     

Regulators of colon cancer angiogenesis

Folkman’s discovery that the growth and spread of tumours depend on angiogenesis has created new avenues of research designed to better understand cancer biology and facilitate the development of new therapeutic strategies. The survival and metastasis of tumours depend on a shift in the normal balance among myriad endogenous angiogenic and anti-angiogenic factors in favour of increased angiogenesis. Several growth factors that regulate angiogenesis in colon cancer have been identified, including the pro-angiogenic factors vascular endothelial growth factor (VEGF), platelet-derived endothelial cell growth factor (PD-ECGF) and the anti-angiogenic factor, thrombospondin. A thorough understanding of the roles that these factors play in the angiogenic process has led to the development of agents intended to inhibit tumour angiogenesis. However, the complexity and redundancy of the angiogenic process continue to present substantial challenges to the development of anticancer therapies.     

Trichostatin A,an inhibitor of histone deacetylase,inhibits hypoxia-induced angiogenesis

Trichostatin A (TSA), a hydroxamate-type inhibitor of mammalian histone deacetylases has been reported to inhibit angiogenesis both in vitro and in vivo. TSA inhibits hypoxia-induced production of the angiogenic mediator vascular endothelial cell growth factor (VEGF) by tumour cells and also inhibits directly endothelial cell migration and proliferation. HDAC inhibitors such as TSA are currently of major interest as potential anticancer therapeutics, largely because of their well documented properties of inhibiting proliferation and inducing apoptosis of tumour cells. The finding that HDAC appears to be a critical regulator of angiogenesis in addition to tumour cell growth will heighten interest in the development of HDAC inhibitors as potential anticancer drugs.     

The VEGF/Rho GTPase signalling pathway: a promising target for anti-angiogenic/anti-invasion therapy

It has become increasingly apparent that current antiangiogenic therapy elicits modest effects in clinical settings. In addition, it remains challenging to treat cancer metastasis through antiangiogenic regimes. Rho GTPases are essential for vascular endothelial growth factor (VEGF)-mediated angiogenesis and are involved in tumour cell invasion. This review discusses novel therapeutic strategies that interfere with Rho GTPase signalling and further explores this network as a target for anticancer therapy through interference with tumour angiogenesis and invasion. Recent findings describe the development of innovative Rho GTPase inhibitors. Positive clinical effects of Rho GTPase targeting in combination with conventional anticancer therapy is of increasing interest.     

Cell adhesion and cancer: is there a potential for therapeutic intervention?

Carcinogenesis involves a disruption in adhesion molecule expression and tissue architecture, and tumour invasion requires adhesion-dependent migration into surrounding tissues. Therefore, a variety of peptide and antibody-based reagents that block integrins, cadherins, immunoglobulin superfamily and selectin adhesion molecules have been developed to treat cancers. Therapeutics directed at adhesion molecules can block interactions between tumour cells, endothelial cells and immune cells to prevent tumour cell invasiveness and metastasis. Blocking the adhesion molecules that facilitate the invasion of tumours by endothelial cells and immune cells can prevent tumour-associated angiogenesis and the recruitment of immune-mediated growth factors which are required for tumour growth and spread. In addition, targeted therapies using anticancer agents attached to antibodies or peptides directed as tumour-specific adhesion molecules are being developed.     

Cell adhesion and cancer: is there a potential for therapeutic intervention?

Carcinogenesis involves a disruption in adhesion molecule expression and tissue architecture, and tumour invasion requires adhesion-dependent migration into surrounding tissues. Therefore, a variety of peptide and antibody-based reagents that block integrins, cadherins, immunoglobulin superfamily and selectin adhesion molecules have been developed to treat cancers. Therapeutics directed at adhesion molecules can block interactions between tumour cells, endothelial cells and immune cells to prevent tumour cell invasiveness and metastasis. Blocking the adhesion molecules that facilitate the invasion of tumours by endothelial cells and immune cells can prevent tumour-associated angiogenesis and the recruitment of immune-mediated growth factors which are required for tumour growth and spread. In addition, targeted therapies using anticancer agents attached to antibodies or peptides directed as tumour-specific adhesion molecules are being developed.     

Antiangiogenic agents targeting vascular endothelial growth factor and its receptors in clinical development

There is ample therapeutic opportunity for the use of antiangiogenic inhibitors in the clinic, as there are several human diseases that are dependent upon angiogenesis [1]. However, no disease has attracted as much attention as a target for antiangiogenic therapy as malignant disorders. There is a vast amount of literature acting as proof-of-principle for the use of angiogenic inhibitors as effective agents for blocking tumour-induced angiogenesis and subverting tumour growth and disease dissemination. One of the unique attractions of targeting tumour angiogenesis is that vascular endothelial cells are a genetically stable population in which acquisition of therapeutic resistance might be less efficient than in genetically unstable tumour cells [2,3]. This review covers inhibitors that target the tumour angiogenic agent vascular endothelial growth factor and its receptors as one such antiangiogenic approach. Many agents in this class are in clinical trials with limited reports of toxicity and some early evidence of clinical benefit.     

Clinical and preclinical modulation of chemotherapy-induced toxicity in patients with cancer

Anticancer treatment is generally associated with toxicity to health issues. One of the reasons for this unpleasant association is that anticancer agents have been mostly selected on the basis of an empirically established toxicity towards cancer cell lines and rapidly growing tumours in animal models, and not on the basis of a sophisticated intervention in tumour-specific biology. This strategy of drug development unavoidably produces drugs with toxicity towards normal cells and tissues which also have a high cell turnover and share many characteristics with tumour cells. Therefore it is a continuing challenge to design therapy which is both effective and also has high specificity for the biology of cancer and/or is efficiently targeted to tumour tissue. This article describes the mechanisms of cytotoxicity of standard chemo- and radiotherapy and discussed the possibilities of currently available cytoprotective agents to reduce or prevent these toxicities. These agents should ideally be selective for normal cells versus cancer cells, be effective in reducing or preventing toxicity, have no negative impact on anticancer therapy and have minimal adverse effects. None of the agents described in this article fulfils these criteria completely and therefore we cannot recommend these agents for standard use in daily anticancer practice. Nevertheless, there are encouraging data concerning the beneficial effects of dexrazoxane for anthracycline-induced cardiomyopathy and amifostine for platinum- and radiotherapy-induced toxicity. These date warrant further studies.     

Antiangiogenic agents targeting vascular endothelial growth factor and its receptors in clinical development

There is ample therapeutic opportunity for the use of antiangiogenic inhibitors in the clinic, as there are several human diseases that are dependent upon angiogenesis [1]. However, no disease has attracted as much attention as a target for antiangiogenic therapy as malignant disorders. There is a vast amount of literature acting as proof-of-principle for the use of angiogenic inhibitors as effective agents for blocking tumour-induced angiogenesis and subverting tumour growth and disease dissemination. One of the unique attractions of targeting tumour angiogenesis is that vascular endothelial cells are a genetically stable population in which acquisition of therapeutic resistance might be less efficient than in genetically unstable tumour cells [2,3]. This review covers inhibitors that target the tumour angiogenic agent vascular endothelial growth factor and its receptors as one such antiangiogenic approach. Many agents in this class are in clinical trials with limited reports of toxicity and some early evidence of clinical benefit.     

Drug targeting systems for cancer chemotherapy

Tumour specific drug targeting has been a very actively investigated area for over 2 decades. Various approaches have involved the use of drug delivery systems that can localise the anticancer agent at the tumour site without damaging the normal cells. For this purpose, various delivery systems that have been utilised are liposomes, microspheres and recently, nanoparticles. Two liposome formulations containing anticancer drugs for example, adriamycin and daunomycin are already on the market in the USA and Europe. Microspheres are also being investigated for delivering various anticancer drugs and protein/peptides for anticancer treatment, and several formulations are in Phase I/II clinical trials. Antitumour drugs have also been linked to tumour specific monoclonal antibodies via various chemical linkages. Doxorubicin was linked to a chimeric monoclonal antibody that was targeted to the Lewis Y antigen. Though this conjugate initially showed potential, it was recently dropped from Phase II clinical trials. Another approach with monoclonal antibodies has been the use of immunotoxins. Immunotoxins initially showed promise as potential anticancer agents at picomolar concentrations but several clinical and preclinical studies have not shown much promise in this regard. Drug containing liposomes and microspheres have been further linked to tumour specific monoclonal antibodies to enhance their tumour specificity. Most of the studies with immunoliposomes or targeted microspheres have not gone beyond the preclinical studies. New therapeutic approaches are presently emerging based on natural products like cytokines, peptide growth factor antagonists, antisense oligonucleotides and specific genes. These approaches need the help of delivery systems to deliver these complex molecules to tumour cells. One of the current pursued approaches is the use of cationic liposomes. Several clinical studies are undergoing with various cationic liposomes and the next few years will demonstrate the usefulness of this approach. In recent years, the problems in cancer treatment have been complicated with the emergence of resistance strains leading to resistant and cross-resistant tumour cells. Several agents have been used to overcome or reverse drug-resistance in solid tumours and it remains a highly pursued area in cancer treatment.     

Drug targeting systems for cancer chemotherapy

Tumour specific drug targeting has been a very actively investigated area for over 2 decades. Various approaches have involved the use of drug delivery systems that can localise the anticancer agent at the tumour site without damaging the normal cells. For this purpose, various delivery systems that have been utilised are liposomes, microspheres and recently, nanoparticles. Two liposome formulations containing anticancer drugs for example, adriamycin and daunomycin are already on the market in the USA and Europe. Microspheres are also being investigated for delivering various anticancer drugs and protein/peptides for anticancer treatment, and several formulations are in Phase I/II clinical trials. Antitumour drugs have also been linked to tumour specific monoclonal antibodies via various chemical linkages. Doxorubicin was linked to a chimeric monoclonal antibody that was targeted to the Lewis Y antigen. Though this conjugate initially showed potential, it was recently dropped from Phase II clinical trials. Another approach with monoclonal antibodies has been the use of immunotoxins. Immunotoxins initially showed promise as potential anticancer agents at picomolar concentrations but several clinical and preclinical studies have not shown much promise in this regard. Drug containing liposomes and microspheres have been further linked to tumour specific monoclonal antibodies to enhance their tumour specificity. Most of the studies with immunoliposomes or targeted microspheres have not gone beyond the preclinical studies. New therapeutic approaches are presently emerging based on natural products like cytokines, peptide growth factor antagonists, antisense oligonucleotides and specific genes. These approaches need the help of delivery systems to deliver these complex molecules to tumour cells. One of the current pursued approaches is the use of cationic liposomes. Several clinical studies are undergoing with various cationic liposomes and the next few years will demonstrate the usefulness of this approach. In recent years, the problems in cancer treatment have been complicated with the emergence of resistance strains leading to resistant and cross-resistant tumour cells. Several agents have been used to overcome or reverse drug-resistance in solid tumours and it remains a highly pursued area in cancer treatment.