Combination of antiangiogenic therapy with other anticancer therapies: results, challenges, and open questions.

Angiogenesis is necessary for tumor growth. Drug discovery efforts have identified several potential therapeutic targets on endothelial cells and selective inhibitors capable of slowing tumor growth or producing tumor regression by blocking angiogenesis in in vivo tumor models. Certain antiangiogenic therapeutics increase the activity of cytotoxic anticancer treatments in preclinical models. More than 75 antiangiogenic compounds have entered clinical trials. Most of the early clinical testing was conducted in patients with advanced disease resistant to standard therapies. Several phase III trials have been undertaken to compare the efficacy of standard chemotherapy versus the same in combination with an experimental angiogenesis inhibitor. Preliminary results of the clinical studies suggest that single-agent antiangiogenic therapy is poorly active in advanced tumors. Although some of the results of combination trials are controversial, recent positive outcomes with an antivascular endothelial growth factor antibody combined with chemotherapy as front-line therapy of metastatic colorectal cancer have renewed enthusiasm for this therapeutic strategy. This article presents an overview of experimental and clinical studies of combined therapy with antiangiogenic agents and highlights the challenges related to the appropriate strategies for selection of the patients, study design, and choice of proper end points for preclinical and clinical studies using these agents.     

Is angiogenesis inhibition the Holy Grail of cancer therapy?

Over the last several decades, oncology research and cancer treatment have concentrated primarily on the cancer cells. Unfortunately, despite the intensive quest to find new and more effective compounds for chemotherapy, the survival rate of patients has not significantly changed. In 1971 Judah Folkman proposed that a solid tumor cannot grow without inducing angiogenesis. Intensive search for molecules blocking the formation of a tumor-nourishing capillary network has identified several promising agents in experimental models. Some of these angiogenesis inhibitors are in clinical trials, but a clear statement about the efficacy cannot be made yet. What are the current trends in angiogenesis research? What areas should we intensively investigate? Can we find the Holy Grail of cancer therapy in the years to come in order to stop the ineffable suffering of millions of cancer patients?     

Tumor progression-dependent angiogenesis in gastric cancer and its potential application

Despite improvements in the early diagnosis, prognosis and therapeutic strategies for gastric cancer (GC), human GC remains one of the most frequently diagnosed malignant tumors in the world, and the survival rate of GC patients remains very poor. Thus, a suitable therapeutic strategy for GC is important for prolonging survival. Both tumor cells themselves and the tumor microenvironment play an important role in tumorigenesis, including angiogenesis, inflammation, immunosuppression and metastasis. Importantly, these cells contribute to gastric carcinogenesis by altering the angiogenic phenotype switch. The development, relapse and spreading of tumors depend on new vessels that provide the nutrition, growth factors and oxygen required for continuous tumor growth. Therefore, a state of tumor dormancy could be induced by blocking tumor-associated angiogenesis. Recently, several antiangiogenic agents have been identified, and their potential for the clinical management of GC has been tested. Here, we provide an up-to-date summary of angiogenesis and the angiogenic factors associated with tumor progression in GC. We also review antiangiogenic agents with a focus on the anti-vascular endothelial growth factor receptor (VEGFR)-mediated pathway for endothelial cell growth and their angiogenesis ability in GC. However, most antiangiogenic agents have reported no benefit to overall survival (OS) compared to chemotherapy alone in local or advanced GC. In phase III clinical trials, only ramucirumab (anti-VEGFR blocker) and apatinib (VEGFR-TKI blocker) have reported an improved median overall response rate and prolonged OS and progression-free survival outcomes as a 2nd-line agent combined with chemotherapy treatment in advanced GC. By providing insights into the molecular mechanisms of angiogenesis associated with tumor progression in GC, this review will hopefully aid the optimization of antiangiogenesis strategies for GC therapy in combination with chemotherapy and adjuvant treatment.     

Targeted therapies for the treatment of breast cancer in the post-trastuzumab era

Targeted therapies for breast cancer are evolving rapidly. Trastuzumab has revolutionized breast cancer treatment and outcome, reducing the risk for recurrence and significantly increasing survival, at least for a subgroup of patients. Other targeted therapies, such as bevacizumab, a monoclonal antibody targeting angiogenesis, lapatinib, a dual human epidermal growth factor receptor (HER)‐1 and HER‐2 inhibitor, other small‐molecule tyrosine kinase inhibitors, and mammalian target of rapamycin inhibitors, have been developed in phase II and III clinical trials. Although there has been rapid approval of these new drugs by health authorities, some questions have emerged about their application in clinical practice. What is the appropriate drug or sequence of drugs? What is the ideal target? How should tumor response be evaluated? Are financial resources sufficient to treat patients? How do we design trials with these molecules? These are emerging as current dilemmas for clinical oncologists.     

Inhibition of angiogenesis.

The concept of antiangiogenic therapy was first proposed in the early 1970s as a method of restricting tumor growth by inhibiting angiogenesis. In subsequent years sufficient knowledge about the process of angiogenesis itself was obtained so that it is now possible to begin to develop antiangiogenic therapy for clinical use. At least three strategies are feasible: (i) inhibition of release of angiogenic molecules from tumor cells; (ii) neutralization of angiogenic molecules that have already been released; and (iii) inhibition of vascular endothelial cells from responding to angiogenic stimulation. Most of the angiogenic inhibitors that have been discovered at the time of writing, directly interfere with the ability of endothelial cells to form new capillary blood vessels. Antiangiogenic activity is a newly found property of alpha-interferon. Although alpha-interferon is a relatively weak angiogenesis inhibitor in comparison to others, it has been very successful in the treatment of life-threatening hemangiomas in children. Early clinical experience with this first angiogenesis inhibitor to reach clinical trial, indicates that optimal antiangiogenic therapy in the future is likely to be based on the long-term use of inhibitors with low toxicity, and with little chance of inducing drug-resistance. It is apparent that different types of angiogenesis inhibitor may be administered together and that these compounds may also be administered to cancer patients as adjuncts to conventional chemotherapy. It is important to recognize that tumor vasculature has other properties besides angiogenesis, which make it a potential specific target for anti-cancer therapy.     

Angiogenesis and hepatic colorectal metastases

Angiogenesis is a critical step in the metastatic cascade of colorectal cancer. Several angiogenesis inhibitors have been evaluated in animal models and have shown efficacy, but challenges remain in using these drugs effectively in the clinical setting. Although several of these angiogenesis inhibitors are currently being evaluated in clinical trials, alone or in combination with cytotoxic chemotherapy, early results suggest that angiogenesis inhibitors alone, when used for advanced disease, have minimal activity. It is likely that this class of drugs will prove more efficacious when used either in the setting of minimal disease as agents that may promote tumor dormancy or in combination with other conventional forms of therapy. In addition, strategies such as metronomic therapy have been proposed whereby lower doses of cytotoxic chemotherapy, given more frequently, may act via an antiangiogenic mechanism [67,68]. Another challenge is identifying methods of assessing response to antiangiogenic therapy. To date, traditional methods of identifying response to treatment have not proven effective. Several investigators are working toward identifying circulating endothelial or tumor-associated factors that may be useful in following treatment. Novel imaging techniques are also being evaluated with enhanced CT and MRI, and newer modalities. Hepatic colorectal metastases provide an opportune setting in which to accomplish these challenges because the high incidence of disease and the ability to measure tumor with a variety of techniques lend themselves to evaluation of antiangiogenic therapy.     

Tumor angiogenesis and tumor angiogenesis inhibitors

It is important to survey the molecular targets which are involved in tumor angiogenesis for the development of antiangiogenic agents as one of the cancer therapy. This article is meant to review the recent molecular targets of tumor angiogenesis and the molecular mechanism of antiangiogenic agents in human clinical trials.     

Delta-like 4 Notch ligand regulates tumor angiogenesis, improves tumor vascular function, and promotes tumor growth in vivo

The vascular endothelial growth factor (VEGF) plays a key role in tumor angiogenesis. However, clinical trials targeting the VEGF pathway are often ineffective, suggesting that other factors/pathways are also important in tumor angiogenesis. We have previously shown that the Notch ligand Delta-like 4 (DLL4) is up-regulated in tumor vasculature. Here, we show that DLL4, when expressed in tumor cells, functions as a negative regulator of tumor angiogenesis by reducing the number of blood vessels in all five types of xenografts, but acts as a positive driver for tumor growth in two of them (human glioblastoma and prostate cancer). The growth of in vivo models was not related to the effects on growth in vitro. DLL4 expressed in the tumor cells activated Notch signaling in host stromal/endothelial cells, increased blood vessel size, and improved vascular function within tumors. The promotion of tumor growth was, to some extent, due to a reduction of tumor hypoxia and apoptosis. DLL4-expressing tumor cells responded to anti-VEGF therapy with bevacizumab. A soluble form of DLL4 (D4ECD-Fc) blocked tumor growth in both bevacizumab-sensitive and bevacizumab-resistant tumors by disrupting vascular function despite increased tumor vessel density. In addition, we show that DLL4 is up-regulated in tumor cells and tumor endothelial cells of human glioblastoma. Our findings provide a rational basis for the development of novel antiangiogenic strategies via blockade of DLL4/Notch signaling and suggest that combined approaches for interrupting both DLL4 and VEGF pathways may improve antiangiogenic therapy.     

Twenty years after：the beautiful hypothesis andthe ugly facts

The limited clinical beneifts from current antiangiogenic therapy for cancer patients have triggered some critical thoughts and insightful investigations aiming to further elucidate the relationship between vessels and cancer. Tumors need blood perfusion but there are mounting evidences that angiogenesis alone does not explain it in all the neoplasms. In this editorial, for a special issue on tumor and vessels published in theChinese Journal of Cancer, we brielfy introduce the history of the evidences that solid tumors can sometimes obtain blood perfusion by alter?native approaches other than sprouting angiogenesis, i.e., vessel co?option and vasculogenic mimicry. This editorial provides also the links to several most recently published discoveries and hypotheses on tumor interaction with blood vessels.     

Redefining the target: chemotherapeutics as antiangiogenics.

Angiogenesis, or new blood vessel formation, is now known to play an important role in both growth and metastasis of many cancers. The central importance of angiogenesis and the understanding of how new blood vessels are formed, has led to novel therapies designed to interrupt this process. Though specific antiangiogenic compounds have only recently entered the clinic, they herald a new era, one in which biology is the basis for therapy. The intense interest in angiogenesis has also lead to a re-examination of the activity of many established cytotoxic agents. Claims of antiangiogenic activity abound, unfortunately, with no common criteria and often little evidence of clinical relevance. What are we to think? Have oncologists unknowingly been administering antiangiogenic therapy all these years? If chemotherapeutics are really antiangiogenics in disguise, why have they failed to cure most solid tumors? Might the hard-learned lessons of chemotherapy resistance pertain to the novel antiangiogenics as well? Though we can offer no certain answers to these important questions, we do offer a framework on which to order the rapidly burgeoning literature. We suggest criteria by which a cytotoxic agent might reasonably be considered to have meaningful antiangiogenic activity. Finally, we describe potential mechanisms of resistance to antiangiogenic chemotherapies-some of which may apply to the pure antiangiogenics currently in development.     

Molecular targets on blood vessels for cancer therapies in clinical trials

This review covers progress to date in the identification of molecular targets on blood vessels in cancers, as well as agents that act on those targets, with emphasis on those currently in clinical trials. Current vascular-targeting therapies comprise two general types--antiangiogenic therapy and antivascular therapy. Advances in antiangiogenic therapies, particularly inhibitors of vascular endothelial growth factors and their receptors, have clarified the capacity of these inhibitors to change tumor-associated vessel structure to a more normal state, thereby improving the ability of chemotherapeutics to access the tumors. The responses of other antiangiogenesis target molecules in humans are more complicated; for example, alphanubeta3 integrins are known to stimulate as well as inhibit angiogenesis, and cleavage of various extracellular proteins/proteoglycans by matrix metalloproteinases produces potent regulators of the angiogenic process. Antivascular therapies disrupt established blood vessels in solid tumors and often involve the use of ligand-based or small-molecule agents. Ligand-based agents, irrespective of the antiangiogenic capacity of the ligand, target antivascular effectors to molecules expressed specifically on blood vessels, such as aminopeptidase N, fibronectin extra-domain B, and prostate-specific membrane antigen. Small-molecule antivascular agents, which are not targeted to molecules on blood vessels, rely on physical differences between the vasculatures in tumors and those in normal tissues.     

Progress in antiangiogenic gene therapy of cancer

BACKGROUND: Because tumors require angiogenesis for growth, inhibiting angiogenesis is a promising strategy for treating cancer patients. Although numerous endogenous angiogenesis inhibitors have been discovered, the clinical evaluation of these agents has been hindered by high dose requirements, manufacturing constraints, and relative instability of the corresponding recombinant proteins. Therefore the delivery of these proteins using gene therapy has become increasingly attractive. METHODS: Based on their own antiangiogenic gene therapy research, the authors evaluated the published experience with antiangiogenic gene therapy models using the National Library of Medicine's PubMed search service and the reference lists of the publications cited. RESULTS: Greater than 40 endogenous inhibitors of angiogenesis have been characterized. Thirteen have been employed in gene therapy models, all of which showed antitumor activity in experimental animals. Other approaches have inhibited the expression or activity of proangiogenic cytokines such as vascular endothelial growth factor. The ideal gene delivery vector would target tumor tissue preferentially to minimize systemic toxicity of the transgene product. However, the low toxicity profile of endogenous inhibitors of angiogenesis has allowed the success of systemic antiangiogenic gene therapy in a number of preclinical models, in which normal host tissues act as a "factory" to produce high circulating concentrations of antiangiogenic proteins. CONCLUSIONS: Difficulties with the large-scale use of antiangiogenic agents have hindered their investigation in clinical trials. Antiangiogenic gene therapy offers the potential for cancer patients to manufacture their own antiangiogenic proteins. This strategy has been increasingly successful in preclinical models and represents an exciting new approach to cancer therapy.     

Anti-angiogenic Treatment Strategies for Malignant Brain Tumors

The use of angiogenesis inhibitors may offer novel strategies in brain tumor therapy. In contrast to traditional cancer treatments that attack tumor cells directly, angiogenesis inhibitors target at the formation of tumor-feeding blood vessels that provide continuous supply of nutrients and oxygen.With respect to brain tumor therapy, inhibitors of angiogenesis display unique features that are unknown to conventional chemotherapeutic agents. The most important features are independence of the blood–brain barrier, cell type specificity, and reduced resistance. Malignant brain tumors, especially malignant gliomas, are among the most vascularized tumors known. Despite multimodal therapeutic approaches, the prognosis remains dismal. Thus, angiogenesis inhibitors may be highly effective drugs against these tumors. In a clinical setting, they could be applied in the treatment of multiple tumors or postsurgically as an adjuvant therapy to prevent recurrence.This article provides an overview of current anti-angiogenic treatment strategies with emphasis on substances already in clinical trials or candidate substances for clinical trials. The cellular and molecular basis of these substances is reviewed.     

Mouse models for studying angiogenesis and lymphangiogenesis in cancer

The formation of new blood vessels (angiogenesis) is required for the growth of most tumors. The tumor microenvironment also induces lymphangiogenic factors that promote metastatic spread. Anti-angiogenic therapy targets the mechanisms behind the growth of the tumor vasculature. During the past two decades, several strategies targeting blood and lymphatic vessels in tumors have been developed. The blocking of vascular endothelial growth factor (VEGF)/VEGF receptor-2 (VEGFR-2) signaling has proven effective for inhibition of tumor angiogenesis and growth, and inhibitors of VEGF-C/VEGFR-3 involved in lymphangiogenesis have recently entered clinical trials. However, thus far anti-angiogenic treatments have been less effective in humans than predicted on the basis of pre-clinical tests in mice. Intrinsic and induced resistance against anti-angiogenesis occurs in patients, and thus far the clinical benefit of the treatments has been limited to modest improvements in overall survival in selected tumor types. Our current knowledge of tumor angiogenesis is based mainly on experiments performed in tumor-transplanted mice, and it has become evident that these models are not representative of human cancer. For an improved understanding, angiogenesis research needs models that better recapitulate the multistep tumorigenesis of human cancers, from the initial genetic insults in single cells to malignant progression in a proper tissue environment. To improve anti-angiogenic therapies in cancer patients, it is necessary to identify additional molecular targets important for tumor angiogenesis, and to get mechanistic insight into their interactions for eventual combinatorial targeting. The recent development of techniques for manipulating the mammalian genome in a precise and predictable manner has opened up new possibilities for the generation of more reliable models of human cancer that are essential for the testing of new therapeutic strategies. In addition, new imaging modalities that permit visualization of the entire mouse tumor vasculature down to the resolution of single capillaries have been developed in pre-clinical models and will likely benefit clinical imaging.     

Cell surface tumor endothelial markers are conserved in mice and humans

We recently identified genes encoding tumor endothelial markers (TEMs) that displayed elevated expression during tumor angiogenesis. From both biological and clinical points of view, TEMs associated with the cell surface membrane are of particular interest. Accordingly, we have further characterized four such genes, TEM1, TEM5, TEM7, and TEM8, all of which contain putative transmembrane domains. TEM5 appears to be a seven-pass transmembrane receptor, whereas TEM1, TEM7, and TEM8 span the membrane once. We identified mouse counterparts of each of these genes, designated mTEM1, mTEM5, mTEM7, and mTEM8. Examination of these mTEMs in mouse tumors, embryos, and adult tissues demonstrated that three of them (mTEM1, mTEM5, and mTEM8) were abundantly expressed in tumor vessels as well as in the vasculature of the developing embryo. Importantly, expression of these mTEMs in normal adult mouse tissues was either undetectable or detected only in a small fraction of the vessels. These results demonstrate conservation of human and mouse tumor angiogenesis at the molecular level and support the idea that tumor angiogenesis largely reflects normal physiological neovasculaturization. The coordinate expression of TEM1, TEM5, and TEM8 on tumor endothelium in humans and mice makes these genes attractive targets for the development of antiangiogenic therapies.     

Angiogenesis as a Therapeutic Target in Malignant Gliomas

Currently, adult glioblastoma (GBM) patients have poor outcomes with conventional cytotoxic treatments. Because GBMs are highly angiogenic tumors, inhibitors that target tumor vasculature are considered promising therapeutic agents in these patients. Encouraging efficacy and tolerability in preliminary clinical trials suggest that targeting angiogenesis may be an effective therapeutic strategy in GBM patients. However, the survival benefits observed to date in uncontrolled trials of antiangiogenic agents have been modest, and several obstacles have limited their effectiveness. This article reviews the rationale for antiangiogenic agents in GBM, their potential mechanisms of action, and their clinical development in GBM patients. Although challenges remain with this approach, ongoing studies may improve upon the promising initial benefits already observed in GBM patients.     

Strategy for the development of novel anticancer drugs

Progress in molecular pharmacology has demonstrated each anticancer drug to have a unique molecular target. Recent drug development has focused on compounds that specifically inhibit and/or modify tumor-specific molecular biological changes (target-based drug development). These compounds are generally classified as either small molecules or macromolecules. With the exception of antibodies, the majority of recently developed target-based drugs are small molecules. Assessing the effects of these compounds on their targets would probably help researchers to predict the antitumor effects of these anticancer drugs; however, actually assessing this hypothesis, even in preclinical models, is difficult. Most preclinical experiments attempt to show tumor growth inhibition or shrinkage, leading to a longer survival period or higher cure rate. Few experiments have examined the correlation between antitumor activity and the effect of a compound on its target. In phase I clinical trials of target-based drugs, the determination of maximum tolerated dose is not enough; the effect of the drug on its target should also be evaluated. Recently, dose-escalation strategies based on the effects of drugs on their targets have been proposed, even though an appropriate target effect is necessary but not sufficient to demonstrate clinical efficacy. Compounds that are not specifically directed against molecular targets on or within tumor cells, but against blood vessels, matrix, etc., usually do not cause tumor shrinkage. These compounds include angiogenesis inhibitors and matrix metalloproteinase inhibitors and are usually used in combination with other treatments at the start of clinical trials. Whether the methodology of clinical trials is sensitive enough to detect the subtle effects of these compounds remains uncertain. The effects of experimental drugs on their targets are rarely examined in clinical trials. Few data from translational studies are available and data obtained using surrogate tissues do not necessarily reflect the effects of the drugs on in situ tumors. Parameters such as time to progression, changes in tumor markers, and growth rates often vary significantly and are regarded as soft endpoints. Phase III trials evaluating survival benefit require extensive resources, including a large number of patients, a sophisticated data center, and well-trained study groups. The problems and future prospects of novel anticancer drug development are discussed.     

Role of hematopoietic lineage cells as accessory components in blood vessel formation

In adults, the vasculature is normally quiescent, due to the dominant influence of endogenous angiogenesis inhibitors over angiogenic stimuli. However, blood vessels in adults retain the capacity for brisk initiation of angiogenesis, the growth of new vessels from pre-existing vessels, during tissue repair and in numerous diseases, including inflammation and cancer. Because of the role of angiogenesis in tumor growth, many new cancer therapies are being conducted against tumor angiogenesis. It is thought that these anti-angiogenic therapies destroy the tumor vessels, thereby depriving the tumor of oxygen and nutrients. Therefore, a better understanding of the molecular mechanisms in the process of sprouting angiogenesis may lead to more effective therapies not only for cancer but also for diseases involving abnormal vasculature. It is widely believed that after birth, endothelial cells (EC) in new blood vessels are derived from resident EC of pre-existing vessels. However, evidence is now emerging that cells derived from the bone marrow may also contribute to postnatal angiogenesis. Most studies have focused initially on the contribution of endothelial progenitor cells in this process. However, we have proposed a concept in which cells of the hematopoietic lineage are mobilized and then entrapped in peripheral tissues, where they function as accessory cells that promote the sprouting of resident EC by releasing angiogenic signals. Most recently we found that hematopoietic cells play major roles in tumor angiogenesis by initiating sprouting angiogenesis and also in maturation of blood vessels in the fibrous cap of tumors. Therefore, manipulating these entrapment signals may offer therapeutic opportunities to stimulate or inhibit angiogenesis.     

Surrogate markers in antiangiogenesis clinical trials

Novel antiangiogenic agents currently being developed may ultimately be more effective against solid tumours and less toxic than cytotoxic chemotherapy. As a result of the early clinical trials of angiogenesis inhibitors, investigators are beginning to appreciate the complexity of targeting angiogenesis and the realisation that developing clinically useful antiangiogenic therapy will be more challenging than originally thought. It is now apparent that new methods and surrogate markers to assess these agents' biological activity are crucial for their successful development. This review summarises the currently available clinical data on the development of surrogate markers of angiogenesis inhibitors.     

Arginine deiminase and other antiangiogenic agents inhibit unfavorable neuroblastoma growth: potentiation by irradiation

In spite of aggressive therapy, children suffering from neuroblastoma have a poor prognosis. Therapeutic failure is most often observed in neuroblastomas with unfavorable features, including amplification/over-expression of the N-myc oncogene, rapid growth, effective angiogenesis and/or the tendency to metastasize. Here, we have used cultured human neuroblastoma cells with such features and we have examined whether antiangiogenic agents alone or in combination with tumor irradiation inhibit their angiogenesis and growth in vivo. We report that antiangiogenic agents (arginine deiminase, SU5416 and DC101) inhibit in vivo growth of neuroblastomas with unfavorable properties and that these effects are potentiated by simultaneous irradiation. Combination of either agent with irradiation leads to a reduction in the absolute number of tumor vessels and of perfused tumor vessels. Combination of arginine deiminase or DC101 with irradiation does not increase tumor hypoxia. Our data demonstrate for the first time that arginine deiminase suppresses the growth of unfavorable experimental neuroblastomas and that this effect is potentiated by irradiation. We suggest that antiangiogenesis alone or in combination with established therapeutic regimen may improve the outcome of unfavorable neuroblastomas in a clinical setting.