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.     

Targeting Angiogenesis for Treatment of Human Cancer

Recent advances in cancer research highlighted the importance of target-specific drug discovery. In view of these advances, the most important mechanism in tumour growth is its ability to stimulate the formation of blood capillaries around itself called tumour-driven angiogenesis. Hence targeting the angiogenesis, inhibits the growth of blood vessels around it and responsible for death of the tumour due to starvation and accumulation of toxic waste. The therapy, thus, indirectly cytotoxic to the tumour cells by targeting newly developing blood vessels. In this review, we summarised the various antiangiogenic agents with their clinical uses and current status.     

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 in cancer therapy: mechanistic perspective on classification and treatment rationales

Angiogenesis, a process of new blood vessel formation, is a prerequisite for tumour growth to supply the proliferating tumour with oxygen and nutrients. The angiogenic process may contribute to tumour progression, invasion and metastasis, and is generally accepted as an indicator of tumour prognosis. Therefore, targeting tumour angiogenesis has become of high clinical relevance. The current review aimed to highlight mechanistic details of anti-angiogenic therapies and how they relate to classification and treatment rationales. Angiogenesis inhibitors are classified into either direct inhibitors that target endothelial cells in the growing vasculature or indirect inhibitors that prevent the expression or block the activity of angiogenesis inducers. The latter class extends to include targeted therapy against oncogenes, conventional chemotherapeutic agents and drugs targeting other cells of the tumour micro-environment. Angiogenesis inhibitors may be used as either monotherapy or in combination with other anticancer drugs. In this context, many preclinical and clinical studies revealed higher therapeutic effectiveness of the combined treatments compared with individual treatments. The proper understanding of synergistic treatment modalities of angiogenesis inhibitors as well as their wide range of cellular targets could provide effective tools for future therapies of many types of cancer.     

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.     

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.     

Antiangiogenic drugs: current knowledge and new approaches to cancer therapy

Angiogenesis--process of new blood-vessel growth from existing vasculature--is an integral part of both normal developmental processes and numerous pathologies such as cancer, ischemic diseases and chronic inflammation. Angiogenesis plays a crucial role facilitating tumour growth and the metastatic process, and it is the result of a dynamic balance between proangiogenic and antiangiogenic factors. The potential to block tumour growth and metastases by angiogenesis inhibition represents an intriguing approach to the cancer treatment. Angiogenesis continues to be a topic of major scientific interest; and there are currently more antiangiogenic drugs in cancer clinical trials than those that fit into any other mechanistic category. Based on preclinical studies, researchers believe that targeting the blood vessels which support tumour growth could help treatment of a broad range of cancers. Angiogenic factors or their receptors, endothelial cell proliferation, matrix metalloproteinases or endothelial cell adhesion, are the main targets of an increasing number of clinical trials approved to test the tolerance and therapeutic efficacy of antiangiogenic agents. Unfortunately, contrary to initial expectations, it has been described that antiangiogenic treatment can cause different toxicities in cancer patients. The purpose of this article is to provide an overview of current attempts to inhibit tumour angiogenesis for cancer therapy.     

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.     

Anti-angiogenic drug discovery: lessons from the past and thoughts for the future

INTRODUCTION: Since the pioneering work of Judah Folkman, the discovery of bevacizumab has introduced the use of anti-angiogenic agents as a new modality for the treatment of cancer. Currently, hundreds of clinical trials involving anti-angiogenic agents, targeting different elements of the tumour angiogenesis pathway, are underway. However, thus far, the benefits of anti-angiogenic therapy in unselected patient populations are often marginal with harmful side effects. AREAS COVERED: This article presents a detailed discussion of the lessons learnt from the use of bevacizumab and other VEGF pathway inhibitors in the clinical setting. Specifically, this article provides a review of the literature on anti-VEGF agents and other angiogenesis inhibitors used in pre-clinical and clinical trials for cancer treatment. EXPERT OPINION: Future anti-angiogenic drug design centres on multiple protein targets and combinations including: growth factors, hypoxia-inducible factor and tumour endothelial cell markers unique to the tumour vasculature. Furthermore, treatment dosing, scheduling and combination with radiation and chemotherapy require further investigation, as does the potential of treating early disease, and the development of biomarkers which accurately predict response to therapy. These are essential for the future development of these drugs with individualised therapy likely to be the ultimate goal.     

Anti-angiogenesis therapy:concepts and importance of dosing schedules in clinical trials

The biological control of angiogenesis is critical to the clinical control of cancer. Understanding the mechanism of formation and regulation of new blood vessel development would open a new avenue for cancer treatment. Intense research effort has revealed a variety of factors which initiate, control and terminate the multi-stage process of angiogenesis, as well as target structures which interfere with this process. Protease inhibitors, inhibitors of the endothelial cell proliferation, suppressors of angiogenic growth factors, copper chelators, and other compounds interfering with the process of angiogenesis were screened for inhibition of tumor angiogenesis and some of them are in clinical trials. Very recently, a new term, ‘metronomic dosing regimen’ has been introduced, which implicates the use of the old cytostatic anticancer agents as anti-angiogenic agents. Results from recent studies will be discussed briefly and the prospects of inhibition of tumor angiogenesis as a new treatment modality will be outlined.     

Apoptotic potency of angiostatic compounds in the treatment of cancer

When tumours outgrow their vascular supply, they become hypoxic because of nutrient deficiency. This increases the expression and secretion of proangiogenic factors, like vascular endothelial growth factor (VEGF), leading to the activation of endothelial cells. The activated endothelial cells migrate, proliferate and form new blood vessels, resulting in increased tumour growth. This process is called tumour angiogenesis. Inhibiting tumour angiogenesis and therefore tumour growth is a well known concept in the treatment of cancer, such as hepatocellular carcinoma (HCC). This can be done by endogenous angiogenesis inhibitors, like angiostatin and its derivates. These are known to affect endothelial cell functions including the induction of apoptosis. The impact of these angiostatic factors on the cell is manifold. This also applies for so called small molecules, which affect tyrosine kinases such as receptors or intracellular signal transduction proteins. Other approaches, like monoclonal antibodies, target a single molecule, mainly VEGF, to inhibit receptor binding and downstream signal transduction. Gene silencing, mainly via RNA interference (RNAi) intervenes on RNAlevel, leading to reduced gene expression and protein secretion. Due to intense research in this field, there is rising evidence that also tumour cells themselves are influenced by angiostatic treatment approaches and the underlying molecular mechanisms are more and more revealed. Here we give a (short) review regarding the pro-apoptotic potency of antiangiogenic compounds like angiostatic molecules, sequestering antibodies, small molecules and RNAi approaches targeting endothelial and tumour cell survival to inhibit angiogenesis and tumour growth.     

Long pentraxin PTX3 as a novel treatment for fibroblast growth factor-8-mediated tumour diseases

While prevailing strategies to treat cancer have concentrated on reducing or eliminating the tumour directly, recently treatments that affect tumour angiogenesis with inhibitors, particularly growth factor inhibitors, have been used in clinical trials. The inhibitors affect availability of growth factors and nutrients to the tumour and restrict access to blood vessels, which affects the spread of tumours to distal sites. This patent application proposes to use long pentraxin PTX3, or one of its derivatives, to treat cancers which are associated with abnormal expression of the fibroblast growth factor (FGF)-8 in ovarian, breast and prostate cancer. Abnormal expression of FGF-8 is associated with increased angiogenesis in tumours and mortality in cancer patients and stimulates growth of endothelial cells. The use of various formulations of PTX3 by itself or in combination with cytotoxic agents are proposed. The data presented shows that the addition of FGF-8 is able to partially inhibit the strong binding of another growth factor FGF-2, to PTX3 in vitro, indicating that PTX3 has affinity for FGF-8. This binding was specific, as the addition of another growth factor FGF-4, instead of FGF-8, had no effect. FGF-8 was shown to have mitogenic effects on an experimental epithelial cell line GM 7373. Addition of PTX3 was also able to inhibit this mitogenic effect. Whilst binding of PTX3 to this growth factor is intriguing, further studies are required to test PTX3 alone or in combination with other therapies to determine whether it may prove useful in selected cancer patients.     

Angiogenesis and angiogenesis inhibitors: a new potential anticancer therapeutic strategy

Tumor cells cannot grow as a mass above 2 to 3 mm3 because diffusion is insufficient for oxygen and glucose requirements, unless the tumor induces a blood supply. This mechanism of induction of a new blood supply from pre-existing vascular bed is called angiogenesis. Furthermore, tumor invasiveness and metastasis require neovascularization. In fact, recent published studies suggest that acquisition of the angiogenic phenotype is a common pathway for tumor progression and neovascularization is linked with other molecular steps leading to tumor progression. Angiogenic process is a complex multi-step cascade under the control of positive and negative soluble factors. A paracrine interaction occurs between tumor and endothelial cells. Angiogenesis involves: endothelial cell proliferation, migration and tubule formation with associated changes in the extra-cellular matrix, allowing subsequent new vessel growth toward the tumor. Each of the above steps may represent a target for antiangiogenic therapy. Antiangiogenesis is to be distinguished from direct targeting and destruction of tumor vasculature (vascular targeting). Inhibition of angiogenesis represents one of the more promising, new approaches, to anticancer treatment and its already in early clinical trials. This review takes into consideration: (i) the biological mechanism underlining angiogenesis process; (ii) the method to assess tumor angiogenesis activity; (iii) inhibition of angiogenesis as an anticancer therapy; (iv) the methodology for the clinical development of angiogenesis inhibitors, that should be considered biological response modifiers; (v) some angiogenesis antagonists that are in development and leader compounds that are under clinical trial.     

Therapies directed at vascular endothelial growth factor

The inhibition of angiogenesis through vascular endothelial growth factor (VEGF) receptor targeting is a strategy that is relatively tumour selective. The high selectivity achieved with neutralising antibodies, soluble receptors and ribozymes reduces the risk of adverse reactions not related to VEGF inhibition itself. Small-molecule, orally-active protein kinase inhibitors provide an attractive alternative for chronic therapy, although specifically targeting a small subset of protein kinases from the ~ 550 expressed in mammalian cells is a challenge. Current efforts have resulted in promising clinical data for several synthetic VEGF receptor kinase inhibitors, of which PTK787/ZK222584 and ZD6474 are proceeding into large size clinical trials. It seems likely that blockers of the VEGF signalling pathway will be unsuitable for monotherapy, and that their role will be as an adjunct to additional antiangiogenic agents together with directly-acting antitumour agents or radiation therapy. Caution is needed with combinations of antiVEGF therapies and cytotoxic agents, as coadministration of cytotoxic agents with either the kinase inhibitor SU5416 or the VEGF antibody avastin appears to be associated with bleeding and thrombotic adverse events.     

Therapies directed at vascular endothelial growth factor

The inhibition of angiogenesis through vascular endothelial growth factor (VEGF) receptor targeting is a strategy that is relatively tumour selective. The high selectivity achieved with neutralising antibodies, soluble receptors and ribozymes reduces the risk of adverse reactions not related to VEGF inhibition itself. Small-molecule, orally-active protein kinase inhibitors provide an attractive alternative for chronic therapy, although specifically targeting a small subset of protein kinases from the approximately 550 expressed in mammalian cells is a challenge. Current efforts have resulted in promising clinical data for several synthetic VEGF receptor kinase inhibitors, of which PTK787/ZK222584 and ZD6474 are proceeding into large size clinical trials. It seems likely that blockers of the VEGF signalling pathway will be unsuitable for monotherapy, and that their role will be as an adjunct to additional antiangiogenic agents together with directly-acting antitumour agents or radiation therapy. Caution is needed with combinations of anti-VEGF therapies and cytotoxic agents, as coadministration of cytotoxic agents with either the kinase inhibitor SU5416 or the VEGF antibody avastin appears to be associated with bleeding and thrombotic adverse events.     

Angiogenesis inhibitors: perspectives for medical, surgical and radiation oncology

In the past decade, many angiogenesis inhibitors have been developed for clinical use in oncology. Surgeons, radiotherapists as well as medical oncologists have been investigating with much effort and enthusiasm the translation of these agents from the preclinical setting into treatment strategies of patients. Recently, for the first time in history, the angiogenesis inhibitor bevacizumab (avastin), a humanized anti-vascular endothelial growth factor (VEGF) antibody, showed a survival benefit of 4.7 months in a phase III clinical trial in patients with advanced colorectal cancer when this agent was given in combination with chemotherapy. At the annual meeting of the American Association of Clinical Oncology 2005, similar results of bevacizumab in lung, breast and ovarian cancer clinical trials have been shown. These landmark studies proofed for the first time in the clinical setting that Dr. Folkman back in 1971 was right by proposing: "in order to stop tumor growth, one should attack its blood supply". Nowadays it seems trivial to propose such a hypothesis, at that time it was a very provocative hypothesis and it took more than 30 years to proof this hypothesis in the clinic. Although one may be excited about this major finding, there is no time to relax. The survival benefit of bevacizumab is only about 4 months. Therefore more potent antiangiogenic agents and more active treatment strategies are urgently warranted. Newer angiogenesis inhibitors that are currently in preclinical or early clinical development have shown in preclinical experiments improved antitumor activities. In addition, combinations of biological agents that interfere in multiple biological pathways in cancer growth including chemotherapy, are of major clinical interest as well. The multimodality approach in which surgeons, radiotherapists and medical oncologists collaborate needs to be explored as well. In a variety of cancer types, like breast colon and lung cancer, these specialists should design multimodality strategies based on current standard treatment in which they incorporate angiogenesis inhibitors in the right time frame of surgery and radiotherapy. In this review we will bring you up to date on the clinical development of angiogenesis inhibitors and we will summarize the multimodality strategies that are under development.     

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.     

Novel pharmacological approaches in the treatment of breast cancer

Breast cancer is the most common malignancy among women. Novel pharmacological agents, including hormonal, cytotoxic and biological therapies, are currently being developed and tested in clinical trials and may offer patients more treatment options and an improved chance of long-term survival. Signal transduction inhibitors that block endocrine or growth factor pathways have demonstrated exciting antitumour effects in clinical trials. In addition to new chemotherapeutic drugs, numerous biological agents including growth factor receptor-directed monoclonal antibodies and tyrosine kinase inhibitors that target specific molecular lesions are being examined as potential breast cancer treatments.